VNA Health

“Observed in Individual Tracer. the Hospice did not notify patients in writing of covered services. The form titled - ‘Medicare Hospice Notice of Election’ reflected under assignment of benefits section- I will receive the hospice services set forth in my care plan, which may include- then it lists all of the hospice services. The section titled -financial responsibility, indicated that patients wound be financially liable for uncovered services. RR#1-RR#23 were not notified in writing upon admission to the hospice of what services were covered by the hospice. This observation was discussed with the director.”

“Observed in Record Review. In 23 of 23 patient records reviewed, the Hospice did not notify patients in writing of covered services. The form titled - ‘Medicare Hospice Notice of Election’ reflected under assignment of benefits section- I will receive the hospice services set forth in my care plan, which may include- then it lists all of the hospice services. The section titled -financial responsibility of this form indicated that patients wound be financially liable for uncovered services. RR#1-RR#23 were not notified in writing upon admission to the hospice of what services wound be covered by the hospice. This observation was discussed with the director.”

“Observed in Individual Tracer. In 23 of 23 patient records reviewed, the Hospice did not have a process in place to routinely evaluate the need for volunteer services. RR#1-RR#3 did not have documentation in the record of the need for volunteer service. This observation was based on review of the social work, chaplain, and RN initial assessments as well as a review of the initial IDT(s). Per the director, volunteer services were placed as needed however there was no process in place to routinely document the assessment of the need for volunteer services for each admission.”

“Observed in Individual Tracer. In 2 of 6 home visits conducted, the RN did not reassess compliance with medication. Based on the review of the medication administration record (MAR) of RR#3, the patient was placed on an antibiotic which was not included on the Hospice medication record. Similarly, the MAR of RR#2 reflected that the patient was given an eye drop utilized to treat glaucoma. This eyedrop was not listed on the Hospice medication profile. These medications hav been given to the patient over the course of weeks and the hospice RN visited these patients at least weekly. This observation was discussed with the director.”

“Observed in Individual Tracer. In 6 of 23 patient records reviewed, the comprehensive assessment was not updated by all members of the core group, specifically the MD. Based on discussions with the director and review of the records, the physician was present during the IDT(s) however there was no clinical summary completed by the physician. There was no summary statement and or documentation of collaboration that was patient specific for RR#1- RR#3. Based on discussions with the director, although present for the IDT(s), the MD did not typically write a narrative as part of the IDT update. RR#4 developed a wound after admission to the hospice and the IDT immediately following the implementation of wound care did not reflect the change in condition and or the effectiveness of treatment. Additionally, the contents of the subsequent IDT (for nursing) was exactly the same as the previous and also did not include an update on the status of the wound. Both RR#9 and RR#11 had volunteer services and none of the IDT’s included updates to the assessments from this discipline. This observation was discussed with the director.”

“Observed in Individual Tracer. In 4 of 23 patient records reviewed, the comprehensive care plan(s) did not have measurable goals. The care plan for RR#1 did not reflect any target dates to achieve goals listed for mobility and wound care. Additionally, while pain was identified as an issue, there was no associated goal on the care plan. Similarly, based on the assessment, RR#2 was a fall risk, had a wound, and mobility and cardiac issues. All of the goals associated with these problems had the same target dates , which was xx/xx/xxxxx or by the end of the certification period. RR#3 had dysphagia, and was a fall risk. The comprehensive care plan for RR#3 did not include goals related to aspiration or falls. Additionally, the goal that addressed medication education did not have a target date. RR#13 had a foley and the comprehensive care plan did not include any goals related to the foley. This observation was discussed with the director.”

“Observed in Individual Tracer. In 4 of 5 patient records reviewed, that had hospice aides, the aide care plans did not comprehensively include required precautions based on the nursing assessment.. RR#1 was at risk for falls and had a wound and the aide care plan did not include instructions/precautions related to these issues. RR#2 had a Hoyer lift and the aide care plan did not include instructions related to the use of this device. Based on the assessment RR#4 was on aspiration precautions and had a wound. Neither wound or aspiration precautions were included on the hospice aide care plan. RR#7 was oxygen dependent and the HHA care plan did not reflect oxygen precautions. RR#13 had a foley catheter and was oxygen dependent and the hospice aide care plan did not include any precautions related to these interventions. This observation was discussed with the director.”

“Observed in Individual Tracer. In 2 of 2 patient records reviewed, that were transferred to another Medicare/Medicaid facility the hospice did not send summary to the next provider. RR#17 was transferred to another hospice and there was no documentation that the discharge summary was sent to the receiving Hospice. RR#18 was transferred to the hospital and there was no documentation that the transfer/discharge summary was sent to the receiving hospital. Per the director, documentation is sent to the receiving facility as it is requested. There was no process in place at the time of the survey to routinely send the summary form to the receiving facility.”

“Observed in Tracer Activities. During the Inpatient Unit Medication Tracer the surveyor was accompanied by a hospice staff registered nurse. During the tracer the surveyor and nurse noted that within the locked storage unit designated for injectable controlled substances ready for use, there was an opened (plastic lid removed) vial of hydromorphone 2mg/ml injection. The vial still contained a small amount of clear liquid and was in a clear plastic bag labeled with a patient name. The staff nurse was able to check medication administration records and determined that a 0.5 mg/0.25 ml dose of hydromorphone had been withdrawn from the vial and administered on October 11th (fourteen days prior to the Inpatient Medication Tracer). In discussion with the IPU Director it was confirmed that proper wasting and disposal of the hydromorphone had not occurred according to policy (immediately after administration and involving two staff members). The remaining contents of the vial were wasted properly while the surveyor was present. 
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