Global Hospice Care

“Observed in Record Review. In 2 of 6 patient records reviewed, with hospice aide services, the organization failed to ensure the RN assess the quality of care and services provided by the hospice aide (HA) to ensure the services meet the patient’s needs no less frequently that every 14 days. In RRNHV#1, there had been a missed HA supervisory visit for the first 14 days of May. In RRDC#1, there had not been a documented HA supervisory visit after the 2nd week of April until the patients passing the first week of May. This observation was reviewed with the Administrator/DPCS.”

“Observed in Record Review. In 5 of 8 patient records reviewed, for active records, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#3 there was documentation of the patient having an allergic reaction with the addition of a Medrol dosepak, yet there was no care plan established to guide the care. In RRNHV#4 there was documentation of being seen by the social worker monthly yet there was no psychosocial care plan to guide the care. In RRNHV#5 there was documentation of issues with hypertension with parameters for medication administration but hypertension was not reflected in the care plan. In RRNHV#6 the patient was being seen by the social worker but no psychosocial care plan was established. Further, the patient had an ostomy, and the nurse documented providing passive range of motion exercises yet neither were reflected in the care plans. In RRNHV#8 the patient was on 2 different anticoagulants but there were no bleeding precautions reflected in the plan of care. These observations were reviewed with the Administrator/DPCS and RN Supervisor.”

“Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide, the organization failed to ensure the staff competence was assessed and documented. On review of HR#2 for the hospice aide there were computer generated competency forms noted in the HR file that were uniform and all looked alike each year the forms specified as Ongoing Competency Assessment were checked that competency was assessed on-site and along with multiple areas checked as competent in such as patient rights, agency complaint mechanism, respect of patient property, basic home property, infection control, etc. There was another section that noted Care observed the included: Venipuncture, Wound care, Foley insertion, IV start, Blood Glucometer, and Vital Signs. The competencies in the aide’s file noted the aide was competent to perform skills even though the aide was not qualified to perform the procedures. There was an identical form in the file for all years the clinician had been with the organization dating back to 2017. There were multiple other competency checklists noted in the files each signed by the aide and a supervisor. On discussion with the CEO, Administrator/DPCS, and RN Supervisor they noted that the forms were computer generated and signed but not following the process for competency assessment per policy.”

“Observed in HR File Review. In 6 of 9 HR files reviewed, the organization failed to ensure the skills and competence of all individuals furnishing care, including volunteers furnishing services. On review of HR#1, HR#3, HR#4, HR#5, HR#6, and HR#8 there were computer generated competency forms noted in the HR file that were uniform, and all looked alike each year. The forms specified as Ongoing Competency Assessment were checked that competency was assessed on-site and along with multiple areas checked as competent such as patient rights, agency complaint mechanism, respect of patient property, basic home property, infection control, etc. There was another section that noted Care observed that included: Venipuncture, Wound care, Foley insertion, IV start, Blood Glucometer, and Vital Signs. In all HR files except the Chaplain all care skills items were checked as observed and the clinician was competent even if the clinician was not qualified to perform the procedures. There was an identical form in the file for all years the clinician had been with the organization some dating back to 2017. There were multiple other competency checklists noted in the files each signed by the clinician and a supervisor. On discussion with the CEO, Administrator/DPCS, and RN Supervisor they noted that the forms were computer generated and signed but not following the process for competency assessment per policy. Observed in HR File Review. In 1 of 1 HR files reviewed, for new employees, the organization failed to ensure the staff competence was initially assessed and documented as part of orientation. In review of HR#7 for the volunteer, there was a computer generated competency form noted in the HR file specified as Ongoing Competency Assessment where checks noted that competency was assessed on-site and along with multiple areas checked as competent in such as patient rights, agency complaint mechanism, respect of patient property, basic home property, infection control, etc. There was another section that noted Care observed that included: Venipuncture, Wound care, Foley insertion, IV start, Blood Glucometer, and Vital Signs. In the HR files for the volunteer all care items were checked as observed and that the clinician was competent even though the volunteer was not qualified to perform the procedures. There were multiple competency checklists noted in the files each signed by the volunteer and a supervisor. On discussion with the CEO, Administrator/DPCS, and RN Supervisor they noted that the forms were computer generated and signed but not following the process for competency assessment per policy.”

“Observed in Record Review. In 7 of 8 patient records reviewed, the organization failed to ensure compliance with all applicable federal, states and local laws and regulations related to the health and safety of patients. On review of all active records except RRNHV#6 there was no documentation that the Patient Notification of Hospice Non-Covered Items, Services, and Drugs was addressed with the patient/patient representative. Discussion with the Leadership noted the organization was using an outdated election of benefits form that lacked the information, but had updated the form. When the new form was used the section to elect or decline the Notification addendum was left blank. This observation was reviewed with the Administrator/DPCS and the RN Supervisor.”

“Observed in Record Review. In 7 of 8 patient records reviewed, the organization failed to ensure the plan of care was established with goals that were specific, measurable and time-bound. On review of the clinical records there was a pattern of goals that were not specific, measurable and time-bound. In RRHV#1 and example was: Pt will have adequate food and fluids as tolerated or desired. Pt will have adequate food and fluids to maintain comfort as exhibited by expressed. In RRHV#2 a goal read Will have adequate food and fluids as tolerated. In RRNHV#4 an example was Facilitate bowel elimination and comfort. Reduce discomfort with improved bowel elimination status. In RRNHV#5 and example was Maintain mobility and independence. Further examples can be seen in RRNHV#6, RRNHV#7, and RRNHV#8. Throughout the record it was also noted that most all achieve by dates were set the end of the benefit period. These observations were reviewed with the Administrator/DPCS and the RN Supervisor.”

“Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRDC#1, RRDC#2, and RRDC#3 who were discharged live, there was no documentation of a discharge order noted on the clinical record. This observation was reviewed with the Administrator/DPCS and RN Supervisor. Observed in Record Review. In 4 of 8 patient records reviewed, for active records, the organization failed to ensure the pan of care include all services needed for the palliation and management of the terminal illness and related conditions to include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. On review of RRHV#2 the patient was being seen by the hospice aide per documentation yet there were no orders noted on the plan of care for the aide’s frequency. On review of RRHV#3 the frequency order for the Medical Social Worker (MSW) read 1 time initial and as needed for psychosocial needs and support yet there was no indication how many as needed visits were ordered. Similar order was noted for the spiritual counselor (SC). Volunteer frequency was as needed and based on availability and patient/caregiver preference. There was no indication of a specific volunteer frequency. In RRNHV#4 there were similar non-specific frequency orders for the MSW, SC, and Volunteer. Further there was no specific order for the RN, the order read initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed for change in condition. Similar non specific frequency for the RN was noted in RRNHV#5. These observations were reviewed with the Administrator/DPCS and RN supervisor.”

“Observed in Record Review. In 3 of 8 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness an related conditions. On review of RRHV#3 there was an order for Medrol dose Pak that had instructions that stated as per pack instructed yet the order did not have specific instructions for use. In RRNHV#4 blood glucose test strips and lancet devices yet there was no specific physician order for blood glucose monitoring. In RRNHV#8 the patient had a foley catheter yet the plan of care noted to change monthly and prn. The order was incomplete as it lacked type, size of catheter and what situation to change as needed. These observations were reviewed with the Administrator/DPCS and RN Supervisor.”

“Observed in Record Review. In 3 of 8 patient records reviewed, The organization failed to ensure care was provided according to the patient’s individualized plan of care. On review of RRNHV#4 the hospice aide frequency was specified as every other day yet the aide was seeing the patient 3 days a week. The Medical Social Worker (MSW) was ordered 1 time initial and as needed yet was documenting scheduled visits monthly. In RRNHV#5 the MSW documentation noted monthly visits yet the order was for 1 visit as needed and at recert. The Chaplain frequency was for 1 visit as needed and at recert but there was no documentation of a Chaplain visit documented at recert. In RRNHV#6 the MSW was ordered 1 time only yet documented monthly visits. These observations were reviewed with the RN supervisor and Administrator/DPCS.”

“Observed in Record Review. In 2 of 3 patient records reviewed, for bereavement records, the organization failed to ensure a bereavement plan of care that specified the type of bereavement services to be offered and frequency of service delivery was developed. In review of RRBR#1 there was no documentation that a bereavement plan of care was developed. In RRBR#3 there was documentation that bereavement services were declined prior to the patient death, yet there was documentation the bereaved was receiving bereavement letters but no bereavement plan of care. These observations were reviewed with the Administrator/DPCS and RN Supervisor.”

“Observed in Record Review. In 3 of 8 patient records reviewed, for active records, the organization failed to ensure the RN provide written patient care instructions for the hospice aide. On review of RRHV#2 there was no documentation of an aide plan of care, the plan of care was established yet it was blank with no tasks assigned. On review of RRHV#1 the aide was ordered to record vital signs yet there were no parameters provided to guide the aide as to when to report. In RRNHV#8 the patient was on Clopidogrel, Eliquis and Oxygen yet there were no bleeding precautions or oxygen precautions listed on the aide plan of care. These observations were reviewed with the Administrator/DPCS and RN supervisor.”

“Observed in Record Review. In 1 of 8 patient records reviewed, for active records, the organization failed to ensure the Medical Director provide written certification that the patient’s life expectancy was six months or less if the illness runs its normal course to include all required elements such as current subjective and objective findings. On review of RRHV#2 the physician’s narrative on the Certificate of Terminal Illness (CTI) stated Patient meets LCD Medical Guidelines to receive hospice service, signed Certification of Terminal Illness. Patient is admitted to hospice care under routine level of care. Patient is certified for hospice and is appropriate for hospice admission with a terminal prognosis of 6 months or less if disease process follows its normal course. The statement lacked all required elements as it lacked related diagnosis and current subjective and objective medical findings. This observation was reviewed with the Administrator/DPCS, CEO, and RN supervisor.”

“Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to ensure that before the recertification period the medical director or physician designee review the patient’s clinical information. On review of RRDC#2 it was noted it was noted the started hospice on benefit period (BP) #3. The certificate of terminal illness was signed by the physician for recertifications in BP #4, 5, 6, and 7. For BP’s number 8, 9, 10 an 11 the CTI was noted to not be signed by the physician and was noted in the signature line to have signature on file/verified by ****,***RN. When asked for the signatures on file the leadership was unable to produce. Further the physician narrative lacked any current subjective and objective clinical information. In RRNHV#4 the recertification CTI had similar lack of current subjective and objective findings. This observation was reviewed with the Administrator/DPCS and RN Supervisor.”

“Observed in Record Review. In 1 of 8 patient records reviewed, the organization failed to ensure the patient record contain all information to reflect the patient’s care, treatment, and services. On review of RRNHV#4 there was a noted 27 day gap in RN comprehensive assessment documentation. On discussion with the Administrator/DPCS and RN Supervisor in was verified through a route sheet that the visit was made as ordered yet the documentation was not entered into the record as required by policy. This observation was reviewed with the Administrator/DPCS and RN Supervisor. Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to ensure the patient record contain all information to reflect the patient’s care, treatment, and services. On review of RRBR#3 there was no documentation in the record of a patient visit at the time of death and who attended the patient death. This observation was reviewed with the Administrator/DPCS and RN Supervisor. Observed in Record Review. In 1 of 3 patient records reviewed, for live discharge, the organization failed to ensure the patient record contain all information to reflect the patients care, treatment, and services. On review of RRDC#2 who was discharged for extended prognosis, there was no documentation noted in the record to support that the patient was no longer terminally ill. There were two nursing visits and a social worker visit documented in the days leading to discharge date yet the documentation did not indicate that the patient was being discharged. This observation was reviewed with the Administrator/DPCS and RN Supervisor.”

“Observed in Record Review. In 7 of 8 patient records reviewed, the organization failed to ensure all entries to the clinical record are authenticated per policy. Throughout the clinical record it was noted that the entries to the record were not authenticated as required. In review of RRHV#1 an example was all LVN visit notes were in review status in the EMR and not signed and dated in the EMR by the clinician. In RRHV#2 the last 2 LVN notes were in review status and not signed/dated, and all but one hospice aide notes had been submitted by the nurse on behalf of the aide and not signed and dated by the clinician. In RRNHV#4 all of the Aide visit notes were not properly authenticated by the aide as they were either submitted on behalf of the aide by the RN or not fully submitted in the system. Further examples can be seen in RRHV#3, RRNHV#5, RRNHV#6, and RRNHV#7. These observations were reviewed with the Administrator/DPCS and RN Supervisor.”

“Observed in Record Review. In 3 of 8 patient records reviewed, for active patients, the organization failed to ensure the patient record is complete, promptly and accurately documented. On review of RRHV#1 the medical record number on the patient consents and admission documents was different that the number listed in the EMR as the patient medical record number. On discussion with the Administrator/DPCS it was acknowledged that the medical record number written on the admission paperwork was an error. In RRNHV#4 there was documentation of a spiritual counselor visit/assessment prior to the patient admission. The Administrator/DPCS and RN Supervisor noted that the spiritual documentation was likely submitted in error. In review of RRNHV#5 the hospice aide services were declined and no aide services were being provided, yet in each RN comprehensive assessment there was a Aide supervisory visit documented. These observations were reviewed with the Administrator/DPCS and RN Supervisor.”