High Quality Hospice Care

“It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure the comprehensive assessment identified the patient’s physical, psychosocial, emotional, and spiritual needs. Clinical Record 2: The patient elected the hospice benefit on 02/13/2024 for the diagnosis of metastatic melanoma. The Registered Nurse (RN) documented on the initial comprehensive assessment dated 02/13/2024 that the Social Worker was declined. Clinical record review revealed no documented evidence that the comprehensive assessment included a psychosocial assessment. Clinical Record 6: The patient elected the hospice benefit on 01/22/2024 for the diagnosis of cardiac disease. The comprehensive assessment dated 01/22/2024 included documentation that the Social Worker and Spiritual Counselor were declined. Clinical record review revealed no documented evidence that the comprehensive assessment included a spiritual assessment and a psychosocial assessment. Clinical Record 11: The patient elected the hospice benefit on 03/29/2023 for the diagnosis of heart disease. Clinical record review revealed the Social Worker entered a note on 04/08/2023 that the comprehensive psychological assessment would be rescheduled for 04/10/2023. The clinical record contained no documented evidence that the Social Worker completed the visit on 04/10/2023 and no documented evidence that a psychosocial assessment was completed as part of the comprehensive assessment. During an interview and joint record review on 05/22/2024, the Administrator/Director of Patient Care Services confirmed the comprehensive assessments did not include the psychosocial or spiritual assessment.”

“It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG [interdisciplinary group] in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the individualized plan of care was followed. Clinical Record 4: The patient elected the hospice benefit on 07/06/2023 for the diagnosis of cardiac disease. The plan of care included orders for Social Worker and Spiritual Counselor visit frequencies of one visit per month. Clinical record review revealed Spiritual Counselor visits dated 09/29/2023 and 11/11/2023. There was no documented evidence that the Spiritual Counselor provided a visit for October 2023 and no documentation of a missed visit for October 2023. The Social Worker documented a visit on 07/15/2023, but no Social Worker visits were documented for August and September 2023 and the record contained no documentation to explain the missed visits. Clinical Record 11: The patient elected the hospice benefit on 03/29/2023 for the diagnosis of heart disease. The plan of care included an order for a Social Worker frequency of visits once a month. The clinical record contained no documented evidence that the Social Worker provided a visit in May 2023 and the record contained no documentation to explain the missed visit. During an interview and joint record review on 05/22/2024, the Administrator/Director of Patient Care Services confirmed the visit frequencies were not provided as ordered on the patients’ plans of care.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure the plan of care was reviewed and revised as frequently as the patient’s condition required. Clinical Record 1: The patient elected the hospice benefit on 02/23/2024 for the diagnosis of multiple myeloma. The plan of care dated 02/23/2024 included the following problem: “Cardiorespiratory. Potential for altered cardiac status.” The clinical record contained an on-call nursing visit dated 03/25/2024 that documented the patient was experiencing shortness of breath and noted adjustments to oxygen. The clinical record contained no documented evidence that the plan of care was updated to reflect the change in the patient’s condition and adjustment in oxygen. Clinical Record 4: The patient elected the hospice benefit on 07/06/2023 for the diagnosis of cardiac disease. The nursing visit note dated 12/09/2023 included documentation that the “Patient has increasing upper back and lower back pain 4/10 to 6/10. New medication order.” The clinical record contained no documented evidence that the plan of care was updated to reflect the change in the patient’s condition and new medication ordered. Clinical Record 6: The patient elected the hospice benefit on 01/22/2024 for the diagnosis of cardiac disease. Documentation in the clinical record dated 02/17/2024 stated “Reported by facility staff that patient has cough for 3 days and tested positive for Covid.” The clinical record contained no documented evidence that the plan of care was updated to reflect the change in the patient’s condition. Clinical Record 10: The patient elected the hospice benefit on 04/26/2024 for malignant neoplasm of the brain. The plan of care dated 04/26/2024 included “Problem: Sleep disorder. Intervention: Melatonin 3 mg at HS (bedtime).” The nursing visit note dated 05/02/2024 included documentation that the patient was complaining of not sleeping well and a new physician order was obtained to discontinue Melatonin and increase Trazadone from 50 mg to 100 mg were obtained. The clinical record contained no documented evidence that the plan of care was updated to reflect the change in the patient’s condition and the change in medications. Clinical Record 14: The patient elected the hospice benefit on 12/30/2023 for the diagnosis of Alzheimer’s disease. Clinical record review revealed the patient was placed on continuous care level of care on 01/15/2024. The clinical record contained no documented evidence that the plan of care was updated to reflect the change in the patient’s level of care. During an interview and joint record review on 05/22/2024, the Administrator/Director of Patient Care Services confirmed the plans of care had not been updated as frequently as the patients’ condition required.”

“It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) 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, observation, and interview. In 5 of 11 (45%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provided specific instructions for the hospice aide. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 02/23/2024 for the diagnosis of multiple myeloma. The patient resided at a nursing facility. During the home visit observation with the Hospice Aide (HA) (Personnel Record 6), the patient was in bed and observed to have a neck brace. The HA was observed to assist the patient to the dining area and removed the neck brace to place a bib for the patient to eat breakfast. The aide care plan dated 02/23/2024 assigned the HA the tasks of showering and shampooing hair. The aide care plan did not include notification to the aide of the patient’s neck brace or specific instructions related to the use of the neck brace while providing care to the patient. Clinical Record 5: The patient elected the hospice benefit on 12/02/2023 for the diagnosis of Parkinson’s disease. The nursing visit noted dated 02/21/2024 included documentation that the patient had a “wound to left arm covered in Xeroform.” The aide care plans dated 12/02/2023 and 02/27/2024 assigned the aide the tasks of bathing via shower, to notify RN of skin breakdown, and peri care. The aide care plans did not notify the aide of the wound or provide the aide with specific instructions related to caring for the wound while providing care to the patient. Clinical Record 8: The patient elected the hospice benefit on 10/20/2023 for the diagnosis of end-stage lung disease. The nursing assessment dated 10/20/2023 included documentation that the patient had a “Bipap with oxygen and a wound on the coccyx covered with Xeroform.” The aide care plan dated 10/20/2023 assigned the aide the tasks of bed bath, peri care, notify RN of skin breakdown, and O2 [oxygen] precautions. The aide care plan did not notify the aide of the wound or provide the aide with instructions on how to care for the wound while providing care to the patient and did not provide specific instructions for the patient’s use of oxygen while providing care to the patient. Clinical Record 11: The patient elected the hospice benefit on 03/29/2023 for the diagnosis of heart disease. The nursing assessment dated 03/29/2023 included documentation “patient to have a Foley catheter.” The aide care plans dated 06/25/2023, 10/18/2023, 11/19/2023, 01/08/2024, and 03/04/2024 did not include instructions to the aide related to the Foley catheter. Clinical Record 14: The patient elected the hospice benefit on 12/30/2023 for the diagnosis of Alzheimer’s disease. The nursing assessment dated 12/30/2023 included documentation “wound to sacrum covered with dry dressing.” The aide care plan dated 12/30/2023 assigned the aide the tasks of bathing via shower, to notify RN of skin breakdown, and peri care. The aide care plan did not notify the aide of the wound or include specific instructions for wound care during tasks assigned. During an interview and joint record review on 05/22/2024, the Administrator/Director of Patient Care Services confirmed the aide care plans did not include specific instructions for the oxygen, neck brace, or wounds.”

“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, observation, and interview. In 1 of 11 (9%) clinical records reviewed with aide services provided, the agency did not ensure the aide reported changes in the patient’s condition to the Registered Nurse as the changes related to the plan of care. Clinical Record 2: The patient elected the hospice benefit on 02/13/2024 for the diagnosis of metastatic melanoma. The patient resided at a nursing facility. During an interview with the Hospice Aide on 05/22/2024, the Administrator/Director of Patient Care Services, Clinical Supervisor, and Site Visitor asked the Hospice Aide if tasks assigned on the aide care plan were being completed during the aide visits provided to the patient. The aide responded that “many of the visits the patient refused tasks.” The Aide was asked about reporting the refusals and stated he “reported these to the facility aide.” The aide did not notify the RN that the patient had refused assigned tasks. During an interview and joint record review on 05/22/2024, the Administrator/Director of Patient Care Services confirmed the aide did not report the patient’s refusal of services to the hospice Registered Nurse.”

“It is required that each patient’s record includes, at a minimum the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the clinical record contained complete and accurate documentation in the clinical notes. Clinical Record2/Home Visit 2: The patient elected the hospice benefit on 02/13/2024 for the diagnosis of metastatic melanoma. During the home visit observation with the Licensed Vocational Nurse (LVN) (Personnel Record 3), it was brought to the attention of the LVN and the site visitor by a facility staff member, that the hospice aide may not be providing all the services as assigned in the hospice aide care plan. The Administrator/Director of Patient Care Services, Clinical Supervisor, and Site Visitor interviewed the Hospice Aide on 05/22/2024. The Hospice Aide was asked if tasks assigned on the aide care plan were being completed during the aide visits provided to the patient. The aide stated, “he wasn’t completing all the tasks on the aide care plan because the patient often refused,” but he was “documenting them as completed because he went to the facility.” During an interview and joint record review with the Administrator/Director of Patient Care Services on 5/22/2024, it was confirmed the hospice aide had documented incorrect information in the patient’s clinical record. The agency confirmed the aide had been counseled and employment had been terminated.”

“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. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed were the patient resided in a SNF/NF [skilled nursing facility/nursing facility], the agency did not ensure there was a written plan of care established and maintained in consultation with the SNF/NF. Clinical Record 2: The patient elected the hospice benefit on 02/13/2024 for the diagnosis of metastatic melanoma. The patient resided at a SNF/NF. Clinical record review revealed no documented evidence that the written plan of care was established and maintained in consultation with the SNF/NF. During an interview and joint record review on 05/22/2024, the Administrator/Director of Patient Care Services confirmed the written plan of care did not include documentation that it had been established and maintained in consultation with the SNF staff.”