In My Home Hospice Care

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards a copy of the hospice discharge summary and the patient’s record, if requested to the patient’s attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed in which a patient revoked the hospice benefit, the hospice did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 3: The patient elected the hospice benefit on 06/14/2023 and revoked the hospice benefit on 04/10/2024. The clinical record contained no documented evidence that the discharge summary was forwarded to the patient’s attending physician. During an interview on 04/17/2024, the Director of Nursing confirmed the finding and stated she didn’t know that she had to send a discharge summary to the attending physician if the patient revoked hospice care. In 1 of 1 (100%) clinical record reviewed in which a patient revoked the hospice benefit revealed the hospice did not ensure the discharge summary was forwarded to the patient’s attending physician.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care or to the patient’s community attending physician upon hospice discharge includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This is a continuing required action. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which the patient was discharged, the hospice did not ensure that the discharge summary included a summary of the patient’s hospice stay. Clinical Record 3: The patient elected the hospice benefit on 06/14/2023. The patient revoked the hospice benefit on 04/10/2024 to seek aggressive treatment. The discharge summary completed by the Registered Nurse on 04/10/2024 did not include a summary of the patient’s hospice stay, including treatment, symptoms, and pain management. During an interview on 04/17/2024, the Director of Nursing confirmed the finding and stated they have put a ticket in with their EMR [electronic medical record] to see if they can link the discharge summary to the most current plan of care. This is a continuing required action. In 1 of 2 (50%) clinical records reviewed in which the patient was discharged revealed the hospice did not ensure that the discharge summary included a summary of the patient’s hospice stay.”

“It is required that hospice aide provides services, ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by review of clinical records and interviews with the Director of Nursing and Director of Quality which revealed issues with the agency’s aide services provide in the following areas: Failure to ensure the Registered Nurse provided specific written patient care instructions for the hospice aide [HCDT.15.I/L625]; Failure to ensure the hospice aide provided services included in the plan of care [HCDT.16.I/L626]; and Failure to ensure the hospice aide reported changes in the patient’s condition/needs to the Registered Nurse [HCDT.18.I/L628]. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.76: Hospice aide and homemaker services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 12: The patient elected the hospice benefit on 08/18/2023 with a terminal diagnosis of malignant neoplasm of the pancreas. The plan of care dated 08/18/2023 included a pain goal that stated, “Pain will be at acceptable level.” The goal was not measurable when it did not describe what an acceptable pain level would be for the patient. During an interview and joint record review on 03/06/2024, the Director of Nursing confirmed the pain goal was not measurable.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following, drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the individualized plan of care included drugs and treatments necessary to meet the needs of the patient. Clinical Record 4: The patient elected the hospice benefit on 02/27/2024 with a terminal diagnosis of malignant neoplasm of the prostate. During the clinical record review on 03/06/2024, it was revealed that no medications had been listed in the plan of care or the medication profile. The skilled nurse documented on the nursing assessment dated 02/29/2024 that the patient “Denies any pain at this time but relies on twice daily Tramadol [a medication prescribed to relieve pain].” On the nursing assessment dated 03/04/2024 the skilled nurse documented “Patient currently has pain from UTI [urinary tract infection] that is managed with Tramadol BID [twice daily].” The clinical record contained information that the patient was taking Aspirin, Bumetanide, Colace, a fiber laxative, Levothyroxine, Lisinopril, Melatonin, Metformin, Metoprolol, Omega 3, Protonix, Tramadol, and Flomax. These medications were not listed on the patient’s plan of care or medication profile. During an interview and joint record review on 03/06/2024, the Director of Nursing confirmed the clinical record did not include a list of the patient’s current medications.”

“It is required the bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) bereavement clinical records reviewed, the agency did not ensure a bereavement plan of care was documented. Clinical Record 13: The patient elected the hospice benefit on 02/03/2023 with a terminal diagnosis of malignant neoplasm of unspecified part of bronchus or lung. Clinical record review revealed no documented evidence of a bereavement plan of care. Clinical Record 14: The patient elected the hospice benefit on 07/12/2023 with a terminal diagnosis of Alzheimer’s disease. Clinical record review revealed no documented evidence of a bereavement plan of care. During an interview and joint record review on 03/07/2024, the Administrator confirmed the bereavement plan of care had not been entered in the clinical record.”

“It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) 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 and interview. In 6 of 13 (46%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse (RN) provided specific written patient care instructions for the hospice aide. Clinical Record 1: The patient elected the hospice benefit on 01/20/2024 with a terminal diagnosis of atherosclerotic heart disease. The initial nursing assessment dated 01/20/2024 included documentation that the patient was prescribed Keppra for seizures and oxygen as needed. The hospice aide care plan assignment dated 01/22/2024 did not include seizure precautions and instructions to the aide related to the use of oxygen during assigned tasks and patient care activities. The aide care plan assigned the aide the task of checking vital signs at every visit. The aide care plan did not include parameters for the vital signs or instructions on when to notify the RN if the vital signs were out of parameters. The skilled nursing assessment dated 02/15/2024 included a physician’s order to remove the foley and noted the foley catheter had been removed. The aide care plan was not updated after the foley catheter was removed. The tasks of foley catheter care and empty catheter bag remained on the aide care plan. Clinical Record 3: The patient elected the hospice benefit on 06/16/2023 with a terminal diagnosis of cerebrovascular disease. The aide care plan dated 12/13/2023 assigned the aide the task of checking vital signs every visit. The aide care plan did not include parameters for the vital signs or instructions on when to notify the RN if the vital signs were out of parameters. Clinical Record 5: The patient elected the hospice benefit on 12/07/2023 with a terminal diagnosis of hypertensive heart disease. The aide care plan dated 12/08/2023 assigned the aide the task incontinent care every visit. The nursing assessment dated 12/19/2023 included documentation that stated, “catheter is leaking urine with change in color.” The nursing assessment dated 01/05/2024 included documentation that stated, “foley catheter is patent, no kinking and draining to gravity.” The aide care plan assignment did not include specific instructions to the aide related to the patient’s foley catheter. Clinical Record 6: The patient elected the hospice benefit on 08/17/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. The aide care plan dated 08/21/2023 assigned the aide the tasks of bathing via shower chair and to check vital signs at every visit. The initial nursing assessment dated 08/17/2023 included documentation that the patient had a decubitus ulcer stage II on the outer right ankle covered with foam non-stick dressing and the patient was on oxygen at 2 liters per minute. The aide care plan did not include instructions to the aide related to the patient’s wound and did not include instruction on how to care for the wound during bathing or what to do if the dressings became dislodged, soiled, or wet. The aide care plan did not provide the aide with specific instructions for the use of oxygen during assigned tasks and while caring for the patient. Clinical Record 9: The patient elected the hospice benefit on 11/14/2023 with a terminal diagnosis of atherosclerotic heart disease. The aide care plan dated 11/14/2023 assigned the aide the task of checking vital signs every visit. The aide care plan did not include parameters for the vital signs or instructions on when to notify the RN if the vital signs were out of parameters. Clinical Record 13: The patient elected the hospice benefit on 02/03/2023 with a terminal diagnosis of malignant neoplasm of unspecified part of bronchus or lung. The aide care plan dated 02/03/2023 assigned the aide the tasks of bathing via shower chair and dressing assistance. The skilled nursing assessment dated 02/24/2023 included documentation that the patient had a PleurX [catheter inserted through the chest wall to drain fluid from the lung] drain, a wound to left heel, sacral dressings, and was a 2-person assist to stand. The aide care plan did not include instructions to the aide related to care of the PleurX drain. The aide care plan did not include instructions to the aide for the wounds and did not include instructions on how to care for the wounds during bathing or what to do if the dressings became dislodged, soiled, or wet. The aide care plan was not updated to reflect the patient becoming a 2-person assist to stand. During an interview and joint record review on 03/06/2024, the Director of Nursing and the Director of Quality confirmed the aide care plans did not contain specific instructions for the wounds, oxygen, foley, and vital sign parameters.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 13 (15%) clinical records reviewed with aide services provided, the agency did not ensure the hospice aide provided services included in the plan of care. Clinical Record 1: The patient elected the hospice benefit on 01/20/2024 with a terminal diagnosis of atherosclerotic heart disease. The hospice aide care plan dated 01/22/2024 assigned the aide the tasks of bed bath, foley catheter care, and empty catheter collection bag. The skilled nursing assessment dated 02/15/2024 included documentation that stated, “Removed foley catheter per MD (Medical Doctor) orders.” The hospice aide notes for visits dated 02/19/2024, 02/22/2024, 02/26/2024, 02/29/2024, and 03/04/2024 had the tasks of “foley catheter care” and “empty collection bag” marked as completed at each visit even though the catheter had been removed on 02/15/2024. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 07/12/2023 with a terminal diagnosis of memory deficit following cerebral infarction. During the home visit observation, the aide was observed shaving the patient. The hospice aide notes for visits dated 02/28/2024, 03/01/2024 and 03/04/2024 included documentation that the task “Facial Hair-Shave” was marked as completed. The aide care plan dated 12/26/2023 did not assigned the aide the task of shaving the patient. During an interview and joint record review on 03/06/2024, the Director of Nursing and the Director of Quality confirmed foley tasks had not been removed from Clinical Record 1 and the aide continued marking them as completed. The aide was shaving the patient in Clinical Record 2 without the task being assigned on the aide care plan.”

“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 1 of 13 (8%) clinical records reviewed with aide services provided, the agency did not ensure the hospice aide reported changes in the patient’s condition/needs to the Registered Nurse (RN). Clinical Record 13: The patient elected the hospice benefit on 02/03/2023 with a terminal diagnosis of malignant neoplasm of unspecified part of bronchus or lung. The aide visit note dated 02/10/2023 included documentation that the patient declined the following tasks: shower, brush hair, shampoo, nails, deodorant, and peri care. The clinical record contained no documented evidence that the RN was notified that the patient had declined tasks. During an interview and joint record review on 03/06/2024, the Director of Nursing confirmed aide notification to the RN was not documented in the clinical record.”

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. This standard was not met as evidenced by document review, personnel record review, and interview. In 5 of 9 (56%) personnel records reviewed, the agency did not ensure documentation that employees completed initial orientation. Agency policy I-027 Orientation, revised February 2024, stated in part, “A personnel orientation checklist will be completed for all new personnel. New personnel will sign and date when completed. Supervisor will then sign and date when completed.” Personnel Record 3: Registered Nurse/Director of Nursing date of hire 07/20/2022. Personnel record review revealed no documented evidence of orientation for the role of Director of Nursing. Personnel Record 4: Registered Nurse date of hire 01/21/2024. Personnel record review revealed no documented evidence of a signed and dated orientation checklist. Personnel Record 5: Medical Social Worker date of hire 09/11/2023. Personnel record review revealed no documented evidence of a signed and dated orientation checklist. Personnel Record 7: Hospice Aide date of hire 11/8/2023. Personnel record review revealed no documented evidence of a signed and dated orientation checklist. Personnel Record 8: Volunteer Coordinator date of hire 10/18/2022. Personnel record review revealed no documented evidence of a signed and dated orientation checklist. During an interview and joint record review on 03/07/2027, the Administrator confirmed the personnel files did not contain the signed orientation checklist.”

“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 6 of 9 (67%) personnel records reviewed, the agency did not ensure skills and competencies were assessed for individuals providing care as required by agency policy. Agency policy 3-001 Competency, revised February 2024, stated in part, “Core competencies, the essential skills will be demonstrated upon hire and annually thereafter.” Personnel Record 2: Administrator/Medical Social Worker date of hire 10/04/2021. Personnel record review revealed no documented evidence of initial and annual competencies. Personnel Record 3: Registered Nurse date of hire 07/20/2022. Personnel record review revealed no documented evidence of annual competency assessment for 2023. Personnel Record 6: Spiritual Counselor/Bereavement Coordinator date of hire 03/04/2022. Personnel record review revealed no documented evidence of annual competency assessment for 2023. Personnel Record 7: Hospice Aide date of hire 11/08/2023. Personnel record review revealed no documented evidence of initial competency assessment. Personnel Record 8: Volunteer Coordinator date of hire 10/18/2022. Personnel record review revealed no documented evidence of initial and annual competencies. Personnel Record 9: Volunteer date of hire 08/08/2022. Personnel record review revealed no documented evidence of annual competency assessment for 2023. During an interview and joint record review on 03/07/2024, the Administrator confirmed the staff had not completed the initial or annual competency assessments as outlined in agency policy.”

“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, current subjective and objective medical findings. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the physician documented the patient’s current subjective and objective clinical findings when completing the certification of terminal illness. Clinical Record 6: The patient elected the hospice benefit on 08/17/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The certification of terminal illness signed by the physician on 08/17/2023 included documentation that stated, “Patient admitted onto routine hospice services due to worsening COPD with DOE [dyspnea on exertion]. Has O2 [oxygen]. Comorbidities include CVA [cerebral vascular accident] with left hemiparesis. Please see RN [Registered Nurse] history for further details.” The certification of terminal illness completed by the physician did not include the patient’s current subjective and objective clinical assessment findings. During an interview and joint record review on 03/06/2024, the Director of Nursing confirmed the certification of terminal illness did not contain all the required elements.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care or to the patient’s community attending physician upon hospice discharge includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. 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 discharge summary included a summary of the patient’s hospice stay, including treatment, symptoms, and pain management. Clinical Record 11: The patient elected the hospice benefit on 10/19/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. The patient was discharged for extended prognosis on 02/07/2024. The discharge summary completed by the Registered Nurse did not include a summary of the patient’s hospice stay, including treatment, symptoms, and pain management. Clinical Record 12: The patient elected the hospice benefit on 08/18/2023 with a terminal diagnosis of malignant neoplasm of the pancreas. The patient revoked hospice services on 08/23/2023. The discharge summary did not include a summary of the patient’s hospice stay, including treatment, symptoms, and pain management. During an interview and joint record review on 03/07/2024, the Administrator confirmed the discharge summaries did not include a summary of the patients’ hospice stay.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by document review, personnel record review, and interview. In 3 of 9 (33%) personnel records reviewed, the agency did not ensure the criminal background check was completed as required by agency policy. Agency policy I-005, revised April 2020, stated in part “A criminal background check will be obtained for all positions as required by law and regulations.” Personnel Record 5: Medical Social Worker date of hire 09/11/2023. Personnel record review revealed no documented evidence that a criminal background check was completed for the employee. Personnel Record 7: Hospice Aide date of hire 11/8/2023. Personnel record review revealed no documented evidence that a criminal background check was completed for the employee. Personnel Record 8: Volunteer Coordinator date of hire 10/18/2022. Personnel record review revealed no documented evidence that a criminal background check was completed for the employee. During an interview and joint record review on 03/07/2024, the Administrator confirmed background checks were not included in the personnel files for personnel records 5, 7, and 8.”