Carelife Hospice LLC

“It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 4 of 7 (57%) clinical records reviewed, the agency did not ensure the patient’s right to be involved in the development of the plan of care. State Administrative Code for Health Services, stated in part, patients have the right to give informed consent for psychotropic medication including information about their diagnosis, nature of the medication, the expected effect, the risk and side effects, any risks if they do not take the medication, alternative treatments, and signs that might require discontinuation of the medication. Clinical Record 1: The patient elected the hospice benefit on 08/21/2023, with a terminal diagnosis of Alzheimer’s disease. Clinical record review revealed the physician wrote an order dated 08/21/2023 for a psychotropic medication that stated in part, “Quetiapine 25mg oral once daily – agitation.” The psychotropic medication consent form signed and dated 08/16/2023 did not include the name of the medication, this section was left blank. The record contained no documented evidence that the patient’s representative provided informed consent related to this medication. Clinical Record 2: The patient elected the hospice benefit on 12/21/2023, with a terminal diagnosis of cerebrovascular disease. Clinical record review revealed the psychotropic medication consent form signed by the patient representative on 12/21/2023 did not include the psychotropic medications ordered for the patient, when the medication list section was left blank. A medication order dated 12/21/2023 and signed by the Nurse Practitioner ordered the following psychotropic medications, Trazodone 100mg oral 1 tablet daily at bedtime, Hydroxyzine 25MG tab oral three times daily as needed for anxiety. The record contained no documented evidence that the patient or the patient representative provided informed consent related to these psychotropic medications. Clinical Record 3: The patient elected the hospice benefit on 12/20/2023, with terminal diagnosis of chronic atrial fibrillation. Clinical record review revealed the physician wrote an order dated 12/20/2023 for psychotropic medications that stated in part, Quetiapine 25mg oral once daily at bedtime for agitation, Quetiapine 25mg oral once daily anxiety, take 1/2 tablet by mouth once daily, and Sertraline 100mg oral once daily, take 1 tablet by mouth daily for depression. The psychotropic medication consent form signed by the patient and dated 12/20/2023 did not include the name of the medications, this section was left blank. The record contained no documented evidence that the patient provided informed consent related to these medications. Clinical Record 4: The patient elected the hospice benefit on 11/13/2023, with a terminal diagnosis of aphasia following cerebral infarct. Clinical record review revealed the physician wrote an order dated 11/13/2023 for psychotropic medications that stated in part, Trazodone 100mg oral 1 tablet daily at bedtime and Escitalopram Oxalate 10MG 1 tab oral once daily. The psychotropic medication consent form signed by the patient representative and dated 11/13/2023 did not include the name of the medications, this section was left blank. The record contained no documented evidence that the patient provided informed consent related to these medications. During joint record review and interview on 01/16/2024, the Administrator, Alternate Administrator, and Director of Clinical Services acknowledged that the agency did not ensure the patients were informed of the specific psychotropic medications they were consenting to.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed, the agency did not ensure the individualized plan of care included planned interventions based on problems identified in the initial comprehensive and updated comprehensive assessments. Clinical Record 4: The patient elected the hospice benefit on 11/13/2023, with a terminal diagnosis of aphasia following cerebral infarct. Review of the initial nursing assessment dated 11/13/2023 included documentation by the skilled nurse that stated “Incontinent of bowel and bladder. Right nephrostomy tube intact. Site has no sign of infection noted. Patient has 16 FR indwelling catheter which is patent and draining yellow, cloudy urine.” The patient’s individualized plan of care dated 11/13/2023 did not include interventions related to the patient’s bowel and bladder incontinence, nephrostomy tube, and indwelling catheter. During a joint review of the record and interview on 01/18/2024, the Administrator, Alternate Administrator, and Director of Clinical Services reviewed the record and agreed that the plan of care was missing documentation of goals and planned interventions based on the problems identified in the initial nursing assessment.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, observation, and interview. In 2 of 3 (67%) home visit observations, the agency did not ensure clinical staff performed hand hygiene as required by agency policy. Agency policy No. 7-009, revised May 2022, stated in part, “hand decontamination with an alcohol-based hand rub should be performed...after removing gloves” and “when hand washing with soap and water use a dry disposable towel to turn off the faucet.” Home Visit 1: During the home visit observation with the Hospice Aide (Staff1), the Aide was observed to wash hands with soap and water but did not use a dry disposable towel to turn off the faucet. Home Visit 2: During the home visit observation with the Registered Nurse (Staff 2), the nurse was observed removing gloves after patient care and did not perform hand hygiene prior to cleaning equipment and returning it to the visit bag. Upon exiting the patient’s room, the nurse went to the kitchen sink, washed, and dried hands but did not use a dry disposable towel to turn off the faucet. During the daily wrap up conference on 01/16/2024, the Administrator, Alternate Administrator and Director of Clinical Services reviewed and acknowledged that the clinicians, Staff 1 and Staff 2 did not follow the agency policy for hand hygiene.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed with aide services provided, the agency did not ensure hospice aides were supervised by a Registered Nurse (RN) who makes an on-site visit to the patient’s home no less frequently than every 14 days. Clinical Record 2: The patient elected the hospice benefit on 12/21/2023, with a terminal diagnosis of cerebrovascular disease. Clinical record review revealed hospice aide services began on 12/21/2023. The RN completed the first on-site supervisory visit on 01/13/2024, 24 days after the aide provided the first aide visit and 10 days outstanding. During a daily wrap up conference on 01/16/2024, the Administrator, Alternate Administrator, and Director of Clinical Services acknowledged the patient was receiving hospice aide services and the record lacked evidence of on-site RN supervisory visit for 24 days from 12/21/2023 to 1/13/2024.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. Review of the agency’s volunteer binder revealed no documented evidence of the agency’s volunteer recruiting efforts. During an interview on 01/18/2024, the Administrator /Volunteer Coordinator and the Alternate Administrator stated the agency has not been recruiting volunteers as they currently have one volunteer available but have had no volunteer needs and they plan to recruit volunteers internally from family members and their church congregations when needed. The agency did not ensure documentation and demonstration of viable and ongoing efforts to recruit and retain volunteers.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. Review of the agency’s volunteer binder provided no documented evidence of volunteer activity or cost savings. During an interview and review of the agency’s volunteer program on 01/18/2024, the Administrator /Volunteer Coordinator and the Alternate Administrator stated that the agency was aware of the five percent requirement but has no volunteer activity and therefore has no cost savings. The agency does have one volunteer available but has not been using them. The agency did not ensure hospice volunteer provided day-to-day or direct patient care services in the amount of at least 5% of the total patient care hours.”

“It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. The hospice administrator is an employee of the organization, informs the governing body about ongoing operations, including patient care delivery issues and QAPI activities, has the education and experience as required by the governing body. If the administrator is not available, another individual is assigned the administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by document review, personnel record review, and interview. In 2 of 2 (100%) personnel records review for the Administrator and Alternate Administrator, the agency did not ensure the appointed Administrator and Alternate Administrator had the education and/or experience as required by the governing body. Review of the agency’s job description for the Executive Director/Administrator, revised May 2022, and approved by the governing body, stated in part position qualifications include “A bachelor’s degree in business administration, master’s degree in health care or related field preferred. Two (2) to Five (5) years of experience in health care management.” Personnel Record 7: Administrator date of hire 05/12/2023. Review of the personnel file revealed no documented evidence that the Administrator had a bachelor’s degree in business administration, master’s degree in health care or related field preferred. The record also did not provide evidence of at least 2 years of health care management experience. Personnel Record 1: Alternate Administrator date of hire 05/12/2023. Review of the personnel file revealed no documented evidence that the Alternate Administrator had a bachelor’s degree in business administration, master’s degree in health care or related field preferred. The record also did not provide evidence of at least 2 years of health care management experience. During a joint review of records and interview on 01/18/2023, the Administrator and the Alternate Administrator acknowledged that their experience and education did not match the agency’s job descriptions.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum, signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 7 (29%) clinical records reviewed, the agency did not ensure the hospice election statement was complete and included the date the hospice benefited was elected. Clinical Record 2: The patient elected the hospice benefit on 12/21/2023, with a terminal diagnosis of cerebrovascular disease. The Election of Medicare Hospice Benefit & Informed Consent form was signed by a patient representative on 12/21/2023 but did not include documentation of the election date. The form included a statement, “I request that authorization benefits begin on __/__/__.” The date was left blank and did not include the actual date hospice benefits were authorized to begin. Clinical Record 3: The patient elected the hospice benefit on 12/20/2023, with terminal diagnosis of chronic atrial fibrillation. The Election of Medicare Hospice Benefit & Informed Consent form was signed by the patient on 12/20/2023 but did not include documentation of the election date. The form included a statement, “I request that authorization benefits begin on __/__/__.” The date was left blank and did not include the actual date hospice benefits were authorized to begin. During joint record review and interview on 01/16/2024, the Administrator, Alternate Administrator and Director of Clinical Services acknowledged that the agency did not ensure the effective date was completed on the Election of Medicare Hospice Benefit.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed for patients that revoked hospice services, the agency did not ensure a copy of the discharge summary was sent to the receiving facility. Clinical Record 4: The patient elected the hospice benefit on 11/13/2023, with a terminal diagnosis of aphasia following cerebral infarct. The patient revoked hospice care on 11/23/2023 and was transported to the hospital. Clinical record review revealed no documented evidence that a discharge summary was sent to the receiving facility. During a joint clinical record review and interview on 01/17/2023, the Administrator and the Alternate Administrator confirmed that a discharge summary was not provided to the hospital.”

“It is required that criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by personnel record review and interview. In 1 of 10 (10%) personnel records reviewed, the agency did not ensure a criminal background check was completed within three months of the date of employment. Personnel Record 10: Volunteer date of hire 05/12/2023. Personnel record review revealed no documented evidence that a criminal background check was completed for the volunteer within three months of volunteer employment. In an interview with the Administrator and Alternate Administrator on 01/17/2024 it was stated by the Alternate Administrator that the agency was waiting to run the background check until they had a need for a volunteer.”