Freedom Home Health and Hospice Care Services, Inc.

“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 but is not limited to identifying the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, 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 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, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the drug regimen review was performed as required by agency policy. Agency policy No. 2-004 Medication Profile, revised 2020, stated in part, “A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, … During subsequent home visits, the medication profile will be used as a care planning…guide…Based on review of the medication profile…changes in the plan of care may be required.” Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 04/11/2024 and resided at a skilled nursing facility (SNF). During the home visit observations with the Medical Social Worker (Personnel Record 3), a medication review was completed by comparing the hospice medication profile with the medication administration record (MAR) from the SNF. The SNF MAR included Fleets enema 7-19GM/18ML every 72 hours as needed, Sennosides 8.6MG tablet every six hours as needed, Systane ultra ophthalmic solution 0.4-0.3% to both eyes every two hours as needed, Ipratropium bromide inhaled solution 0.02%/2.5ML every six hours, Loratadine 10MG tablet every 24 hours as needed, Milk of Magnesia suspension 400MG/5ML give 30ML every 24 hours as needed, Olopatadine hydrochloride ophthalmic solution 0.1% both eyes every morning and at bedtime, Pradaxa 110MG capsule every morning and at bedtime, and Tylenol 325MG tablet every 4 hours as needed. The hospice plan of care and medication profile dated 05/28/2024 did not include Fleets enema, Sennosides, Systane ultra, Ipratropium bromide, Loratadine, Milk of Magnesia, Olopatadine hydrochloride, Pradaxa, and Tylenol and the medications were not included in the medication review. Clinical Record 5: The patient elected the hospice benefit on 05/08/2024. The initial nursing assessment dated 05/08/2024 included documentation that the patient’s pain was well managed with Hydrocodone/Acetaminophen tablet 7.5MG/325MG as needed. The plan of care and medication profile dated 05/08/2024 did not include Hydrocodone/Acetaminophen tablet 7.5MG/325MG. The medication was not included in the medication review. During joint clinical record reviews and interviews on 05/31/2024, the Administrator, Director of Nursing, and the Quality Assurance Performance Improvement Nurse confirmed the hospice medication profile did not include all medications ordered.”

“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 but is not limited to the identification of duplicate drug therapy. 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, the agency did not ensure the medication review process identified duplicate drug therapy. Clinical Record 8: The patient elected the hospice benefit on 02/03/2024. Clinical record review revealed the medication profile dated 02/03/2024 included two orders for Acetaminophen for minor aches and pains: Acetaminophen 500MG tablets, two tablets every four hours as needed not to exceed 12 tablets in 24 hours, and Acetaminophen 650MG every six hours as needed. There was no documented evidence in the clinical record that duplicate drug therapy was identified, when the medication profile contained two orders for Acetaminophen. Clinical Record 13: The patient elected the hospice benefit on 03/01/2024. Clinical record review revealed the medication profile included two orders for Senna 8.6MG as needed for constipation: Senna 8.6MG tablet, two tablets at bedtime as needed, and Senna 8.6MG tablet, two tablets twice a day as needed. There was no documented evidence in the clinical record that duplicate drug therapy was identified, when the medication profile contained two orders for Senna. Clinical Record 19: The patient elected the hospice benefit on 06/07/2023. Clinical record review revealed the medication profile dated 06/07/2023 included two orders for Dulcolax 10MG suppositories daily as needed for constipation. There was no documented evidence in the clinical record that duplicate drug therapy was identified, when the medication profile contained two orders for Dulcolax. During joint clinical record reviews and interviews on 05/31/2024, the Administrator, Director of Nursing, and the Quality Assurance Performance Improvement Nurse confirmed that the clinical records did not contain evidence that medication reviews were completed to identify duplicate drug therapy.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies 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 8 of 19 (42%) clinical records reviewed, the agency did not ensure the individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in comprehensive assessments. Agency policy No. 9-017 Plan of Care, dated November 2020, stated in part, “The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments… This plan will focus on identified problems, goals, and interventions. The written plan of care will contain, but will not be limited to, the following… individualized interventions to assist with end-of-life care…statement of treatment goals and documentation of the progress outcomes.” Clinical Record 2: The patient elected the hospice benefit on 12/07/2023. The comprehensive psychosocial assessment dated 12/10/2023 included documentation that the patient had depression due to the loss of independence and was estranged from two children. The spiritual assessment dated 12/08/2023 identified isolation from family and friends as a problem for the patient. The initial plan of care dated 12/07/2023 and updated no less frequently than every 15 days through 05/29/2024 did not include patient and family goals and planned interventions associated with depression, loss of independence, and isolation. Clinical Record 3: The patient elected the hospice benefit on 04/11/2024. The comprehensive psychosocial assessment dated 04/12/2024 included documentation that the patient’s family was emotionally distraught, and assistance was needed with funeral planning. The initial plan of care dated 04/11/2024 and updated by the Medical Social Worker on 04/12/2024 and no less frequently than every 15 days through 05/29/2024 did not include patient and family goals and planned interventions associated with the family’s emotional issues and funeral planning. Clinical Record 5: The patient elected the hospice benefit on 05/08/2024. The initial psychosocial assessment dated 05/12/2024 included documentation that the patient’s family was emotional, reported family deaths, and dynamics that could affect the patient’s care needs, and was at moderate risk for complicated grief. The plan of care dated 05/15/2024 did not include patient and family goals and planned interventions associated with the family’s emotional issues and family dynamics affecting the patient’s care. Clinical Record 7: The patient elected the hospice benefit on 03/19/2024 with a terminal diagnosis of senile degeneration of the brain, not elsewhere classified. The initial nursing assessment dated 03/19/2024 included documentation that the patient was restless and lethargic. The initial plan of care dated 03/19/2024 did not include patient and family goals and planned interventions. Clinical Record 8: The patient elected the hospice benefit on 02/03/2024. The recertification comprehensive assessment dated 04/23/2024 included documentation that the patient had two plus pitting edema to bilateral lower extremities. The clinical record contained no documented evidence that the plan of care was updated to reflect patient and family goals and planned interventions associated with the patient’s edema. Clinical Record 9: The patient elected the hospice benefit on 01/13/2024 with the terminal diagnosis of unspecified systolic congestive heart failure. The initial nursing assessment dated 01/13/2024 included documentation that the patient had one plus edema of bilateral lower extremities and a medication regime that included Lasix 40MG daily to manage swelling. The initial plan of care dated 01/13/2024 did not include patient and family goals and planned interventions associated with the patient’s edema. Clinical Record 12: The patient elected the hospice benefit on 04/01/2024 with a terminal illness of acute on chronic systolic congestive heart failure. The initial nursing assessment dated 04/01/2024 included documentation that the patient had a suprapubic indwelling urinary catheter. The initial plan of care dated 04/01/2024 included patient and family goals for the indwelling catheter to remain patent, intact, and free of infection, but the plan of care did not include interventions associated with achieving the indwelling catheter goals established. Clinical Record 16: The patient elected the hospice benefit on 08/24/2023 with a terminal diagnosis of liver cell carcinoma. The initial nursing assessment dated 08/24/2024 included documentation that the patient had shortness of breath at rest and refused to wear oxygen. The initial plan of care dated 08/24/2024 did not include patient and family goals and planned interventions associated with the patient’s shortness of breath. During joint clinical record reviews and interviews on 05/31/2024, the Administrator, Director of Nursing, and the Quality Assurance Performance Improvement Nurse confirmed that the initial and updated plans of care did not include patient and family goals and planned interventions associated with identified issues including depression, emotional distress, isolation, restlessness, edema, shortness of breath, and indwelling urinary catheterization.”

“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 measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 19 (11%) 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. Agency policy No. 9-017 Plan of Care, dated November 2020, stated in part, “The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments… This plan will focus on identified problems, goals, and interventions. The written plan of care will contain, but will not be limited to, the following… measurable outcomes anticipated from implementing and coordinating the plan of care.” Clinical Record 5: The patient elected the hospice benefit on 05/08/2024 with a terminal diagnosis of unspecified chronic obstructive pulmonary disease. The initial nursing assessment dated 05/08/2024 included documentation that the patient had four plus pitting edema in bilateral lower extremities. The plan of care dated 05/08/2024 identified the goal, edema will be reduced to an optimal level. The goal was not measurable when it did not identify what optimal reduction in edema would be for the patient. Clinical Record 6: The patient elected the hospice benefit on 04/22/2024 with a terminal diagnosis of unspecified B-cell lymphoma of unspecified site. The initial plan of care dated 04/22/2024 included goals and interventions associated with the patient’s potential for pain. The plan of care included goals to identify and manage barriers to pain management and an optimal level of consciousness would be maintained in balance with symptom management, but the plan of care did not include an anticipated measurable outcome associated with the patient’s pain. During joint clinical record reviews and interviews on 05/31/2024, the Administrator, Director of Nursing, and the Quality Assurance Performance Improvement Nurse confirmed the identified plans of care did not include measurable outcomes for edema and pain.”

“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 for up to one (1) year following the death of the patient. 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 1 of 3 (33%) clinical records reviewed with bereavement services provided, the agency did not ensure bereavement services reflected the needs of the bereaved per the bereavement plan of care that identified the types and frequency of bereavement services to be delivered. Agency policy No. 9-023 Bereavement Services, dated November 2020, stated in part, “A bereavement file will be maintained on each family/caregiver unit of care. Each file will contain the following information: …a bereavement plan of care…” Clinical Record 19: The patient elected the hospice benefit on 06/07/2022 and died at home on 06/24/2023. A condolence call dated 07/14/2023 included documentation that a bereavement risk assessment was completed and identified the bereaved at low risk for complicated grief and documented that the bereaved accepted a plan for a follow-up phone call and supportive emails for 13 months. There was no documented evidence in the clinical record that a bereavement plan of care including the types and frequency of bereavement services was developed for the bereaved. During joint clinical record reviews and interviews on 05/31/2024, the Administrator, Director of Nursing, and the Quality Assurance Performance Improvement nurse confirmed the clinical record did not contain a bereavement plan of care.”

“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 [Registered Nurse] who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provided patient specific care instructions to the hospice aide. Clinical Record 1: The patient elected the hospice benefit on 11/13/2023 with a terminal diagnosis of Alzheimer’s disease. The initial plan of care dated 11/13/2023 included an order for puree consistency diet with nectar thick liquids. The hospice aide care plan dated 04/20/2024 included a diet of “as tolerated” and instructed the aide to assist with feedings and encourage fluids as tolerated if not contraindicated. Although the aide’s care plan alerted the aide to the patient’s aspiration risk, the plan did not include notification to the aide of the patient’s pureed diet with nectar-thickened liquids. Clinical Record 3: The patient elected the hospice benefit on 04/11/2024. The initial nursing assessment dated 04/11/2024 included documentation that the patient was Spanish-speaking and required an interpreter. The hospice aide care plan dated 04/11/2024 did not alert the aide to the patient’s language barrier and the need for an interpreter. During joint clinical record reviews and interviews on 05/31/2024, the Administrator, Director of Nursing, and the Quality Assurance Performance Improvement Nurse confirmed that the hospice aide care plans did not alert the aide to specific dietary needs and language barriers.”

“It is required that a hospice aide provides services that are 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 standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 17 (18%) clinical records reviewed with hospice aide services provided, the agency did not ensure the aide provided services as ordered by the Interdisciplinary Group (IDG) and included in the plan of care Agency policy No. 6-022 Clinical/Service Data Collection, revised November 2020, stated in part, “Entries into the clinical/service record will be made on the day care/service is provided to the patient.” Clinical Record 5: The plan of care dated 05/08/2024 included an order for hospice aide visit frequency of two visits per week. The hospice aide documented that the patient refused aide visits on 05/09/2024, 05/14/2024, and 05/16/2024. The clinical record contained no documented evidence that the aide provided visits from 05/17/2024 to 05/30/2024 and no documentation as to why the visits were missed. Clinical Record 12: The plan of care dated 04/01/2024 included an order for hospice aide visit frequency of two visits per week. The clinical record contained no documented evidence that the hospice aide provided visits from 05/19/2024 to 05/30/2024 and no documentation as to why the visits were missed. Clinical Record 13: The plan of care dated 03/01/2024 included an order for hospice aide visit frequency of two visits per week. The clinical record contained no documented evidence that the hospice aide provided visits from 05/19/2024 to 05/30/2024 and no documentation as to why the visits were missed. During joint clinical record reviews and interviews on 05/31/2024, the Administrator, Director of Nursing, and the Quality Assurance Performance Improvement Nurse confirmed the clinical records did not contain evidence that hospice aide visits were completed as ordered.”

“It is required that each patient’s record includes, physician orders. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure the clinical record contained physician orders for care and services provided. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 04/11/2024 with a terminal diagnosis of severe protein-calorie malnutrition. The patient resided at a skilled nursing facility (SNF). During the home visit observation with the Medical Social Worker (Personnel Record 3) on 05/29/2024, a treatment review was completed by comparing the hospice plan of care with the treatment record from the SNF. The SNF treatment record included orders for a mechanical soft texture, thin liquid consistency diet, and a house shake nutritional supplement, to be given with meals. The hospice plan of care dated 05/29/2024 and the clinical record did not contain a physician order for the mechanical soft diet and the house shake. Clinical Record 6: The patient elected the hospice benefit on 04/22/2024. The initial nursing assessment dated 04/22/2024 included documentation that the patient had an indwelling urinary catheter in place with irrigation performed as needed. The clinical record did not contain a physician order for the indwelling urinary catheter care, change, and irrigation. Clinical Record 19: The patient elected the hospice benefit on 06/07/2023. The initial nursing assessment dated 06/07/2024 included documentation that the patient reported a poor appetite and was supplementing dietary needs with electrolyte drinks throughout the day. The clinical record did not contain a physician’s order for an electrolyte drink. During joint clinical record reviews and interviews on 05/31/2024, the Administrator, Director of Nursing, and the Quality Assurance Performance Improvement Nurse confirmed the clinical records did not contain physician orders for the mechanical soft diet, nutritional supplement drinks, and indwelling urinary catheter care, change, and irrigation.”

“It is required that 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 2 (50%) clinical records reviewed where the patient resided in a skilled nursing facility (SNF), the agency did not ensure the hospice plan of care specified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 6: The patient elected the hospice benefit on 04/22/2024. The patient resided in the SNF. The initial nursing assessment dated 04/22/2024 included documentation that the patient had pressure wounds to the coccyx and upper back. Clinical record review revealed the physician wrote orders for daily wound care on 04/23/2024, 04/26/2024, 05/05/2025, 05/07/2024, and 05/13/2024. The hospice plan of care was updated to include the ordered wound care but did not identify the specific provider responsible for performing the wound care as ordered by the physician. During joint clinical record reviews and interviews on 05/31/2024, the Administrator, Director of Nursing, and the Quality Assurance Performance Improvement Nurse confirmed the hospice plan of care did not specify which provider would perform the wound care ordered.”

“It is required that the hospice designates a member of each Interdisciplinary Group (IDG) who is responsible for a patient/resident in a SNF/NF or ICF/IDF. The designated IDG member provides overall coordination of care of the patient/resident, working with the facility representative staff. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 2 (50%) clinical records reviewed where the patient resided in a skilled nursing facility (SNF), the agency did not ensure a designated Interdisciplinary Group (IDG) member worked with a facility representative and provided the overall care coordination of the patient. Agency policy No. 1-030 Provision of Care to Residents Of SNF/NF Or ICF/IID, revised November 2020, stated in part, “The organization will assume responsibility for professional management of the resident’s hospice services provided. …The organization will designate a member of each Interdisciplinary Group that is responsible for a patient who is a resident of the SNF/NF… The designated member is responsible for: …Providing overall coordination of hospice care of the resident with the facility representatives. Communicating with the facility representatives… to ensure quality of care for the patient and family.” Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 04/11/2024 with a terminal diagnosis of severe protein-calorie malnutrition. The patient resided in a skilled nursing facility (SNF). During the home visit observation with the Medical Social Worker (Personnel Record 3), a medication review was completed by comparing the hospice medication profile with the SNF medication administration record (MAR). The review revealed duplicate drug therapies that included: Acetaminophen 500MG capsule every 6 hours as needed for moderate pain management, Acetaminophen Extra Strength 500MG tablet, 1000MG every six hours as needed for mild pain management, Tylenol (Acetaminophen) 325mg tablet, two tablets every four hours as needed for mild pain, Guaifenesin 100MG/5ML liquid, 10ML every four hours as needed for cough or congestion, and Guaifenesin 100MG/5ML oral syrup, 10ML every four hours as needed for cough and congestion. The clinical record did not contain documented evidence that the designated IDG member coordinated patient care with the SNF representative to remove duplicate medications from the facility’s MAR. During joint clinical record reviews and interviews on 05/31/2024, the Administrator, Director of Nursing, and the Quality Assurance Performance Improvement Nurse confirmed the clinical record did not contain documented evidence that the designated IDG member worked with a facility representative to coordinate the patient’s care and remove duplicated medications from the MAR.”