Bonita Springs Hospice Care LLC

“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 effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. 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 document review, clinical record review, and interview. In 13 of 14 (93%) clinical records reviewed, the agency did not ensure that the drug profile included the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy and as a result, the medication reconciliation and review did not include all the patient’s current medications. Document 1: Policy 11.10.1 Medication Profile review date 2015 stated in part “The RN [Registered Nurse] checks all medications a patient may be taking and documents on the medication profile. All prescribed medications, over the counter (OTC) medications and home remedies will be documented on the medication profile.” Clinical Record 1: The patient elected the hospice benefit on 01/04/2024. Clinical record review revealed a physician order dated 01/04/2024 for Oxygen 2-6 lpm [liters per minute] via nasal cannula as needed for shortness of breath. The clinical record contained no documented evidence that Oxygen was included on the patient’s medication profile dated 01/04/2024 and no evidence Oxygen was included in the medication review dated 01/15/2024. Clinical Record 2: The patient elected the hospice benefit on 03/22/2023. Clinical record review revealed a physician order dated 03/21/2023 for Oxygen 2-6 lpm via nasal cannula as needed for shortness of breath. The clinical record contained no documented evidence that Oxygen was included on the patient’s medication profile dated 03/22/2023 and no evidence Oxygen was included in the medication review. Clinical Record 3: The patient elected the hospice benefit on 12/20/2023. Clinical record review revealed a physician order dated 12/20/2023 for Oxygen 2-6 lpm [liters per minute] via nasal cannula as needed for shortness of breath and a physician order dated 01/24/2024 for Ciprofloxacin 500mg bid [twice daily] for 7 days. The clinical record contained no documented evidence that Oxygen and Ciprofloxacin were included on the patient’s medication profile dated 12/20/2023 and no evidence Oxygen and Ciprofloxacin were included in the medication reviews dated 01/01/2024, 01/15/2024, and 01/29/2024. Clinical Record 4: The patient elected the hospice benefit on 12/05/2023. Clinical record review revealed a physician order dated 12/05/2023 for Oxygen 2-6 lpm via nasal cannula as needed for shortness of breath. The clinical record contained no documented evidence that Oxygen was included on the patient’s medication profile dated 12/05/2023 and no evidence Oxygen was included in the medication review dated 12/18/2023. Clinical Record 5: The patient elected the hospice benefit on 11/06/2023. Clinical record review revealed a physician order dated 11/06/2023 for Oxygen 2-6 lpm via nasal cannula as needed for shortness of breath. The clinical record contained no documented evidence that Oxygen was included on the patient’s medication profile dated 11/06/2023 and no evidence Oxygen was included in the medication review dated 11/20/2023. Clinical Record 6: The patient elected the hospice benefit on 08/10/2023. Clinical record review revealed a physician order dated 08/09/2023 for Oxygen 2-6 lpm via nasal cannula as needed for shortness of breath. The clinical record contained no documented evidence that Oxygen was included on the patient’s medication profile dated 08/10/2023 and no evidence Oxygen was included in the medication review dated 08/14/2023. Clinical Record 7: The patient elected the hospice benefit on 02/05/2024. Clinical record review revealed a physician order dated 02/05/2024 for Oxygen 2-6 lpm via nasal cannula as needed for shortness of breath. The clinical record contained no documented evidence that Oxygen was included on the patient’s medication profile dated 02/05/2024 and no evidence Oxygen was included in the medication review dated 02/12/2024. Clinical Record 8: The patient elected the hospice benefit on 02/29/2024. Clinical record review revealed a physician order dated 02/28/2024 for Oxygen 2-6 lpm via nasal cannula as needed for shortness of breath. The clinical record contained no documented evidence that Oxygen was included on the patient’s medication profile dated 02/29/2024 and no evidence Oxygen was included in the medication review dated 03/11/2024. Clinical Record 9: The patient elected the hospice benefit on 12/01/2023. Clinical record review revealed a physician order dated 12/01/2023 for Oxygen 2-6 lpm via nasal cannula as needed for shortness of breath. The clinical record contained no documented evidence that Oxygen was included on the patient’s medication profile dated 12/01/2023 and no evidence Oxygen was included in the medication review dated 12/04/2023. Clinical Record 10: The patient elected the hospice benefit on 08/02/2023. Clinical record review revealed a physician order dated 08/02/2023 for Oxygen 2-6 lpm via nasal cannula as needed for shortness of breath. The clinical record contained no documented evidence that Oxygen was included on the patient’s medication profile dated 08/02/2023 and no evidence Oxygen was included in the medication review dated 08/14/2023. Clinical Record 12: The patient elected the hospice benefit on 10/27/2023. Clinical record review revealed a physician order dated 10/27/2023 for Oxygen 2-6 lpm via nasal cannula as needed for shortness of breath. The clinical record contained no documented evidence that Oxygen was included on the patient’s medication profile dated 10/27/2023 and no evidence Oxygen was included in the medication review dated 11/06/2023. Clinical Record 13: The patient elected the hospice benefit on 01/28/2023. Clinical record review revealed a physician order dated 01/27/2023 for Oxygen 2-6 lpm via nasal cannula as needed for shortness of breath. The clinical record contained no documented evidence that Oxygen was included on the patient’s medication profile dated 01/28/2023 and no evidence Oxygen was included in the medication review dated 01/30/2023. Clinical Record 14: The patient elected the hospice benefit on 03/19/2023. Clinical record review revealed a physician order dated 03/19/2023 for Oxygen 2-6 lpm via nasal cannula as needed for shortness of breath. The clinical record contained no documented evidence that Oxygen was included on the patient’s medication profile dated 03/19/2023. During an interview and review of findings on 03/19/2024, the Director of Patient Care Services and the Licensed Vocational Nurse (staff 4) confirmed that the hospice medication profiles, and medication reviews did not include all the patient’s medications.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group [IDG], who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the updated comprehensive assessment included information on the patient’s progress towards desired outcomes and reassessment of the patient’s response to care. Agency policy 9.8.1 Reassessments/Update to the Comprehensive Assessment, revised February 2021, stated in part “Staff will analyze the date from assessments and reassessments. Such analysis of data will assist staff in identifying and prioritizing patient needs and problems to direct care and services and update the IDG care plan.” Agency policy 9.12.3 IDG Care Planning Process, revised February 2022, stated in part “The IDG in collaboration with the patient’s attending physician, if any reviews, revises and documents the individualized plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. The revised plan of care includes information from the patient’s updated comprehensive assessment and notes the patient’s progress toward outcomes and goals specified in the plan of care, advance directives, effectiveness of pain and symptom management, and spiritual and psychosocial needs. Clinical Record 3: The patient elected the hospice benefit on 12/20/2023 with a terminal diagnosis of senile degeneration of the brain. The clinical record included a physician order for Cephalexin [antibiotic] 500mg BID [twice daily] beginning 01/24/2024, Calazime to peri area every brief change and as needed until resolved beginning 02/14/2024, and Cephalexin 500mg QID [four times a day] for 7 days beginning 03/01/2024, for suspected urinary infections and related skin breakdown. Review of nursing notes and IDG updates to the plan of care from the date of initiation of care on 01/24/2024 through the date of record review on 03/19/2024 revealed no documented evidence of reassessment of the patient’s response to care related to the medications initiated. During an interview and record review on 03/19/2024, the Director of Patient Care Services and the Licensed Vocational Nurse (staff4) confirmed that clinical record 3 lacked evidence of the reassessment of the patient’s response to care.”

“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 document review, clinical record review, and interview. In 6 of 14 (43%) clinical records reviewed, the agency did not ensure the hospice care and services provided to patients and families followed the patient’s individualized plan of care. Agency policy 9.20.2 Physician Orders, revised 2014, stated in part “Care and services will be provided according to physician orders. Orders are current and updated. The IDG [interdisciplinary group] plan of care is established in consultation with the physician, Medical Director, hospice staff, the patient, and members of the patient’s family. The plan of care may include types of services required, equipment and supplies required.” Agency policy 9.12.1 IDG Care Planning Process, revised February 2022, stated in part “An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated assessments. The plan of care is written to include all services necessary for the palliation and management of the terminal illness.” Clinical Record 1: The patient elected the hospice benefit on 01/04/2024 with a terminal diagnosis of atherosclerotic heart disease. The Registered Nurse (RN) obtained a physician order for wound care on 01/04/2024 to cleanse the wound with normal saline, pat dry, cover with bandage and wrap with kerlix as needed. The Licensed Vocational Nurse (LVN) completed a visit on 01/05/2024 and documented wound care provided as “Cleanse with wound cleanser, pat dry, apply foam dressing.” The LVN documented on the nursing visit note dated 01/08/2024 “Skin tear appears to be healing well and scabbing. Covered wound with bordered gauze.” The clinical record contained no documented evidence that the LVN provided wound care as ordered by the physician and included on the plan of care. The updated plan of care dated 02/12/2024 included an order for social worker visits once a month and as needed. The clinical record contained no documented evidence that a social worker visit was completed in February. Clinical Record 2: The patient elected the hospice benefit on 03/22/2023 with a terminal diagnosis of Alzheimer’s disease. The updated plan of care dated 01/10/2024 included an order for social worker visits once a month and as needed. The clinical record contained no documented evidence that a social worker visit was completed in February. Clinical Record 3: The patient elected the hospice benefit on 12/20/2023 with a terminal diagnosis of senile degeneration of the brain. The clinical record included a physician order for Cephalexin [antibiotic] 500mg BID [twice daily] beginning 01/24/2024, Calazime to peri area every brief change and as needed until resolved beginning 02/14/2024, and Cephalexin 500mg QID [four times a day] for 7 days beginning 03/01/2024, for suspected urinary infections and related skin breakdown. Review of nursing notes and IDG updates to the plan of care from the date of initiation of treatment on 01/24/2024 through the date of record review on 03/19/2024 revealed no documented evidence of nursing assessment or reassessment of the patient’s response to the medications initiated. Clinical Record 4: The patient elected the hospice benefit on 12/05/2023, with a terminal diagnosis of atherosclerotic heart disease. The updated plan of care dated 12/05/2024 and the updated plan of care dated 01/01/2024 included orders for hospice aide visits once a week. The clinical record contained no documented evidence that the hospice aide provided a visit the week of 12/31/2023, the visit was scheduled 01/04/2024. The record contained no documentation of a missed visit or physician notification of missed visit. Clinical Record 6: The patient elected the hospice benefit on 08/10/2023 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed the skilled nurse documented on the 12/19/2024 visit note, that wound care was provided to “Left ankle cleansed, pat dry, apply wound dressing, cover with sterile gauze.” The clinical record lacked evidence that physician orders were obtained for wound care provided on 12/19/2023 or that a wound care order was included in the updated plans of care dated 12/18/2023 and 01/01/2024. Clinical Record 13: The patient elected the hospice benefit on 01/28/2023. The Licensed Vocational Nurse documented on the skilled nurse visit note dated 05/22/2023 that the “Pt [patient] transferred back into Geri chair and brought to living room prior to leaving.” The updated plan of care dated 05/22/2023 did not include an order for the Geri chair. During an interview and review of records on 03/19/2024, the Director of Patient Care Services and the Licensed Vocational Nurse (staff 4) confirmed that the clinical records did not include documentation that staff provided services as ordered by the physician and included in the plan of care.”

“It is required that each patient’s individualized written plan of care reflect patient and family goals, and identify planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the patient’s individualized written plan of care included goals and planned interventions based on problems identified in the updated comprehensive assessment. Agency policy 9.12.1 IDG Care Planning Process, revised February 2022, stated in part “An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated assessments. The plan of care is written to include all services necessary for the palliation and management of the terminal illness.” Clinical Record 2: The patient elected the hospice benefit on 03/22/2023 with a terminal diagnosis of Alzheimer’s disease. The skilled nurse documented on the nursing visit note dated 01/18/2024 “Pt’s [patient’s] hands noted to begin to get contracted. Reinforced with caregivers using hand rolls or rolled towels if needed to prevent further contractures in patient.” The clinical record contained no documented evidence that the interventions implemented to prevent further contractures were included in the plan of care dated 01/15/2024 and updated plan of care dated 01/29/2024. During an interview and review of findings on 03/19/2024, the Director of Patient Care Services and the Licensed Vocational Nurse (staff 4) confirmed that the individualized written plan of care for clinical record 2 did not include goals and planned interventions based on problems identified in the updated comprehensive assessment.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 2 (100%) bereavement clinical records reviewed, the agency did not ensure the clinical record included a bereavement plan of care that reflected the types of bereavement services offered and the frequency of service delivery. Agency policy 4.26.1 Bereavement Services, revised June 2019, stated in part “An initial Bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment. Depending on the initial assessment, a plan of care will be developed to include specific counseling to patient and family members to be provided by the Social Worker, Chaplain, or Bereavement Counselor. The [bereavement] plan of care will reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery.” Clinical Record 13: Clinical record review revealed the patient’s date of death was 05/28/2023. The clinical record contained no documented evidence that a bereavement plan of care was created that included the types of bereavement services offered and the frequency of service delivery. Clinical Record 14: Clinical record review revealed the patient’s date of death was 03/26/2023. A Bereavement Initial Assessment/Care Plan form was added to the clinical record and dated 04/06/2023. The clinical record contained no documented evidence that the bereavement plan of care included the types of bereavement services offered and the frequency of service delivery. During an interview and review of findings on 03/202/2024, the Director of Patient Care Services and the Licensed Vocational Nurse (staff 4) confirmed that the clinical records did not include a bereavement plan of care that reflected the types of bereavement services that were offered and the frequency of service delivery.”

“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 document review, clinical record review, and interview. In 8 of 14 (57%) clinical records reviewed, the agency did not ensure that the clinical record included past and current clinical notes and correct clinical information as required by agency policy. Agency policy 11.2.1 Patient Record Content, revised 2015, stated in part “Hospice will initiate and maintain an individual and accurate patient record containing past and current findings for each patient receiving care in compliance with all federal/state laws and regulations. The record must contain correct clinical information that is available to the patient’s attending physician and Hospice staff.” Agency policy 11.6.1 Timely Submission of Patient Documentation, revised 2014, stated in part “Itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding three (3) business days.” Clinical Record 1: Clinical record review revealed a skilled nursing visit was provided to the patient on 01/08/2024, but documentation for the completed visit was signed and submitted on 01/14/2024, 4 business days after the visit was completed and 1 day outstanding. The skilled nurse completed a nursing visit on 01/11/2024, but documentation for the completed visit was signed and submitted on 01/19/2024, 5 business days after the visit was completed and 2 days outstanding. A skilled nursing visit was completed on 01/15/2024, but documentation for the completed visit was signed and submitted on 01/21/2024, 4 business days after the visit was completed and 1 day outstanding. Clinical Record 3: Clinical record review revealed a skilled nursing visit was completed on 02/20/2024. The documentation for the completed visit was signed and submitted on 03/05/2024, 9 business days after the visit was completed and 6 days outstanding. The skilled nurse completed a nursing visit on 02/06/2024, documentation for the completed visit was signed and submitted on 02/19/2024, 8 business days after the visit was completed and 5 days outstanding. The hospice aide completed a visit on 12/27/2023, documentation for the completed aide visit was signed and submitted on 01/28/2024, 20 business days after the visit was completed and 17 days outstanding. A hospice aide visit was completed on 01/22/2024, but documentation for the completed aide visit was signed and submitted on 02/20/2024 20 business days after the visit was completed and 17 days outstanding. Clinical Record 4: Clinical record review revealed the social worker provided a visit to the patient on 01/02/2024. The documentation for the completed visit was signed and submitted on 03/08/2024, 47 business days after the visit was completed and 44 days outstanding. Clinical Record 6: Clinical record review revealed the skilled nurse provided a nursing visit to the patient on 12/19/2023. The documentation for the completed visit was signed and submitted on 01/02/2024, 7 business days after the visit was completed and 4 days outstanding. Clinical Record 8: Clinical record review revealed a skilled nursing visit was provided to the patient on 02/20/2024, but documentation for the completed visit was signed and submitted on 03/05/2024, 9 business days after the visit was completed and 6 days outstanding. The skilled nurse completed a nursing visit on 02/06/2024, documentation for the completed visit was signed and submitted on 02/19/2024, 8 business days after the visit was completed and 5 days outstanding. The hospice aide completed a visit on 12/27/2023. The documentation for the completed visit was signed and submitted on 01/28/2024, 20 business days after the visit was completed and 17 days outstanding. A hospice aide visit was completed on 01/22/2024, but documentation for the completed visit was signed and submitted on 02/20/2024, 20 business days after the visit was completed and 17 days outstanding. Clinical Record 9: Clinical record review revealed the spiritual counselor provided a visit on 12/12/2023, documentation for the completed visit was signed and submitted on 01/01/2024, 12 business days after the visit was completed and 9 days outstanding. Clinical Record 12: Clinical record revealed the social worker provided a visit on 11/14/2023, documentation for the completed visit was signed and submitted on 12/12/2023, 18 business days after the visit was completed and 15 days outstanding. A social worker visit was completed on 12/01/2023. The documentation for the completed visit was signed and submitted on 12/12/2023, 6 business days after the visit was completed and 3 days outstanding. Clinical Record 13: Clinical record review revealed the social worker provided a visit to the patient on 05/02/2023, documentation for the completed visit was signed and submitted on 05/31/2023, 19 business days after the visit was completed and 16 days outstanding. A social worker visit was completed on 05/22/2023. The documentation for the completed visit was signed and submitted on 05/31/2023, 5 business days after the visit was completed and 2 days outstanding. During an interview on 03/19/2024, the Director of Patient Care Services and the Licensed Vocational Nurse (staff 4) confirmed the findings that that documentation was not completed timely as required by agency policy.”