Ability Hospice

“It is required that the written Patient Bill of Rights includes the right to refuse care or treatment. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient live discharge, the agency did not ensure the clinical record included documentation that the patient and/or family consented to revocation of the hospice benefit. Clinical Record 11: The patient elected the hospice benefit on 10/06/2023 for the diagnosis of hypertensive chronic kidney disease. The patient revoked the hospice benefit on 11/04/2023 and was discharged. The discharge summary written by the hospice nurse stated, “Patient was sent to hospital for treatment of UTI (urinary tract infection). They (the family) wanted to DC (discharge) the patient and work with physical therapy before signing on to hospice services again.” The clinical record did not include a signed revocation form. Clinical Record 12: The patient elected the hospice benefit on 02/06/2024 for the diagnosis of Alzheimer’s disease. The patient revoked the hospice benefit on 03/05/2024 and was discharged. The discharge summary written by the hospice nurse stated, “Patient’s POA (power of attorney) declined hospice services.” The clinical record did not include a signed revocation form. During an interview and joint record review on 04/03/2024, the Administrator/Alternative Director of Nursing confirmed the clinical records did not include a signed revocation form.”

“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, and 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/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 3 (33%) home visit observations, the agency did not ensure the drug profile contained the patient’s current prescription, over the counter drugs, supplements, and herbal remedies. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 07/18/2023 for the diagnosis of protein-calorie malnutrition. During the home visit observation, a medication review was conducted with the caregiver of the assisted living facility (ALF) where the patient resided. The medication list included in the hospice record contained two medications that were not listed on the medication list at the ALF. The hospice medication list included Levothyroxine 100mcg take one tablet daily, Start Date 07/18/2023 and Trazadone 50mg 2 tablets at bedtime, Start Date 02/28/2024. Levothyroxine and Trazadone were not on the medication list at the ALF. During an interview and joint record review on 04/03/2024, the Administrator/Alternative Director of Nursing confirmed a medication reconciliation would need to be performed.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the individualized plan of care was reviewed or revised as frequently as the patient’s condition changed. Clinical Record 7: The patient elected the hospice benefit on 11/18/2023 for the diagnosis of chronic obstructive pulmonary disease. Clinical record review revealed the patient received two on-call visits dated 11/19/2023 and 12/03/2023 for anxiety. The plan of care was not updated to include a problem, goal, or intervention to manage and address the patient’s anxiety. Clinical Record 12: The patient elected the hospice benefit on 02/06/2024 for the diagnosis of Alzheimer’s disease. Clinical record review revealed a physician note that included documentation that the patient “currently lives alone but is unsafe.” The Medical Social Worker documented reviewed plan of care and collaborate with hospice team on the Interdisciplinary Group note dated 03/01/2024. The plan of care was not updated to include the patient safety concerns identified. During an interview and joint record review on 04/03/2024, the Administrator/Alternative Director of Nursing confirmed the plans of care had not been updated when the patients’ condition had changed.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse 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, observation, and interview. In 5 of 13 (38%) clinical records reviewed with aide services provided, the agency did not ensure the hospice Registered Nurse (RN) provided the aide with patient specific care instructions. Clinical Record 3: The patient elected the hospice benefit on 02/28/2024 for the diagnosis of chronic obstructive pulmonary disease. The initial nursing assessment dated 02/28/2024 identified the patient was using Oxygen continuously at 3 liters per minute. The hospice aide care plan dated 02/28/2024 did not include specific instructions to the aide related to the patient’s Oxygen use. Clinical Record 7: The patient elected the hospice benefit on 11/18/2023 for the diagnosis of chronic obstructive pulmonary disease. The initial nursing assessment dated 11/18/2023 included documentation that the patient was using Oxygen continuously at 2 liters per minute. The hospice aide care plan dated 11/19/2023 assigned the aide the tasks of shower and assisting the patient in dressing. The aide care plan identified the patient was on Oxygen but did not provide specific instructions for the use of Oxygen during the tasks assigned. Clinical Record 13: The patient elected the hospice benefit on 02/27/2024 for the diagnosis of Non-Hodgkins Lymphoma. The hospice aide care plan dated 03/06/2024 included the relevant tasks of shower and assisting the patient in dressing. The nursing assessment dated 03/14/2024 included documentation that the patient had a “wound and a dressing on RU (right upper) arm was changed with today’s visit.” The hospice aide care plan was not updated to include notification to the aide of the wound nor specific instructions for the dressing. Clinical Record 14: The patient elected the hospice benefit on 08/13/2023 for the diagnosis of hypertensive heart disease. The initial nursing assessment dated 08/13/2023 included documentation that the patient was on Oxygen continuously at 4 liters per minute. The hospice aide care plan dated 08/13/2023 assigned the aide the tasks of bed bath and assisting the patient to dress. The aide care plan identified the patient was on Oxygen but did not provide specific instructions for the oxygen during tasks. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 07/18/2023 for the diagnosis of protein-calorie malnutrition. The hospice aide care plan dated 07/18/2023 assigned the aide the task of showering the patient. During home observation with the Hospice Aide (Staff 6), the aide was observed to give the patient a bed bath. The Aide stated the patient “screamed when he/she had to get in the shower, and it was easier to get [the patient] to agree to a bed bath.” The Aide did state she had been able to get the patient to “get in the shower last Thursday but mostly she gave the patient a bed bath.” The aide care plan assignment did not include patient specific instructions for the aide related to the patient’s care and condition. During an interview and joint record review on 04/03/2024, the Administrator/Alternative Director of Nursing confirmed the hospice aide care plans did not contain patient specific care instructions for the aide.”

“It is required that hospice aides must 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 and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 5 of 13 (38%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide reported changes to the Registered Nurse (RN). Clinical Record 3: The patient elected the hospice benefit on 02/28/2024 for the diagnosis of chronic obstructive pulmonary disease. The aide visit note dated 3/1/2024 included documentation that the following tasks which had been ordered in the aide care plan, bed bath, foot care, and peri care had not been completed. The aide visit note dated 3/19/2024 included documentation that bed bath and peri care had not been completed. The aide visits notes did not include documentation that the RN was notified of the tasks not preformed. Clinical Record 7: The patient elected the hospice benefit on 11/18/2023 for the diagnosis of chronic obstructive pulmonary disease. The aide visit note dated 03/04/2024 included documentation “Patient in a lot of pain. Did not feel comfortable enough to transfer for a shower. Helped [the patient] get mail, went through letters in regard to upcoming surgery. Will follow up on next visit.” The aide visit note did not include documentation that the RN was notified of the patient’s pain and that the shower was not completed as ordered on the aide care plan. Clinical Record 11: The patient elected the hospice benefit on 10/06/2023 for the diagnosis of hypertensive chronic kidney disease. The aide visit dated 10/09/2023 included documentation that the following tasks which had been ordered in the aide care plan, assist with dressing, comb hair, peri care, shampoo hair, and shower had not been completed. The aide visit note did not include documentation that the RN was notified of the tasks not preformed. Clinical Record 12: The patient elected the hospice benefit on 08/13/2023 for the diagnosis of hypertensive heart disease. The aide visit note dated 08/31/2023 included documentation that all tasks which had been ordered in the aide care plan had not been completed. The aide visit note did not include documentation that the RN was notified of the tasks not preformed. Clinical Record 14: The patient elected the hospice benefit on 08/13/2023 for the diagnosis of hypertensive heart disease. The aide visit note dated 08/31/2023 included documentation that all tasks which had been ordered in the aide care plan had not been completed. The aide visit note did not include documentation that the RN was notified of the tasks not preformed. During an interview and joint record review on 04/03/2024, the Administrator/Alternative Director of Nursing confirmed the clinical records did not contain documentation of report to the RN of tasks that had not been completed.”

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. This standard was not met as evidenced by document review, personnel record review, and interview. In 4 of 8 (50%) personnel records reviewed, the agency did not ensure initial orientation included the employee’s job specific duties. Agency policy No 1-004-2 Personnel Administration, dated January 2021, stated in part, “A specific orientation program will be conducted which addresses the job responsibilities.” Personnel Record 2: Administrator /Alternate Director of Nursing /Registered Nurse date of hire 10/03/2022. The personnel record contained no documented evidence that the employee was oriented to job-specific duties for Alternate Director of Nursing and Registered Nurse. Personnel Record 3: Director of Nursing /Alternate Administrator /Registered Nurse date of hire 11/13/2023. The personnel record contained no documented evidence that the employee was oriented to job-specific duties for Alternate Administrator or Registered Nurse. Personnel Record 5: Spiritual Counselor/Bereavement Coordinator date of hire 10/28/2022. The personnel record contained no documented evidence that the employee was oriented to job-specific duties for Bereavement Coordinator. Personnel Record 7: Volunteer Coordinator date of hire 03/18/2024. The personnel record contained no documented evidence that the employee was oriented to job-specific duties for Volunteer Coordinator. During an interview and joint record review on 04/03/2024, the Administrator/Alternative Director of Nursing confirmed the employees who held dual roles only had completed one job description and orientation.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, personnel record review, and interview. In 4 of 8 (50%) personnel records reviewed, the agency did not ensure competencies were completed as required. Agency policy No 1-008-1 Competency Assessments, dated January 2021, stated in part, “The competence of all hospice staff (employed, contract and volunteers) will be assessed during orientation, during the probationary period, periodically throughout the course of a year, when job responsibilities or duties change, and during the annual performance evaluation. Ongoing Assessments. Competency assessments will be completed at least one (1) time per year.” Personnel Record 1: Medical Director date of hire 11/01/2022. The personnel record contained no documented evidence of annual competency assessment for 2023. Personnel Record 2: Administrator /Alternate Director of Nursing /Registered Nurse date of hire 10/03/2022. The personnel record contained no documented evidence of annual competency assessment for 2023. Personnel Record 5: Spiritual Counselor/Bereavement Coordinator date of hire 10/28/2022. The personnel record contained no documented evidence of annual competency assessment for 2023. Personnel Record 7: Volunteer Coordinator date of hire 03/18/2024. The personnel record contained no documented evidence of initial competency assessment. During an interview and joint record review on 04/03/2024, the Administrator/Alternative Director of Nursing confirmed that annual competencies were not completed for 2023.”

“It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: The primary terminal condition; Related diagnosis(es), if any; Current subjective and objective medical findings; Current medication and treatment orders; Information about the medical management of any of the patient’s conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure the hospice Medical Director provided a written certification of terminal illness. Clinical Record 5: The patient elected the hospice benefit on 05/11/2023 for the diagnosis of Alzheimer’s disease. The certification of terminal illness (CTI) narrative was word for word the same as the admission nurse’s assessment narrative dated 05/11/2023 and did not include a medical summary written by the physician. Clinical Record 7: The patient elected the hospice benefit on 11/18/2023 for the diagnosis of chronic obstructive pulmonary disease. The CTI narrative was word for word the same as the admission nurse’s assessment narrative dated 11/18/2023 and did not include a medical summary written by the physician. Clinical Record 11: The patient elected the hospice benefit on 10/06/2023 for the diagnosis of hypertensive chronic kidney disease. The CTI narrative was word for word the same as the admission nurse’s assessment narrative dated 10/06/2023 and did not include a medical summary written by the physician. Clinical Record 12: The patient elected the hospice benefit on 02/06/2024 for the diagnosis of Alzheimer’s disease. The CTI narrative was word for word the same as the admission nurse’s assessment narrative dated 02/06/2024 and did not include a medical summary written by the physician. Clinical Record 13: The patient elected the hospice benefit on 02/27/2024 for the diagnosis of Non-Hodgkins Lymphoma. The CTI narrative stated, “Patient passed away” and did not include a medical summary written by the physician. During an interview and joint record review on 04/03/2024, the Administrator/Alternative Director of Nursing confirmed the CTI narratives were copied and pasted from the admission nurse’s narrative. The Administrator stated, “they had previously spoken to the hospice medical director about writing see Interdisciplinary Group note in the CTI narrative and now would have to speak to him about this.””

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) clinical records reviewed with recertification, the agency did not ensure the recertification of the terminal illness was completed by the physician no later than two calendar days after the first day of the benefit period and no more than 15 days before the next benefit period. Clinical Record 1: The patient elected the hospice benefit on 07/18/2023 for the diagnosis of protein-calorie malnutrition. Clinical record review revealed the third benefit period started on 01/14/2024 and the recertification of terminal illness was signed by the hospice Medical Director on 01/20/2024, 6 days after the start of the benefit period and 4 days outstanding. Clinical Record 7: The patient elected the hospice benefit on 11/18/2023 for the diagnosis of chronic obstructive pulmonary disease. Clinical record review revealed the second benefit period started on 01/17/2024 and the recertification of terminal illness was signed on 02/01/2024, 15 days after the start of the benefit period and 13 days outstanding. The third benefit period started on 03/17/2024 and the recertification of terminal illness was signed on 03/25/2024, 8 days after the start of the benefit period and 6 days outstanding. Clinical Record 10: The patient elected the hospice benefit on 11/28/2023 for the diagnosis of neurocognitive disorder. Clinical record review revealed the fourth benefit period started on 01/27/2024 and the recertification of terminal illness was signed on 03/01/2024, 34 days after the start of the benefit period and 32 days outstanding. During an interview and joint record review on 04/03/2024, the Administrator/Alternative Director of Nursing confirmed the recertification of terminal illness had been signed outside of the required time frame. Clinical record review revealed the ninth benefit period started on 12/7/2023and recertification of terminal illness was signed by the physician on 11/22/2023, 16 days before the start of the benefit period, and 1 day outstanding.”