Bristol Hospice- Northern Los Angeles

“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; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. 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 and interview. In 3 of 19 (16%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient’s medications. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 03/22/2021 with the diagnoses of hemiplegia and hemiparesis following cerebral infarction. The patient resided in an Assisted Living Facility (ALF). During the home visit with the Spiritual Counselor [Personnel Record 6] on 10/29/2024, the hospice medication profile was compared to the ALF medication list. The hospice medication profile documented the following medications not listed on the ALF medication list: Albuterol-ipratropium 2.5 mg-0.5 mg/3ml solution by nebulizer every four hours as needed for congestion, effective 11/18/2022; Artificial tears 1-2 drops in each eye 4 times a day as needed for dry eyes, effective 09/15/2023; Imodium 2 mg capsule one (1) tablet every 6 hours as needed for diarrhea, effective 04/25/2023; Thick-It 1 packet orally continuous for dysphagia, effective 06/11/2024. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 01/26/2024 with a diagnosis of endometrial cancer. The patient resided in an ALF. During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 10/30/2024, the hospice medication profile was compared to the ALF medication list. The hospice medication profile documented the following medication not listed on the ALF medication list: Oxycodone 5 mg tablet every 6 hours as needed for moderate pain, effective 01/26/2024. Clinical Record 4/Home Visit 4: The patient elected the hospice benefit on 08/03/2023 with a diagnosis of atherosclerotic heart disease. The patient resided in a Skilled Nursing Facility (SNF). During the home visit with the Hospice Aide (HA) [Personnel Record 7] on 10/30/2024, the hospice medication profile was compared to the SNF medication list. The hospice medication profile documented the following medication not listed on the SNF medication list: Haldol 2mg/ml every 6 hours as needed for agitation, effective 05/16/2024. During an interview and a joint record review on 10/30/2024, the Regional Director of Operations the discrepancies were confirmed.”

“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 6 of 19 (32%) clinical records reviewed, the agency did not ensure the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 3: The patient elected the hospice benefit on 08/29/2023 with a diagnosis of Parkinson’s disease. The plan of care (POC) dated 08/29/2023 documented the patient’s goal, “Patient skin integrity will be maintained within limits of the disease process.” “Within limits of disease” is not a measurable outcome. Clinical Record 4: The patient elected the hospice benefit on 08/03/2023 with a diagnosis of atherosclerotic heart disease. The POC dated 09/26/2024 documented the patient’s goal, “Nutritional intake will be consistent with terminal phase of illness within the certification period.” “Nutritional intake consistent with the terminal phase of terminal illness” was not a goal with a measurable outcome. Clinical Record 6: The patient elected the hospice benefit on 08/21/2024 with a diagnosis of Alzheimer’s disease. The plan of care dated 08/21/2024 documented the patient intervention: “The patient will experience less pain as evidenced by improved life enjoyment.” “Less pain” was not a measurable outcome. Clinical Record 10: The patient elected the hospice benefit on 06/15/2024 with a diagnosis of senile degeneration of the brain. The POC dated 09/09/2024 documented the patient intervention: “Patient will maintain bowel function within limits of disease for optimal comfort as evidenced by patient weekly report of bowel movements.” “Optimal comfort” would need to be clarified to be a measurable outcome. Clinical Record 13: The patient elected the hospice benefit on 09/26/2024 with a diagnosis of malignant neoplasm of the lung. The POC dated 09/26/2024 documented the patient intervention: “Position patient in optimal position to decrease work of breathing.” “Optimal position” would need to be clarified to be a measurable outcome. Clinical Record 14: The patient elected the hospice benefit on 05/31/2024 with a diagnosis of malignant neoplasm of the colon. The POC dated 05/31/2024 documented the patient intervention “Patient will have optimal skin care.” “Optimal skin care” would need to be clarified to be a measurable outcome. During an interview and a joint record review on 10/30/2024, the Director of Patient Care agreed that words like “optimal” were not measurable without quantifiers.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) provided services as ordered by the Interdisciplinary Group (IDG). Clinical Record 10: The patient elected hospice care on 06/15/2024 with a diagnosis of senile degeneration of the brain. The plan of care ordered HA services two (2) times per week. The HA care plan dated 06/15/2024 assigned the HA the relevant tasks: shampoo, toileting, and showering every visit. A clinical record review revealed no aide visit notes documented from 10/03/2024 to 10/25/2024. During an interview and a joint record review on 10/30/2024, the Director of Patient Care Services confirmed the finding and indicated the aide was on “vacation from 10/03/2024 to 10/25/2024.””

“It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by observation, clinical record review, and interview. In 1 of 1 (100%) home visit with a Hospice Aide (HA), the agency did not ensure that the Hospice Aide provided services included in the plan of care. Home Visit 4/Clinical Record 4: The patient elected hospice care on 08/03/2023. During the home visit with the Hospice Aide [Personnel Record 7] on 10/30/2024, the HA shaved the patient. The HA care plan dated 09/26/2024 documented the visit frequency of two (2) times per week and assigned the HA the relevant tasks of bed bath, shampoo, peri care, and applying lotion every visit. The HA care plan did not assign the HA task of shaving the patient. During an interview and a joint record review on 10/30/2024, the Regional Director of Operations confirmed the finding, stating that the task of shaving “might have been left off the more recent aide care plans.””

“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 3 of 18 (17%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure the HA reported changes to a Registered Nurse (RN). Clinical Record 5: The patient elected hospice care on 02/12/2024 with a diagnosis of Alzheimer’s disease. The plan of care ordered HA services two (2) times per week. The HA care plan assigned the HA the relevant tasks: shower, oral care, incontinent care, and applying lotion every visit. The HA visit note dated 05/27/2024 documented “all tasks refused,” the HA visit note dated 09/05/2024 documented “refused visit completely,” and the HA visit note dated 10/08/2024 was a narrative note with no documentation of task(s) being completed. A clinical record review revealed no documentation that the HA notified the RN of the changes to the care plan and the task(s) not completed. Clinical Record 10: The patient elected hospice care on 06/15/2024 with a diagnosis of senile degeneration of the brain. The plan of care ordered HA services two (2) times per week. The HA care plan dated 06/15/2024 assigned the HA the relevant tasks: shampoo, toileting, and showering every visit. The HA visit notes dated 10/29/2024 and 10/31/2024 documented shampoo, toileting, and showering as “refused.” A clinical record review revealed no documentation that the HA notified the RN of the changes to the care plan and the task(s) not completed. Clinical Record 17: The patient elected hospice care on 04/17/2023 with a diagnosis of Alzheimer’s disease. The plan of care ordered HA services three (3) times per week. The HA care plan dated 04/17/2023 assigned the HA the relevant tasks: oral care, bath, and shampoo every visit. The HA visit note dated 09/13/2023 documented “refused shampoo,” the HA visit note dated 08/30/2023 documented “refused bath,” and the HA visit note dated 08/23/2023 documented “refused all tasks.” A clinical record review revealed no documentation that the HA notified the RN of the changes to the care plan and the task(s) not completed. During an interview and a joint record review on 10/30/2024, the Regional Director of Operations confirmed the findings and stated that when the hospice aide missed a visit, the electronic medical record (EMR) sent notifications to a general mailbox called “Quick Notes.” Quick Notes went to all members of the team but were not specifically acknowledged nor saved to a specific chart. Per the interview, it did not appear the Registered Nurse addressed the “Quick Note” specifically per patient.”

“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 1 of 11 (9%) clinical records reviewed of patients 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 hospice care on 03/22/2021 with the diagnoses of hemiplegia and hemiparesis following cerebral infarction. A clinical record review revealed that the twentieth (20) benefit period started on 05/19/2024. The recertification of terminal illness was signed by the hospice medical director on 05/27/2024, eight (8) days after the start of the benefit period. The verbal order was signed on 05/03/2024, sixteen (16) days before the start of the benefit period. An interview with the Director of Patient Care Services confirmed the recertification of terminal illness was not signed within the required time frame.”

“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; 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 standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients with a live discharge, the agency did not ensure the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Clinical Record 16: The patient elected the hospice benefit on 09/05/2024 with a diagnosis of end-stage cirrhosis. The patient was noted to have “multiple masses suspicious for cancer upon admission.” On 09/12/2024, the patient elected to revoke the hospice benefit. The discharge summary listed the medications and the diagnosis. The narrative written by the nurse stated the following: “Patient’s daughter informed hospice she is revoking services immediately. MD (medical director) notified.” The discharge summary did not include a summary of the patient’s hospice stay, treatments, pain management, plan of care, or other information relevant to post-discharge continuity of care. During an interview and a joint record review on 10/31/2024, the Regional Director of Operations confirmed the discharge summary did not include a summary of the patient’s hospice stay, including treatments, symptoms, and pain management.”