Elite Hospice

“Based on clinical record review and staff interview, it was determined the Agency Chaplain failed to complete a Spiritual Needs Assessment as part of the Initial Comprehensive Assessment within 5 days after the election of Hospice services in 1 (#18) of 19 (#1-19) clinical records reviewed. This failed practice by the Chaplain had the potential to affect all admissions to the Agency in that, there could be a delay in identification of patient and family spiritual needs and could place patient and/or family at risk of inadequate coping mechanisms with end-of-life issues, lack of resources and ineffective family support. Findings follow: Review of clinical record #18 with a start of care of 02/06/24 revealed a patient with a diagnosis of Amyotrophic Lateral Sclerosis. A document titled “Client Coordination Note Report” dated 02/13/24 and a note type “EVALUATION SCHEDULED AFTER 5 DAYS” revealed the spiritual assessment completed 7 days after start of care (2 days past 5-day requirement). An interview on 02/29/24 at 10:45 AM with Agency Personnel #1 confirmed the Spiritual Needs Assessment was not completed within the required 5-day time frame as part of the Comprehensive Assessment.”

“Based on clinical record review and staff interview, the Skilled Nurse (SN) failed to include Oxygen on the patient’s “Medicine List” (a section of the Agency’s Care Plan containing the medication profile) in 1 (#14) of 9 (#1, #3, #4, #5, #9, #10, #14, #16, and #19) clinical records reviewed of patients utilizing oxygen. This deficient practice presented a potential risk to patients currently requiring Oxygen therapy by delaying pertinent information to the attending Physician regarding the patients individualized medication regimen. Findings follow: !. Review of clinical record #14 with a start of care of 02/16/24 revealed a patient with a diagnosis of Esophageal Cancer. A document titled Visit Note Report” and dated 02/20/24 revealed treatments utilized included “Intermittent Oxygen”. Home visit made on 02/28/24 at 11:00 AM to patient #14. Oxygen cylinder observed in the home and patient confirmed it was for his use when “I get to the point I need it.” Patient reports has not needed or utilized oxygen as of today’s visit, 02/28/24. No documentation of Oxygen included on the patient’s “Medicine List”. 2. An interview on 02/29/24 on 02/29/24 at 1:01 PM with Agency Personnel #1 confirmed oxygen was not included on the medication profile.”

“Based on clinical record review and personnel interview, it was determined that a specific and individualized care plan was not in place for the management of the primary diagnosis for 4 (#1, #2, #4, #12 ) of 19 (#1 -#19) clinical records reviewed. This failed practice had the potential to affect all patients admitted as the agency had not documented instruction on primary diagnosis specific care interventions required for the individual patients. Findings follow: Review of clinical record #1 revealed a start of care date of 01/10/24 and a diagnosis of Neoplasm of unspecified site of right female breast. The plan of care did not include the primary hospice diagnosis. Review of clinical record #2 revealed a start of care date of 01/12/24 and a diagnosis of Parkinsonism. The plan of care did not include the primary hospice diagnosis. Review of clinical record #4 revealed a start of care date of 02/02/24 and a diagnosis of Hypertensive Heart Disease with Heart Failure. The plan of care did not include the primary hospice diagnosis. Review of clinical record #12 revealed a start of care date of 01/11/24 and a diagnosis of Atrial Fibrillation. The plan of care did not include the primary hospice diagnosis.”

“Based on clinical record review and personnel interview, it was determined that a specific and individualized care plan was not in place for the management of pain for 3 (#1, #2, and #5) of 19 (#1- #19) clinical records reviewed. This failed practice had the potential to affect all patients admitted as the agency had not documented instruction on specific pain interventions for individual patients. Findings follow: Review of clinical record #1 revealed a start of care date of 01/10/24 and a diagnosis of Neoplasm of unspecified site of right female breast. The plan of care did not include the management of pain. Review of clinical record #2 revealed a start of care date of 01/12/24 and a diagnosis of Parkinsonism. The plan of care did not include the management of pain. Review of clinical record #5 revealed a start of care date of 01/11/24 and a diagnosis of Respiratory Failure with hypoxia. The plan of care did not include the management of pain.”

“Based on clinical record review and personnel interview, it was determined that the agency did not reassess and adjust visit frequencies for hospice aide care, social worker, and chaplain services after a sudden departure of a family member for 1 (#1) of 19 (#1 - #19) clinical records reviewed. This lack of individualized plan of care including specific scope and frequency of visits could potentially result in a failure to meet the patient’s physical, psychosocial, and spiritual needs for all patients on the current census. Findings follow: Review of clinical record #1 revealed a start of care date of 01/10/24 and diagnosis of Neoplasm of unspecified site of right female breast. A Medical Social Worker (MSW) narrative dated 01/12/24 documented, “... [Family name] states that patients cognitive state is declining, as she is more forgetful and confused. She states that patients short term memory is not good, and that patient has realized this, making her more irritable and agitated at times... [Family name] stated that patient told her not too long ago that she was afraid to die because she did something really bad and was afraid she would not go to heaven...” An Interdisciplinary Group (IDG) meeting held on 01/23/24 documented the caregiver had refused aide, social worker, and chaplain visits. A document titled, “Hospice IDG comprehensive assessment and plan of care update report” documented, “...Over the past two weeks, patient’s daughter has moved out of the home. Patient has increased anxiety and decreased food intake...” There were no plans documented to reassess and offer aide, social worker, and chaplain visits due to the change of the patient’s living status and living alone. On 02/29/24 at 9:35 a.m., the administrative staff were informed of these findings and there was no additional information provided by the end of the survey.”

“Based on clinical record review and personnel interview, it was determined the Agency did not ensure all orders were complete and accurate in 2(#4 and #14) of 9 (#1, #3, #4, #5, #9, #10, #14, #16, and #19) records reviewed with oxygen orders and 2 (#13 and #16) of 4 (#9, #10, #13, #16, and #18) records reviewed with urinary catheter orders. This failed practice could result in potential harm for all patients on census in that the agency did not obtain individual and specific orders to address the patient’s specific needs. Findings follow: Review of clinical record #14 with a start of care of 02/16/24 revealed a patient with a diagnosis of Esophageal Cancer. A document titled “;Visit Note Report” and dated 02/20/24 revealed treatments utilized included “Intermittent Oxygen”. Home visit made on 02/28/24 at 11:00 AM to patient #14. Oxygen cylinder observed in the home and confirmed with patient interview it was for his use when “I get to the point I need it.” Patient reports has not needed or utilized oxygen as of today’s visit, 02/28/24. Review of a document titled “;HOSPICE CERTIFICATION AND PLAN OF CARE” did not include oxygen. Review of clinical record #16 with a start of care of 01/24/24 revealed a patient with a diagnosis of Cerebral Palsy. A document titled “;HOSPICE CERTIFICATION AND PLAN OF CARE” included orders FOR “;HOSPICE NURSE TO PLACE INDWELLING (Type of catheter inserted through the urethra into the bladder) CATHETER 18 FR WITH 10 CC BALLOON. INSTILL 10 CC OF STERILE WATER INTO BALLOON. MAY IRRIGATE WITH STERILE WATER. CHANGE INDWELLING CATHETER EVERY 30 DAYS.” A document titled “;VISIT NOTE REPORT” and dated 01/27/2024 showed a patient assessment by the Registered Nurse (RN) included type of catheter “;SUPRAPUBIC (Type of catheter inserted directly through the abdomen into the bladder)” and catheter size “;18”. A document titled “;VISIT NOTE REPORT” and dated 02/22/2024 showed a patient assessment by the RN included type of catheter “;SUPRAPUBIC” and catheter size “;16”. An interview on 02/29/24 at 1:01 PM with Agency Personnel #1 confirmed the orders were not complete and accurate. Review of clinical record #4 revealed a start of care dated 02/02/24 and a diagnosis of Hypertensive Heart Disease with Heart Failure. An order dated 02/13/24 documented, “... Continuous O2 [oxygen] order...” The medication list as part of the IDG (interdisciplinary Group) dated 02/20/24 documented the use of oxygen at 5.5 liters. Additionally, it was noted at 5 liters on previous IDG notes, and 6 liters in vital signs section of the IDG document. There was not a specific and accurate order for the use of oxygen. Review of clinical record #13 revealed a start of care dated 07/27/23 and a diagnosis of Neurocognitive Disorder with Lewy Body. An order dated 02/17/24 documented, “...Remove and then replace foley catheter d/t [due to] leaking. Change Q [every] 30 d [days] & prn [as needed] ...” The client coordination note dated 02/17/24 noted, “... 20 Fr [French] 10 ml [milliliters] foley catheter was placed. Balloon inflated with 10 cc [cubic centimeters] sterile water...” On 02/29/24 at 9:30 a.m., the Executive Director was asked to provide any additional information and there was no further documentation provided.”

“Based on clinical record review and personnel interview, it was determined that the plan of care was not specific and individualized for 4 (#1, #3, # 4, #5) of 9 (#1, #3, #4, #5, #9, #10, #14, #16, and #19) patients who had oxygen orders for use and did not have a have a specific, an individualized plan of care for 2 (#3, # 4) of 2 patients who had orders for O2 saturations, and 1 (#13) of 5 (#9, #10, #13, #16, and #18) patients who had an indwelling catheter. This failed practice could result in potential harm for all patients on census in that the agency did not have an individualized care plan to address the patient’s specific needs. Findings follow: Review of Clinical Record #1 revealed a patient with a start of care of 01/10/24 and a diagnosis of Neoplasm of unspecified site of right female breast. An order dated 01/12/24 noted O2 (oxygen) at 2L (liters) as needed. The plan of care did not include the specifics on this oxygen order. Review of Clinical Record #3 revealed a patient with a start of care of 01/19/24 and a diagnosis of Pulmonary Fibrosis. An order dated 01/19/24 noted, “...Oxygen at 8L [liters] via NC [nasal cannula]. The plan of care did not include the specifics on this oxygen order. An order dated 01/23/24 noted, “...new order to update plan of care regarding monitoring SAO2 levels. This should be done as needed for dyspnea...” The plan of care did not include the specifics on this O2 saturation order, including parameters and what the plan would be for particular O2 sat readings. Review of Clinical Record # 4 revealed a patient with a start of care of 02/02/24 and a diagnosis of Hypertensive Heart Disease with Heart Failure. An order dated 02/13/24 noted, “...Continuous O2 order...” The Interdisciplinary Group (IDG) meeting notes dated 02/20/24 revealed patient #4 was using oxygen at 5 liters/minute as of the previous IDG meeting, oxygen was at 5.5 Liters/minute on the medication list, and vital signs documented 2/6/24 oxygen at 5 liters/minute, 2/15/24 and 2/19/24 oxygen at 6 liters/minute. The plan of care did not have specific and individualized instructions on the oxygen settings and the O2 saturation readings. Review of Clinical Record #5 revealed a patient with a start of care of 01/11/24 and a diagnosis of Respiratory Failure with Hypoxia. An RN (Registered Nurse) note dated 02/01/24 noted the use of O2 @ 10L. The problem list in the plan of care did not include the use of oxygen with the specific settings required for this patient. Review of Clinical Record #13 revealed a patient with a start of care of 07/27/23 and a diagnosis of Neurocognitive Disorder with Lewy Body. On 02/29/24 @9:30 a.m., the Executive Director was asked to provide any additional information regarding the oxygen, O2 saturations, and indwelling catheter specifics and none was provided.”

“Based on clinical record review and staff interview, it was determined the Agency failed to facilitate or coordinate with the patients identified local clergy to provide support of the patient and/or family spiritual needs in 2 (#3 and #5) of 19 (#1 - #19) clinical records reviewed. This lack of facilitation and coordination had the potential to affect the patients and families in obtaining relief from spiritual and/or emotional conflict to improve the quality of life for the patient and/or family. Findings follow: Review of Clinical Record #3 revealed a start of care date of 01/19/24 and a diagnosis of Pulmonary Fibrosis. A chaplain visit note dated 01/24/24 documented the patient was Baptist and active in their religious community. There was no documentation of coordination with the clergy of the patient’s church. Review of Clinical Record #5 revealed a start of care of 01/11/24 and a diagnosis of Respiratory Failure with Hypoxia. A chaplain visit note dated 02/13/24 documented the patient and the family are of the Church of Christ faith and are active in their religious community. There was no documentation of coordination with the clergy of the patient’s church. On 02/29/24 at 9:30a.m, the Executive Director was asked to provide any additional documentation, and none was provided by the end of the survey.”

“Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) failed to supervise and assess the quality of care and services through on-site supervisory aide visits (SAV) every 14 days in 1 (#6) of 7 (#6, #8, #9, #10, #11, #16, and #18) current patients records reviewed with Hospice Aide (HA) services. This lack of supervision by the RN had the potential to place all patients receiving HA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the Plan of Care by the HA or possible changes in the needs of the patient and family. Findings follow: Review of clinical record #6 with a start of care of 06/29/23 revealed a patient with a diagnosis of Hemiplegia following Cerebral infarction. Review of a document titled “Aide Care Plan Report” revealed orders for HA services. No documentation of SAV prior to patient’s discharge on 07/17/23 An interview on 02/29/24 at 12:50 PM with personnel #1 confirmed the agency failed to conduct an aide supervisory visit within 14 days as required.”

“Based on Clinical Record review and personnel interview, it was determined that the Agency failed to ensure an Advance Directive form was completed accurately for 1 (#12) of 19 (#1 - #19) clinical records reviewed. The failed practice had the potential to affect all patients on the census as it would direct staff on end-of-life measures. Findings follow: Review of Clinical Record # 12 revealed a start of care of 01/11/24 and a diagnosis of Atrial Fibrillation. A signed POLST (Physician Orders for Life-Sustaining Treatment) was incomplete as it did not have an option checked for “...Section A... Attempt Resuscitation/CPR [Cardiopulmonary Resuscitation] ... Do Not Attempt Resuscitation/DNR [Do Not Resuscitate] ...” Section B was also incomplete, which included options for Full Treatment, Selective Treatment, or Comfort Treatment. During an interview on 2/29/24 at 12:30 p.m., the Executive Director stated a new form was going out to the patient and family to get this Advance Directive corrected.”