Mercy Hospice

“Based on interview, and record review, this agency failed to ensure one of 19 sampled patients (Patient 4), was assessed by a registered nurse within 48-hours of their referral for hospice (end of life care) services, and did not notify the physician when there was a delayed start of care (admission to agency). This failure could result in changes to care without physician knowledge or approval, and a lack of adequate physician oversight leading to negative clinical outcomes. Findings: The agency’s policy titled, “Admission Criteria Process, and Initial Hospice Assessment,” revised 8/22/23, was reviewed and indicated, that the Hospice Registered Nurse (RN) must complete an initial assessment within 48-hours of their referral to Hospice Care, unless the physician, patient, or representative requests that the initial assessment is completed in less than 48-hours. During a review, of Patient 4s clinical record, Patient 4 was admitted to the agency on 4/2/23, for hospice care, with diagnoses that included Alzheimers disease (a type of dementia, a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out simple tasks), high blood pressure, dysphagia (difficulty swallowing), and cardiac disease. During a review, of Patient 4s visit documentation, it was noted that Patient 4 was referred to services on 3/29/23, but the start of care date was not until 4/2/23 (4-days later). There was no documentation, that the physician had been notified of this delay in the start of care. During a concurrent record review, and interview, on 2/6/23 at 1:04 pm, the Quality Coordinator confirmed there was no documentation of a reason for a delay of the start of care, and no update sent to the physician to notify them that services were delayed. During an interview, on 2/6/23 at 2:30 pm, the Administrator confirmed, that it was the expectation and policy of this agency, as well as a Federal regulations, to open all patients to service within 48-hours of their referral date, and to notify the physician if there was a delay.”

“Based on interview and record review the facility failed to include outcome measures (the amount of time a patient goal would be completed) on a plan of care (POC, a detailed plan of physician orders that described care provided to patients) for three out of 19 sampled patients (Patient 1, 2, and 6) when patient specific goals did not include a measurable timeframe. This failure had the potential for negative clinical outcomes to occur and goals of patient care to go unmet. Findings: A review of Patient 6s, “;Hospice Certification and Plan of Care (physician orders)” dated 5/7/23, indicated, that Patient 4 was admitted to the agency for hospice with diagnoses that included Alzheimers disease (a type of dementia, a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out simple tasks), acquired absence of digestive tract (removal of a part of the intestines or colon that digest and assist with absorption of nutrients), moderate protein-calorie malnutrition (poor nutrition), and history of malignant neoplasm (cancerous tumor) of breast. During a concurrent interview, and record review, on 2/8/23 at 3:45 pm, the Administrator (Admin) confirmed, that Patient 4s “;Hospice Certification and Plan of Care,” dated 5/7/23, did not include a measurable goals such as a date for the section titled, “;Goals,” that indicated “;Patient/caregiver will verbalize and demonstrate understanding of how to use oxygen safely and effectively throughout the episode.” The Admin confirmed, that a date should be added to ensure safety while oxygen is stored and used in the home, and this specific goal for oxygen use should be a priority for education for the family. The Admin confirmed, that the goal for oxygen used for Patient 4 did not list a measurable outcome needed. During an interview, on 2/8/23 at 4:15 pm, the Quality Coordinator (QC) confirmed, that the staff is working on measurable goals with dates, not listing goals as end of the episode. QA also stated, “;This is part of my job, making sure the nurses understand to be more specific on the Plan of Care for all goals, and interventions.” Findings: A review, of Patient 2s, “;Hospice Certification and Plan of Care,” dated 11/9/23, indicated, that Patient 2 was admitted to the agency with the diagnosis of Liver Cell Carcinoma (cancer of the liver; the liver was a large organ in the body that cleaned the blood). During a concurrent interview, and record review, on 2/7/24 at 2:55 pm, with the agencys Admin, Patient 2s “;Hospice Certification and Plan of Care,” dated 11/9/23 was reviewed. Admin stated, the “;Hospice Certification and Plan of Care” with the section titled “;Goals,” indicated, “;Hospice comfort medication will be provided to the patient.” Admin confirmed the goal did not include a measurable outcome that indicated when Patient 2 would have Hospice comfort medication (medication used to treat end of life symptoms such as pain, anxiety, and shortness of breath) available in the home for use. The Admin stated, the “;Hospice Certification and Plan of Care,” with the section titled “;Goals,” indicated, Patient 2s caregiver would “;...verbalize understanding of signs and symptoms of imminent death, plan for symptom management and what to do at time of death.” Admin stated, the goal did not include a measurable outcome that indicated when Patient 2s caregiver would be able to verbalize signs of Patient 2s imminent (about to happen) death, understanding of how to control Patient 2s symptoms, or what to do when Patient 2 passes away. Admin stated, the “;Hospice Certification and Plan of Care” with the section titled “;Goals,” indicated, “;A Medical Social Worker plan of care would be established.” Admin confirmed there was no measurable outcome that indicated when the Medical Social Worker POC would be established and stated there should be. A review of Patient 1s, “;Hospice Certification and Plan of Care,” dated 2/19/23, indicated, that Patient 1 was admitted to the agency with diagnoses that included Parkinsons Disease (a progressive disorder of the nerves that causes tremors,) dementia, and depression. During a concurrent interview, and record review, conducted on 2/8/24 at 3: 58 pm, with Admin, Patient 1s “;Hospice Certification and Plan of Care,” was reviewed. The section titled “;Goals,” indicated, that Hospice comfort medications will be provided to the patient. Admin confirmed, that this goal did not include a measurable outcome, and needed a more specific time frame.”

“Based on interview, and record review, the facility failed to notify the physician of a visit frequency (number of ordered home visits) change for five out of 19 sampled patients (Patients 3, 8, 9, 12, and 18), when physician ordered home visits were missed. This failure had the potential for patient needs to not be met, which could lead to negative clinical outcomes. Findings: A review, of the agencys undated document titled, “;Missed Visit Process in HCHB-Home Health/Hospice,” indicated, that missed visit notes are faxed to the physician. A review. of Patient 3s “;Hospice Certification and Plan of Care,” dated 1/25/23, indicated, that Patient 3 was admitted to the agency with the diagnosis of hypertensive heart (heart problems that occurred from high blood pressure) and chronic kidney disease (kidneys cannot filter waste from the blood) with heart failure (inability to pump blood from the heart throughout the body). During a concurrent interview, and record review, on 2/7/24 at 3:24 pm, with the agencys Administrator (Admin), Patient 3s “;Missed Visit Notification,” dated 2/16/23 was reviewed. Admin stated, the “;Missed Visit Notification” indicated, the Medical Social Worker had a physician ordered, scheduled visit with Patient 3 on 2/16/23, and the visit was missed due to patient request. Admin stated, when the “;Missed Visit Notification,” reached the medical records department, medical records personnel would fax the “;Missed Visit Notification,” to the patients physician and enter a note that indicated, the physician had been notified. Admin confirmed the “;Missed Visit Notification,” did not include a note that indicated, Patient 3s physician had been notified of the missed visit, and should have. A review, of Patient 12s “;Hospice Certification and Plan of Care,” dated 11/29/23, indicated, Patient 12 was admitted with the diagnosis of acute myeloblastic leukemia (cancer in the blood and bone marrow (spongy tissue inside the middle of the bone). During a concurrent interview, and record review, on 2/7/24 at 2:55 pm, with Admin, Patient 12s “;Missed Visit Notification,” dated 1/25/24, was reviewed. Admin stated the “;Missed Visit Notification,” indicated, the Licensed Nurse (LN) missed a routine nursing visit when LN called to schedule a visit time and Patient 12 did not return the call. Admin confirmed, that the “;Missed Visit Notification,” did not include a note that indicated, Patient 12s physician had been notified of the missed visit and should have. A review, of Patient 8s “;Hospice Certification and Plan of Care,” dated 12/16/23, indicated Patient 8 was admitted to the agency with diagnoses that included dementia and dysphagia (difficulty swallowing.) The Plan of Care indicated Patient 8 would be receiving the services of a home health aid twice a week for 8 weeks, starting 12/17/23. During an interview, and concurrent record review, with Quality Coordinator (QC) on 2/9/24 at 11:55 am, she reviewed the Plan of Care for scheduled visits and the facility calendar of scheduled and completed visits. QC confirmed, that on the week beginning 1/21/24 and ending 1/27/24, that only one home health aid visit occurred, but two should have. QC confirmed there was no documentation to indicate, that Patient 8 had refused the visit, nor that it had been rescheduled within the expected time frame. There was no documentation that the physician had been notified to modify ordered visits. A review, of Patient 9s “;Hospice Certification and Plan of Care,” dated 1/11/24, indicated, that Patient 9 was admitted to the agency with diagnoses that included cirrhosis of the liver (damage that leads to organ failure) and hepatic encephalopathy (loss of brain function due to liver damage.) The Plan of Care indicated Patient 9 would be receiving the services of a chaplain once in the first month. During an interview, and concurrent record review, with QC on 2/9/24 at 11:55 am, she reviewed the Plan of Care for scheduled visits and the facility calendar of scheduled and completed visits for Patient 9. QC confirmed, that no chaplain visit had occurred during the reviewed dated on 1/11/24 – 2/8/24. The QC further stated that the agency expectation is for the visit to occur within five days of the order. QC confirmed there was no documentation to indicate Patient 9 had refused the visit, nor that it had been rescheduled within the expected time frame. There was no documentation that the physician had been notified to modify ordered visits. A review, of Patient 18s “;Hospice Certification and Plan of Care,” dated 1/20/24, indicated Patient 18 was admitted to the agency with diagnoses that included cancer of the pancreas and high blood pressure. The Plan of Care indicated that Patient 18 would be receiving the services of a chaplain once within the first month. During an interview, and concurrent record review, with QC on 2/9/24 at 10:55 am, she reviewed the Plan of Care for scheduled visits and the facility calendar of scheduled and completed visits for Patient 18. QC confirmed, that Patient 18s Plan of Care indicated the patient should have received a visit from the agency chaplain and that the facility calendar for scheduled and completed visits for Patient 18 did not indicate that a chaplain visit had occurred. QC found documentation in a nurses note, dated 1/25/24 that indicated the family declined a chaplain visit, and requested it to be scheduled for “next week” (1/28/24 - 2/3/24.) QC confirmed there was no documentation to indicate Patient 18 had refused a visit after that, and that no chaplain visit had occurred. QC further confirmed there was no documentation that the physician had been notified to modify ordered visits.”