Sutter Care at Home

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] 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 10 of 19 (53%) clinical records reviewed, the agency did not ensure that the plan of care (POC) identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice care on 12/12/2023 and resided in a Skilled Nursing Facility (SNF). The physician’s Certificate of Terminal Illness (CTI) dated 12/12/2023 documented that the patient had: “Episodes of anxiety, more prominent skeletal features, eating 50% of her meals, previously 100%.” The POC dated 04/10/2023 did not include documentation of a goal(s) and intervention(s) for anxiety and nutrition. The CTI dated 02/28/2024 documented that the patient was incontinent of the bladder and bowel. The POC dated 04/10/2023 did not include documentation of a goal(s) and intervention(s) for bladder and bowel incontinence. Clinical Record 2: The patient elected hospice care on 03/29/2024. The CTI dated 03/29/2024 documented that the patient was incontinent of the bladder and experienced increasing episodes of agitation. The POC dated 04/11/2024 did not include documentation of a goal(s) and intervention(s) for bladder incontinence and agitation. Clinical Record 3: The patient elected hospice care on 02/23/2024. The initial nursing assessment dated 02/23/2024 documented that the patient was incontinent of the bladder. The POC dated 04/11/2024 did not include documentation of a goal(s) and intervention(s) for bladder incontinence. Clinical Record 4: The patient elected hospice care on 02/12/2024. The initial nursing assessment dated 02/12/2024 documented that the patient was incontinent of the bladder. The POC dated 04/11/2024 did not include documentation of a goal(s) and intervention(s) for bladder incontinence. Clinical Record 5: The patient elected hospice care on 05/10/2023. On 05/10/2023, the physician ordered: “Oxygen 2 liters per minute via nasal cannula, as needed (prn) and may be increase up to 5 liters per minute for shortness of breath (SOB).” The POC dated 05/10/2023 had a goal for respiratory. The SOB intervention documented, “Instruct on reason for oxygen and liter flow per physician order.” The POC intervention for shortness of breath did not include documentation of specific instructions from the physician’s order for as-needed oxygen. On 10/17/2023, the physician ordered, “Skilled nurse or caregiver to provide wound care using clean technique 3 times per week and prn for soilage or loss of integrity; location - left upper back; and wound type - open wound from growth. Clean wound with mild soap and water or normal saline or wound cleanser - Apply/pack triple antibiotic topically to wound bed, and cover with dry foam dressing.” The POC dated 05/10/2023 documented a goal for skin integrity. The wound intervention documented, “Provide wound care per physician order.” The wound intervention did not include documentation of the specifics of the wound care ordered. Clinical Record 6: The patient elected hospice care on 05/29/2023. On 03/25/2024, the physician ordered, “Skilled nurse or caregiver to provide wound care using clean technique 2 times per week and prn for soilage or loss of integrity location; location - sacrum; and wound type - unstageable pressure ulcer. Clean wound with mild soap and water or normal saline or wound cleanser; protect periwound with sureprep and apply medihoney to wound bed, and cover with foam dressing.” The POC dated 03/25/2024 documented a goal for skin integrity. The wound intervention documented, “Provide wound care per physician order.” The wound intervention did not include documentation of the specifics of the wound care ordered. Clinical Record 11: The patient elected hospice care on 02/22/2023. On 08/29/2023, the physician ordered, “Insert 18 French Foley catheter with 10 milliliter (ml) balloon; change as needed if detached or leaking. May perform irrigation with 60 ml normal saline solution for foley catheter maintenance.” The POC dated 09/30/2023 documented a goal and intervention for urinary catheter and catheter irrigation. The intervention documented did not include the specifics of the catheter and irrigation care ordered. Clinical Record 12: The patient elected hospice care on 10/24/2023. The CTI dated 10/24/2023 documented, “The patient was on a pureed diet with a poor appetite and very cachectic.” The POC dated 10/24/2023 did not include documentation of a goal(s) and intervention(s) for nutrition. Clinical Record 13: The patient elected hospice care on 01/09/2023. On 07/28/2023, the physician ordered: “A volunteer 1-2 times per month for companionship.” The POC dated 07/29/2023 did not include documentation of a goal(s) and intervention(s) for the volunteer services. Clinical Record 19: The patient elected hospice care on 02/22/2024. On 02/23/2024, the physician ordered: “Skilled nurse or caregiver to provide wound care using clean technique 2 times per week and prn for soilage or loss of integrity; location - coccyx; and wound type - Stage II pressure ulcer. Clean wound with wound cleanser, apply medihoney to wound bed, and secure with foam dressing.” The POC dated 02/27/2024 documented a goal for skin integrity. The POC did not include documentation of an intervention for wound care with the specifics of the wound care. During an interview on 04/18/2024, the Administrator, Director of Patient Care Services, Clinical Effectiveness Consultant, Regional Director of Hospice Operations, Manager of Quality and Safety, Executive Director of Home Health and Hospice, and the Chief Medical Officer confirmed that the POC did not include intervention specifics based on problems identified in the initial and updated comprehensive assessments.”

“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: related diagnosis(es), if any. This standard was not met as evidenced by clinical record review and interview. In 10 of 19 (53%) clinical records reviewed, the hospice did not ensure that the Certificate of Terminal Illness (CTI) included the consideration of the patient’s related diagnosis. Clinical Record 1: The patient elected hospice care on 12/12/2023 and resided in a Skilled Nursing Facility (SNF). The “Health and Physical” (H & P) received from the SNF on 12/12/2023 documented the patient’s comorbidities: cellulitis, dysphagia, protein-calorie malnutrition, gastroesophageal reflux disease (GERD), and anemia. The initial CTI dated 12/12/2023 did not document the patient’s related diagnoses. Clinical Record 2: The patient elected hospice care on 03/29/2024. The H&P received from the discharging hospital’s emergency department on 03/29/2024 documented the patient’s comorbidities: hypertension (HTN), cardiac pacemaker, atherosclerosis of aorta, and history of transient ischemic attack. The initial CTI dated 03/29/2024 did not document the patient’s related diagnoses. Clinical Record 5: The patient elected hospice care on 05/10/2023. The H & P received from the hospitalist at the discharging hospital on 05/07/2023 documented the patient’s comorbidities: cerebrovascular vascular accident (CVA), diastolic congestive heart failure (CHF), diabetes type II, HTN, mild to moderate dementia, and alcohol abuse. The initial CTI dated 05/10/2023 did not document the patient’s related diagnoses. Clinical Record 11: The patient elected hospice care on 02/22/2023. The H & P received from the hospitalist at the discharging hospital on 02/22/2023 documented the patient’s comorbidities: vascular dementia, HTN, atrial fibrillation with anticoagulant use, and history of CVA. The initial CTI dated 02/22/2023 did not document the patient’s related diagnoses. Clinical Record 12: The patient elected hospice care on 10/24/2023. The H & P received from the Primary Care Physician (PCP) on 10/24/2023 documented the patient’s comorbidities: chronic kidney disease (CKD) stage 3, anemia, HTN, hypothyroidism, and memory loss. The initial CTI dated 10/24/2023 did not document the patient’s related diagnoses. Clinical Record 13: The patient elected hospice care on 01/09/2023. The H & P received from the PCP on 01/09/2023 documented the patient’s comorbidities: chronic combined systolic and diastolic heart failure and chronic respiratory failure with hypoxia, CKD stage 4. The initial CTI dated 01/09/2023 did not document the patient’s related diagnoses. Clinical Record 14: The patient elected hospice care on 04/02/2024. The H & P received from the hospitalist at the discharging hospital on 04/02/2024 documented the patient’s comorbidities: atrial fibrillation, long-term anticoagulation, HTN, and spinal stenosis. The initial CTI dated 04/02/2024 did not document the patient’s related diagnoses. Clinical Record 15: The patient elected hospice care on 01/04/2024. The H & P received from the hospitalist at the discharging hospital on 01/04/2024 documented the patient’s comorbidities: acute encephalopathy, leukocytosis, recent right hip fracture (managed nonoperatively), HTN, and anemia. The initial CTI dated 01/04/2024 did not document the patient’s related diagnoses. Clinical Record 18: The patient elected hospice care on 03/18/2024. The H & P received from the Hematology-Oncology Clinic on 03/18/2024 documented the patient’s comorbidities: HTN, nausea/vomiting, symptomatic bradycardia, status-post pacemaker implantation, and atrial fibrillation. The initial CTI dated 03/18/2024 did not document the patient’s related diagnoses. Clinical Record 19: The patient elected hospice care on 02/22/2024. The H & P received from the hospitalist at the discharging hospital on 02/22/2024 documented the patient’s comorbidities: acute metabolic encephalopathy, chronic leg contractures, hypokalemia, and leukocytosis. The initial CTI dated 02/22/2024 did not document the patient’s related diagnoses. During an interview on 04/18/2024, the Administrator, Director of Patient Care Services, Clinical Effectiveness Consultant, Regional Director of Hospice Operations, Manager of Quality and Safety, Executive Director of Home Health and Hospice, and Chief Medical Officer confirmed that the CTI did not include consideration of the patient’s related diagnoses.”