Green Valley Hospice, Inc.

“It is required that a 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 clinical record review, interviews, and review of findings with the Director of Patient Care Services, which revealed the following issues regarding Hospice Aide services: Failure to ensure the hospice Registered Nurse provided the aide with patient specific written care instructions [HCDT.15.I/L625]; Failure to ensure the hospice aide provided services included in the plan of care [HCDT.16.I/L626]; Failure to ensure the hospice aide documented provision of services in accordance with state law and regulation [HCDT.16.I/L626]; Failure to ensure the aide reported changes in the patient’s needs to the Registered Nurse [HCDT.18.I/L628]; and Failure to ensure the Registered Nurse made on-site aide supervisory visits no less frequently than every 14 days [HSRM.25.I/L629]. 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 home health care service from the agency.”

“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 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, observation, and interview. In 1 of 4 (25%) home visit observations, the agency did not ensure the drug profile was updated at the time of the comprehensive assessment. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 04/03/2023 with a terminal diagnosis of congestive heart failure. During the home visit observation with the Registered Nurse (RN), a medication review was completed with the family and the RN. Atropine 1% drops were in the patient’s comfort kit but had not been listed on drug profile. Pradaxa was ordered on the drug profile to take 2 caps once a day, and the prescription bottle ordered 1 cap twice a day. Pradaxa was entered on the medication profile during admission on 04/03/2023 and the family confirmed it had not changed and the bottle was correct. During an interview and joint record review with the Director of Patient Care Services on 3/28/2024, it was confirmed the drug profile had not been reconciled correctly.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plans as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure the plan of care was updated as frequently as the patient’s condition required. Clinical Record 7: The patient elected the hospice benefit on 12/13/2023 with a terminal diagnosis of Alzheimer’s disease. The Social Worker documented on the 02/27/2024 visit note, “MSW [Medical Social Worker] spoke with caregiver who requested respite care as soon as possible. Family also looking for long term placement options due to decline.” The patient was transferred to respite on 02/27/2024. The plan of care was not updated for the respite stay. During an interview and joint record review with the Director of Patient Care Services on 3/28/2024, it was confirmed the plan of care had not been updated as the patient’s needs changed.”

“It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by clinical record review and interview. In 9 of 19 (47%) clinical records reviewed, the agency did not ensure spiritual counseling services were provided as ordered on the plan of care. Clinical Record 1: The patient elected the hospice benefit on 07/07/2023 with a terminal diagnosis of protein-calorie malnutrition. The plan of care included an order for the Spiritual Counselor (SC) to provide visits one time per month. Clinical record review revealed the SC provided visits to the patient on 09/14/2023 and 12/01/2023. The clinical record contained no documented evidence that the SC provided visits to the patient in October and November 2023, and no SC visits have been documented since the 12/01/2023 visit. The clinical record contained no documentation of the reason for the missed visits. Clinical Record 2: The patient elected the hospice benefit on 04/15/2022 with a terminal diagnosis of Alzheimer’s disease. The plan of care dated 10/12/2022 included an order for the SC to provide visits one time per month to provide prayer, readings, sacramental support. Clinical record review revealed the last visit provided by the SC was dated 12/29/2023. The clinical record contained no documented evidence that the SC provided visits to the patient in January and February 2024 and the clinical record contained no documentation of the reason for the missed visits. Clinical Record 3: The patient elected the hospice benefit on 04/03/2023 with a terminal diagnosis of congestive heart failure. The plan of care dated 04/03/2023 included an order for the SC to provide visits one time per month to facilitate the patient’s or caregiver’s spiritual needs based on their current faith and beliefs and assess for spiritual distress and need for spiritual support. Clinical record review revealed the last visit provided by the SC was dated 05/04/2023. The clinical record contained no documented evidence that the SC provided visits to the patient after 05/04/2023 and no documentation of the reason for the missed visits. Clinical Record 5: The patient elected the hospice benefit on 11/27/2023 with a terminal diagnosis of Alzheimer’s disease. The plan of care included an order for the SC to provide visits one time per month. The clinical record contained no documented evidence that the SC provided visits to the patient and no documentation of the reason the visits were not provided. Clinical Record 6: The patient elected the hospice benefit on 10/16/2022 with a terminal diagnosis of malignant neoplasm of the breast. The plan of care included an order for the SC to provide visits one time per month. Clinical record review revealed the last SC visit was dated 01/31/2024. The clinical record contained no documented evidence that the SC provided visits to the patient after 01/31/2024 and no documentation of the reason for the missed visits. Clinical Record 10: The patient elected the hospice benefit on 06/01/2023 with a terminal diagnosis of neurocognitive disorder with Lewy bodies. The plan of care included an order for the SC to provide visits one time per month. Clinical record review revealed the SC provided a visit on 10/27/2023 but there was no documented evidence a SC visit was completed in November 2023. The next SC visit was dated 12/01/2024 but the clinical record contained no evidence that SC visits were provided in January and February 2024 and no documentation of the reason for the missed visits. Clinical Record 11: The patient elected the hospice benefit on 8/3/2023 with a terminal diagnosis of congestive heart failure. The plan of care included an order for the SC to provide visits one time per month. Clinical record review revealed the SC completed visits on 10/12/2023 and 12/06/2023. The clinical record contained no documented evidence that the SC provided visits, in November 2023, January 2024, and February 2024 and no documentation of the reason for the missed visits. Clinical Record 12: The patient elected the hospice benefit on 05/04/2023 with a terminal diagnosis of malignant neoplasm of bronchus or lung. The plan of care included an order for the SC to provide visits one time per month. Clinical record review revealed the last SC visit was dated 12/12/2023. The clinical record contained no documented evidence that the SC provided visits to the patient after 12/12/2023 and no documentation of the reason for the missed visits. Clinical Record 19: The patient elected the hospice benefit on 01/12/2024 with a terminal diagnosis of malignant neoplasm of the bladder. The plan of care included an order for the SC to provide visits one time per month. The clinical record contained no documented evidence that the SC provided visits to the patient and no documentation of the reason the visits were not provided. During an interview and joint record review with the Director of Patient Care Services (DPCS) on 03/28/2024, it was confirmed the plans of care had orders for monthly visit frequency for “most patients” and that orders to discontinue the visits had not been written for patients who had declined the spiritual counseling services. The DPCS also agreed the clinical records did not include reasons for the missed visits.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse 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 5 of 19 (26%) clinical records reviewed with aide services provided, the agency did not ensure the hospice Registered Nurse provided the aide with patient specific written care instructions. Clinical Record 2: The patient elected the hospice benefit on 04/15/2022 with a terminal diagnosis of Alzheimer’s disease. The plan of care dated 03/20/2024 included documentation that the patient had a Stage II pressure ulcer on bilateral buttocks. The hospice aide care plan dated 04/15/2022 assigned the aide the tasks of bathing the patient and assistance with dressing. The aide care plan did not include information on the patient’s stage II pressure ulcer and did not provide the aide with information on how to care for the wound dressing while bathing the patient and assisting with dressing and did not include directions on what to do if the wound dressing becomes soiled, wet or dislodged. Clinical Record 3: The patient elected the hospice benefit on 04/03/2023 with a terminal diagnosis of congestive heart failure. The nurse documented on the nursing assessment dated 02/09/2024 a “Stage II [wound] left buttocks cover with optifoam.” The nursing assessment dated 03/15/2024 included documentation of a “Left chest ulcerated lesion apply Medihoney to wound bed and cover with bordered gauze.” The hospice aide care plan was not updated to include the presence of the left buttocks and left chest wounds. The aide care plan did not provide the aide with information on how to care for the wound dressings while bathing the patient and did not include directions on what to do if the wound dressing becomes soiled, wet, or dislodged. Clinical Record 6: The patient elected the hospice benefit on 10/16/2022 with a terminal diagnosis of malignant neoplasm of the breast. The nursing assessment dated 03/24/2024 included documentation of a “wound right buttocks, cover with gauze.” The hospice aide care plan was not updated to include the presence of the right buttocks wound. The aide care plan did not provide the aide with information on how to care for the wound dressings while bathing the patient and did not include directions on what to do if the wound dressing becomes soiled, wet, or dislodged. Clinical Record 12: The patient elected the hospice benefit on 05/04/2023 with a terminal diagnosis of malignant neoplasm of bronchus or lung. The nursing assessment dated 05/05/2023 included documentation that the patient was on Oxygen at 2 LPM [liters per minute] continuously. The nurse documented on the nursing visit dated 7/20/2023 “skin biopsy to left nose and right elbow covered with bordered gauze.” The nursing assessment dated 02/06/2024 included documentation “right arm skin tear covered with bordered gauze.” The hospice aide care plan was not updated to include the patient’s use of Oxygen and the presence of the skin tear and biopsy site with border gauze covering. The aide care plan did not provide the aide with information on how to care for the wounds dressings while bathing the patient and did not include directions related to the patient’s Oxygen use, including if the patient could bathe with or without the Oxygen. The aide care plan dated 12/05/2023 assigned the aide the tasks of assessing skin integrity and overall condition of skin including s/s [signs and symptoms] of skin breakdown. Perform wound care/dressing change. Assess patient’s and caregivers’ current knowledge of wound care regimen. Assess patient’s risk for developing pressure ulcers. Assess for signs/symptoms of skin infection. Teach patient/caregiver regarding preventing pressure ulcers and skin breakdown. Assess for signs/symptoms of wound infections. The aide care plan included assessment and nursing treatments that should be ordered for the skilled nurse to complete. The agency did not ensure the aide care plan included tasks appropriate for the aide. Clinical Record 15: The patient elected the hospice benefit on 05/16/2023 with a terminal diagnosis of congestive heart failure. The nurse documented on the nursing assessment dated 06/08/2023 a “wound on left elbow, cleanse with wound cleanser and apply dry dressing. Wound on left knee, cleanse with wound cleanser and covered with bordered dressing.” The hospice aide care plan was not updated to include the presence of the left elbow and left knee wounds. The aide care plan did not provide the aide with information on how to care for the wound dressings while bathing the patient and did not include directions on what to do if the wound dressing becomes soiled, wet, or dislodged. During an interview and joint record review with the Director of Patient Care Services on 03/28/2024, it was confirmed that the aide care plans had not been updated and did not include patient specific care instructions to the aide.”

“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 and interview. In 2 of 19 (10%) 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 7: The patient elected the hospice benefit on 12/13/2023 with a terminal diagnosis of Alzheimer’s disease. The aide care plan dated 12/13/2023 assigned the aide the task of showering the patient. The aide documented on the aide visit note dated 12/29/2023 that a bed bath was provided and, on the aide visit note dated 02/27/2024 the aide noted a sponge bath was given instead of a shower. The aide did not provide a shower as assigned on the aide care plan. Clinical Record 19: The patient elected the hospice benefit on 01/12/2024 with a terminal diagnosis of malignant neoplasm of the bladder. The plan of care included an order for aide services twice a week for the week of 01/15/2024. Clinical record review revealed no aide visits were documented for the week of 01/15/2024. During an interview and joint record review with the Director of Patient Care Services on 3/28/2024, it was confirmed the aides had not been following the plan of care.”

“It is required that a hospice aide provides services permitted to be performed under state law and regulation. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the hospice aide documented provision of aide services in accordance with state law and regulation. Clinical Record 12: The patient elected the hospice benefit on 05/04/2023 with a terminal diagnosis of malignant neoplasm of bronchus or lung. The aide care plan dated 12/05/2023 assigned the aide the tasks of assessing skin integrity and overall condition of skin including s/s [signs and symptoms] of skin breakdown. Perform wound care/dressing change. Assess patient’s and caregivers’ current knowledge of wound care regimen. Assess patient’s risk for developing pressure ulcers. Assess for signs/symptoms of skin infection. Teach patient/caregiver regarding preventing pressure ulcers and skin breakdown. Assess for signs/symptoms of wound infections. The aide care plan included assessment and nursing treatments that should be ordered for the skilled nurse to complete. The agency did not ensure the aide care plan included tasks appropriate for the aide. Review of the clinical record indicated the hospice aide had been checking each of these tasks off every visit as being completed from December 2023 through the date of record review on 03/28/2024. These tasks of performing wound dressing change and teaching patient/caregiver regarding skin breakdown are not in the aide’s scope of service. During an interview and joint record review on 03/28/2024, the Director of Patient Care Services confirmed the hospice aide had been checking off the tasks as being completed and was unsure how the skilled nursing tasks were added to 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 3 of 19 (16%) clinical records reviewed with hospice aide services provided, the agency did not ensure the aide reported changes in the patient’s needs to the Registered Nurse (RN). Clinical Record 6: The patient elected the hospice benefit on 10/16/2022 with a terminal diagnosis of malignant neoplasm of the breast. The Hospice Aide documented on the 03/13/2023 aide visit note that all tasks were marked as not completed. The aide documented patient refused all baths, supply drop only. The clinical record contained no documented evidence that the patient’s refusal of aide services was reported to the RN. Clinical Record 7: The patient elected the hospice benefit on 12/13/2023 with a terminal diagnosis of Alzheimer’s disease. The Hospice Aide documented on the 02/02/2024 aide visit note that the patient refused shower and all tasks. The aide documented the patient doesn’t want to get up, wanted to sleep more. The clinical record contained no documented evidence that the patient’s refusal of aide services was reported to the RN. Clinical Record 8: The patient elected the hospice benefit on 01/19/2024 with a terminal diagnosis of Parkinson’s disease. The Hospice Aide documented on the 01/30/2024 aide visit note that the patient refused shower and many tasks were checked as not applicable. The clinical record contained no documented evidence that the patient’s refusal of aide services was reported to the RN. During an interview and joint record review with the Director of Patient Care Services on 03/28/2024, it was confirmed there was no documentation in the clinical record of the report to the RN.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse (RN) made on-site aide supervisory visits no less frequently than every 14 days. Clinical Record 9: The patient elected the hospice benefit on 01/20/2024 with a terminal diagnosis of Huntington’s disease. Review of the clinical record revealed the RN documented “no aide in the home” in the supervisory visit portion of the nursing notes. Clinical record review revealed the aide provided visits to the patient as ordered on the aide care plan dated 01/20/2024. The clinical record contained no documented evidence that the RN completed aide supervisory visits from 01/20/2024 through the date of record review on 03/27/2024. During an interview and joint record review with the Director of Patient Care Services on 3/28/2024, it was confirmed that the Registered Nurse was documenting there was not an aide in the home and had not completed the supervisory visits.”

“It is required that volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with volunteer services accepted, the agency did not ensure volunteer services were included in the plan of care. Clinical Record 15: The patient elected the hospice benefit on 05/16/2023 with a terminal diagnosis of congestive heart failure. Clinical record review revealed the volunteer provided visits to the patient on 06/23/2023 and 06/29/2023. Clinical record review revealed the plan of care had not been updated to include volunteer services. During an interview and joint record review with the Director of Patient Care Services and Volunteer Coordinator on 03/27/2024, it was confirmed the Volunteer had made visits and the plan of care had not been updated.”

“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 3 of 9 (33%) personnel records reviewed, the agency did not ensure the skills and competencies of individuals providing care had been assessed per agency policy. Agency policy No C:3-023.2, dated April 2017, stated in part, “The organization will clearly identify and define the skills, which are essential to observe for the determination of competence for each job category. In the identification of core competence, the essential skills will be demonstrated upon hire and annually thereafter.” Personnel Record 1: Medical Director date of hire 03/08/2018. Review of the personnel record revealed no documented evidence that annual performance competency assessments were completed. Personnel Record 2: Administrator and Volunteer Coordinator date of hire 09/01/2011. Review of the personnel record revealed no documented evidence that annual competency assessments were completed for the role of Volunteer Coordinator. Personnel Record 8: Volunteer date of hire 10/08/2019. Review of the personnel record revealed no documented evidence that annual competency assessments were completed. During an interview and joint record review with the Administrator and Director of Patient Care Services on 03/27/2024, it was confirmed that the competencies had not been completed per agency policy.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed in which the patient resided in a SNF/NF, the agency did not ensure the hospice plan of care identified the care and services needed for the patient and which provider is responsible to provide the service. Clinical Record 7: The patient elected the hospice benefit on 12/13/2023 with a terminal diagnosis of Alzheimer’s disease. The patient entered a skilled nursing facility (SNF) on 02/27/2024 for respite level of care. Review of the clinical record revealed the hospice plan of care was not updated to reflect the respite order, facility coordination, or determination of hospice and facility responsibilities. During an interview and joint record review on 03/28/2024, the Director of Patient Care Services confirmed the plan of care had not been updated to reflect the coordination of care and stated, “only the address was changed in the system.””