Elite Hospice

“Based on clinical record review and personnel interview, it was determined the Agency failed to ensure there was a continued discussion regarding advance directives with 1 (#16) of 19 (#1 - #19) patients and/or their responsible party as #16 had a decline in condition and subsequently underwent cardiopulmonary resuscitation (CPR). The failed practice had the potential to affect all patients under the care of the Agency staff and did not have an established advance directive. Findings follow: Clinical record review of #16 revealed a patient with a start of care date of 04/11/24 and had a diagnosis of Malignant Neoplasm of the Descending Colon. The document titled, “Hospice Certification and Plan of Care” with a certification period of 04/11/24 - 07/09/24 noted “...Advance Directives: Resuscitate...” The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 04/25/24 noted, “...P [Problem] ACTIVELY DYING G: [Goal] Caregiver will verbalize understanding of the physical signs and symptoms a patient experiences at end of life, during the active stages of the dying process by 4/30/24. I: [Intervention] SN [Skilled Nurse] Provide education to the caregiver on physical signs and symptoms, as well as care for the patient, at end of life...” There were no care plans to address a continued conversation with the patient and/or caregiver regarding Advance Directives as the patient’s condition declines. A Registered Nurse (RN) Visit Note Report dated 05/06/24 noted the patient was “...restless, moving legs, gripping neck, bracing on side rails, furrowed eyebrows, groaning occasionally...Abnormal breath sounds...Based upon the nutritional score, indicate actions to be taken: Death is imminent-No action required...Narrative: Patient received by Hospice SN [skilled nurse] lying in hospital bed in bedroom. Alert, unable to assess orientation due to patient not verbally responding. Patient rubbing neck and moving legs constantly, caregiver states patient has had a sore neck from staying in the same position. Skin with poor turgor, caregiver states patient is eating very little, drinking less than 3 cups daily, bowel sounds hypoactive...cachectic, bony prominences noted, heart rate irregular and tachycardic, lung sounds diminished...” A RN Visit Note Report dated 05/08/24 noted, “...Narrative: Patient received by hospice SN laying in hospital bed in bedroom. Patient unresponsive to stimuli. Eyes partially open, not focusing on objects. No verbal or nonverbal indicators of pain noted. Caregiver reports patient has not eaten in 2 days, not drinking or taking oral medications. Bowel sounds hypoactive, heart rate tachycardic and irregular, lung sounds diminished, crackles heard throughout, instructed caregiver to comfort pack medication...” There was documentation of ongoing education to the family member regarding “...medication regimen, fall prevention, oxygen safety, incontinence care, frequent repositioning to offload pressure, hospice 24 hour on call number, and notifying hospice with any uncontrollable symptoms.” On 05/08/24, after the RN visit, the family member called Emergency Medical Services (EMS) and CPR was performed. Patient #16 was pronounced (expired) by the coroner and the hospice nurse was then called. There were no other notes in the RN visit notes 05/06/24 and 05/08/24 to indicate the patient and/or responsible party were offered further discussion regarding advance directives as the patient’s death was imminent. There were no other notes from the Medical Social Worker (MSW) to indicate a continued discussion occurred to offer more information on advance directives. On 05/23/24 at 1:30 PM, the Agency administrative staff were asked to provide any further information regarding this finding, and none was provided by the end of the survey.”

“Based on clinical record review and staff interview, it was determined the Agency Medical Social Worker (MSW) failed to complete an initial assessment as part of the comprehensive assessment within 5 days after the election of Hospice services in 1 (#1) of 19 (#1 - #19) clinical records reviewed. This failed practice by the MSW had the potential to affect all admissions to the Agency in that, there could be a delay in identification of patient and family needs and could place patient and/or family at risk of inadequate lack of resources and ineffective family support. Findings follow: 1. Review of clinical record #1 with a start of care of 03/30/24 revealed a patient with a diagnosis of Acute Respiratory Failure with hypoxia. The MSW initial assessment was dated 04/09/24 which was day 10 after hospice admission which was 5 days late. 2.On 05/23/24 at 3:30 p.m., the Agency staff stated they are understaffed for Medical Social Workers by one and the sister agency in the nearby town has a MSW who is assisting with the case load. 3. On 05/23/24, the Agency staff was not able to provide any further information regarding this delayed visit.”

“Based on clinical record review and personnel interview, the Agency failed to ensure the frequency of visits by the interdisciplinary staff was included in the updated plan of care for 1 (#12) of 19 (#1 - #19) clinical records reviewed. This failed practice had the potential to affect all patients that receive services from the Agency as there was no specific plan for continued assessments, provision of care, and evaluation of the care and services provided. Findings follow: Clinical record #12 with a start of care date of 05/08/23 revealed a patient with a diagnosis of Chronic Lymphocytic Leukemia of B-Cell Type. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 05/16/24 did not include any details on visit frequency by the interdisciplinary team. On 05/23/24 at 1:30 p.m., the Agency personnel were asked to provide any further information, and none was provided by the exit conference.”

“Based on clinical record review and personnel interview, it was determined the Agency failed to ensure there was an accurate order for 1 (# 6) of 13 (#1 - #6, #9- #11, #14, #15, #17, #18) of those patients reviewed that utilize oxygen. Additionally, the Agency failed to ensure there were complete orders for 3 (# 6, #10, and #15) of 6 (#3, #6, #10, #15, #17, and #18) of those patients reviewed that have indwelling catheters, 2 (#5, #16) of 7 (#2, #3, #5, #7, #8, #16, and #18) of those patients reviewed that have a wound, and 1 of 1 (#16) of those patients reviewed that have an ostomy. This failed practice had the potential to affect all patients under the care of the Agency that have orders for oxygen, indwelling catheters, wounds, and/or have an ostomy as there was a lack of specific direction for the direct caregiver. Findings follow: A. Clinical Record Review of oxygen use revealed the following: Clinical record review # 6 revealed a patient with a start of care date of 04/20/24 and a diagnosis of Metabolic Encephalopathy. The Hospice Certification and Plan of Care with a certification 04/20/24 - 07/18/24 documented, “... Medications... Oxygen 2 Liters PRN [as needed] Reason: Shortness of breath Instructions: Administer Oxygen at 4 Liters per Nasal Cannula as needed...” B. Clinical Record Review of foley catheter use revealed the following: Clinical record review # 6 revealed a patient with a start of care date of 04/20/24 and a diagnosis of Metabolic Encephalopathy. The Registered Nurse (RN) notes dated 04/20/24 documented 16FR (French) indwelling catheter due to be changed 05/14/24. The Hospice Certification and Plan of Care with a certification 04/20/24 - 07/18/24 did not include specific orders for the size of the catheter or bulb size. The IDG dated 04/25/24 did not include specifics on the size, bulb size, and frequency of catheter change. Clinical record review #10 revealed a patient with a start of care date of 04/23/24 and a diagnosis of Hypertensive Heart Disease & Chronic Kidney Disease (CKD) with heart failure. The RN Start of Care note dated 04/23/24 documented the use of a suprapubic catheter, size 18. The Hospice Certification and Plan of Care with a certification 04/23/24 - 07/21/24 did not include orders for the suprapubic catheter. Clinical record review #15 revealed a patient with a start of care date of 02/28/24 and a diagnosis of Hypertensive Heart Disease with heart failure. The RN Start of Care note dated 02/28/24 documented the patient had a 14 French coude’ with a 10 ml (milliliter) bulb and due to be changed 03/28/24. Additionally, it was noted there were blood clots. The physician’s orders revealed a catheter change on 03/04/24 due to leakage and inserted a 16 French, 03/13/24 due to leakage and inserted an 18 French, 04/30/24 changed from an 18 French to 20 French catheter. On 05/23/24 at 1:30 PM, the administrative Agency staff were asked to provide the original order for the catheter and care. None was provided by the end of the survey. C. Clinical Record Review of wound dressing change orders revealed the following: Clinical record review #5 revealed a patient with a start of care date of 04/05/24 and a diagnosis of Heart Failure. A Physician’s order dated 05/09/24 documented, “...Add Optifoam dressings to supply list for coccyx DTI [Deep Tissue Injury]...” There were no specific orders relative to how to treat the DTI using the optifoam, frequency of dressing changes, and by whom. Clinical record review #16 revealed a patient with a start of care date of 04/11/24 and a diagnosis of Malignant Neoplasm of Descending Colon. The IDG Comprehensive Assessment and Plan of Care Update Report did not include orders or care instructions on the care plan for the stage II coccyx pressure ulcer identified on 04/28/24. D. Clinical Record Review of a patient with an ostomy revealed the following: Clinical record review #16 revealed a patient with a start of care date of 04/11/24 and a diagnosis of Malignant Neoplasm of Descending Colon. The Hospice Certification and Plan of Care with a certification 04/11/24 - 07/09/24 documented, “...DME [Durable Medical Equipment] and Supplies...ostomy supplies...” There was no order for ostomy care, specifics on what ostomy supplies to use, how often and by whom. E. On 05/23/24 at 1:30 PM, the administrative Agency personnel were asked to provide any further information regarding the above concerns, and none was provided by the end of the survey.”

“Based on clinical record review and personnel interview, it was determined the Agency failed to ensure all services necessary for the management of the terminal illness was included in the plan of care for 1 (#2) of 13 (#1 - #6, #9 - #11, #14, #15, #17, #18) clinical records reviewed that utilize oxygen, 2 (#5 and #16) of 7 (#2, #3, #5, #7, #8, #16 and #18) of those patients reviewed that have a wound, 3 (#6, #10 and #16) of 6 (#3, #6, #10, #15, #17, and #18) of those patients reviewed that have indwelling catheters, and 1 of 1 (#16) of those patients reviewed that have an ostomy. This failed practice had the potential to affect all patients that have orders for the use of oxygen, wound care, indwelling catheters, and colostomies in that the specifics on these medical supplies and devices would not be easily accessible for the direct caregiver. Findings follow: Clinical record #2 with a start of care date of 03/30/24 revealed a diagnosis of Acute Respiratory Failure with hypoxia. The document titled, “Hospice Certification and Plan of Care” revealed, “Medications...O2-Oxygen 2 liters prn [as needed] shortness of breath...” There was no specific oxygen orders or care plan in the Orders of Discipline and Treatments section, nor the Goals section. There was no specific care plan in the Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report. There was no specific care plan for the management of the terminal illness of Acute Respiratory Failure. Clinical record #5 with a start of care date of 04/05/24 revealed a diagnosis of Heart Failure. The IDG Comprehensive Assessment and Plan of Care Update Report dated 05/09/24 did not include a thorough plan of care for the Deep Tissue Injury (DTI) wound to the coccyx. Clinical record # 6 with a start of care date of 04/20/24 revealed a diagnosis of Metabolic Encephalopathy. The IDG Comprehensive Assessment and Plan of Care Update Report dated 05/09/24 did not include specific instructions for the use of the indwelling catheter. It did not include size, bulb size, when to change the catheter and by whom. Clinical record #10 with a start of care date of 04/23/24 revealed a diagnosis of Hypertensive Heart Disease and Chronic Kidney Disease (CKD) with heart failure. The IDG Comprehensive Assessment and Plan of Care Update Report dated 05/09/24 did not include specific instructions for the care of the indwelling catheter. Clinical record #16 with a start of care date of 04/11/24 revealed a diagnosis of Malignant Neoplasm of Descending Colon. The IDG Comprehensive Assessment and Plan of Care Update Report dated 04/25/24 did not include specific instructions for the use and care of the indwelling catheter, colostomy, and Stage II pressure ulcer care. On 05/23/24 at 1:30 p.m., the Agency personnel were informed of these findings and no further information was provided at the time of the exit conference.”

“Based on clinical record review and personnel interview, it was determined the Agency failed to ensure the hospice aide was providing services according to the plan of care for 3 (# 6, #8, #9) of 14 (#1 - #3, #5, #6, #8- #11, #13, #14, #16 - #18) clinical records reviewed who had a plan of care for Aide visits. This failed practice had the potential to affect all patients that have a plan of care for aide services with the Agency. Findings follow: Clinical record #6 with a start of care date of 04/20/24 revealed a patient with a diagnosis of Metabolic encephalopathy. The document titled, “Hospice Certification and Plan of Care” with a certification period of 04/20/24 - 07/18/24 documented hospice aide care 3 times a week for 10 weeks then 2 times a week for 3 weeks. The weeks of 04/21/24 and 05/12/24 there were two (2) visits rather than three (3). Clinical record #8 with a start of care date of 03/15/24 revealed a patient with a diagnosis of Malignant Neoplasm of Prostate. The document titled, “Hospice Certification and Plan of Care” with a certification period of 03/15/24 -06/12/24 documented hospice aide care 2 times a week for 12 weeks, then 1 time for a week. The week of 03/17/24 there was one (1) visit by the aide rather than two (2). Clinical record #9 with a start of care date of 04/09/24 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) with Exacerbation. The document titled, “Hospice Certification and Plan of Care” with a certification period of 04/09/24- 07/07/24 documented hospice aide care 1 visit the first week then 2 times a week for 12 weeks. The week of 04/14/24 there was one (1) visit by the aide rather than two (2). On 05/23/24 at 1:30 p.m., the Regional Vice President (RVP) and interim Executive Director (ED) were asked to provide any further information regarding these visits according to the plan of care that were missed. There was no more information provided by the exit conference.”

“Based on clinical record review and personnel interview, it was determined the Agency failed to ensure there was coordination of visits with the patient’s local clergy for 7 (#6, #7, #9, #10, #15, #16, #18) of 7 (#6, #7, #9, #10, #15, #16, #18) clinical records reviewed that have an identified church and/or pastor by the Agency chaplain. This failed practice had the potential to affect the patients and families in obtaining relief from spiritual and/or emotional conflict in order to improve the quality of life for the patient and/or family. Findings follow: 1.During clinical record review, it was noted the Agency chaplain documented in the initial assessment the patient had a local church. There was no documentation from the Agency personnel regarding a coordination of visits with the clergy from their identified local church for the following patients: a. Clinical record #6 with a start of care date of 04/20/24 revealed a patient with a diagnosis of Metabolic Encephalopathy. b. Clinical record #7 with a start of care date of 04/26/24 revealed a patient with a diagnosis of Alzheimer’s disease. c. Clinical record #9 with a start of care date of 04/09/24 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) with exacerbation. d. Clinical record #10 with a start of care date of 04/23/24 revealed a patient with a diagnosis of Hypertensive Heart Disease and Chronic Kidney Disease (CKD) with heart failure. e. Clinical record #15 with a start of care date of 02/28/24 revealed a patient with a diagnosis of Hypertensive Heart Disease with heart failure. f. Clinical record #16 with a start of care date of 04/11/24 revealed a patient with a diagnosis of Malignant Neoplasm of Descending Colon. g. Clinical record #18 with a start of care date of 04/10/24 revealed a patient with a diagnosis of Malignant Neoplasm of Thorax. 2. On 05/23/24 at 1:30 p.m., the Agency personnel were asked to provide any further information, and none was provided by the time of the exit conference.”

“Based on record review and personnel interview, it was determined the Agency failed to ensure there was an active hospice volunteer program. This failed practice had the potential to affect all patients and families under the care of the Agency. Findings follow: On 05/23/24 at 1:30 p.m., the Regional Vice President (RVP) was asked to provide volunteer program information. She stated, “We haven’t had a volunteer coordinator since December. We have someone hired now and they are making their rounds meeting the patients and getting started. They just started this week.” On 05/23/24 at 3:35 p.m., the Regional Vice President (RVP) and interim Executive Director (ED) completed the CMS-417 and had zero (0) documented for volunteer personnel. The interim ED stated they had one volunteer left, but they were leaving. The Agency Quality Assurance Performance Improvement (QAPI) and Governing Board meeting minutes were reviewed. The volunteer % graph documented a drop to 4% in November 2023, 5% in December 2023, and then a plummeted % down to 0% in March 2024.”

“Based on record review and personnel interview, it was determined the Agency failed to ensure there was an active hospice volunteer program which equaled 5% of total patient care hours. This failed practice had the potential to affect all patients and families under the care of the Agency. Findings follow: On 05/23/24 at 1:30 p.m., the Regional Vice President (RVP) was asked to provide volunteer program information. She stated, “We haven’t had a volunteer coordinator since December. We have someone hired now and they are making their rounds meeting the patients and getting started. They just started this week.” On 05/23/24 at 3:35 p.m., the RVP and interim Executive Director (ED) completed the CMS-417 and had zero (0) documented for volunteer personnel. The interim ED stated they had one volunteer left, but they were leaving. The Agency Quality Assurance Performance Improvement (QAPI) and Governing Board meeting minutes were reviewed. The volunteer % graph documented a drop to 4% in November 2023, 5% in December 2023, and then a plummeted % down to 0% in March 2024.”