Perpetual Care Hospice, Inc.

“It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed in which a patient was discharged for extended prognosis revealed the agency did not ensure the patient was given sufficient notice of non-coverage. Clinical Record 11: The patient elected the hospice benefit on 10/15/2022 for the diagnosis of encephalopathy. The patient was discharged for extended prognosis on 11/06/2023. The notification of Medicare non-coverage (NOMNC) was signed by the patient/family on the day of discharge, instead of the required 48 hours before discharge. During an interview and joint record review with the Director of Patient Care Services on 07/31/2024, stated she “realized the notice should have been given to the family earlier than the day of discharge.””

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the interdisciplinary group completed the initial comprehensive assessment within five (5) calendar days after the election of hospice care. Clinical Record 4: The patient elected the hospice benefit on 07/16/2024 with a diagnosis of chronic obstructive pulmonary disease. The social worker’s initial comprehensive assessment was completed on 07/23/2024, seven (7) days after the election of hospice care. During an interview and joint record review with the Director of Patient Care Services on 07/31/2024, she stated “There should have been a communication note explaining a reason if the social worker assessment was late.””

“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 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the individualized plan of care was revised as frequently as the patient’s condition required. Clinical Record 7: The patient elected the hospice benefit on 06/05/2024 for the diagnosis of malignant neoplasm of the right breast. The initial plan of care dated 06/05/2024 included a problem titled “Pain/Fever greater than 100 due to disease process.” A nursing visit dated 07/15/2024 included “Tramadol 50 mg for moderate c/o pain.” A nursing visit dated 07/27/2024 noted “pain 8/10, physician consulted, and medication changes made. Patient now reporting pain managed.” The written plan of care was not updated to reflect the changes noted in the nursing visits. Clinical Record 13: The patient elected the hospice benefit on 12/22/2023 for the diagnosis of malignant neoplasm of the bladder. A nursing visit was made on 01/03/2024 in which it was noted “patient declining and now needs aide assistance. Pain has increased. Medication changes were made.” During the time frame of 01/03/2024 to 01/06/2024 the patient’s daughter called the hospice office to express the patient had “vomited green bile and was continuing to decline.” She was advised to give medications from the comfort kit for nausea/vomiting. On 01/06/2024 a nursing visit was made that noted, “the patient was imminent.” The patient died later that day. During this time frame, the plan of care was not updated to reflect the changes in patient status. During an interview and joint record review with the Director of Patient Care Services on 07/31/2024, she stated “I need to update the plan of care during the visits or while things happen instead of just putting it in my notes.””

“It is required that 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 4 of 10 (40%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. Clinical Record 1: The patient elected the hospice benefit on 02/29/2024 for the diagnosis of acute kidney failure. The initial nursing assessment dated 02/29/2024 noted the patient to have 18 wounds in various stages (Stage II to Stage IV) covered with foam dressings. The hospice aide care plan dated 02/29/2024 included the relevant tasks of bathing via bed bath and visualize skin and report changes to nurse. Home Visit 1 was conducted on 07/31/2024 to observe Staff 7 (hospice aide). During this home visit, the care home’s owner advised the site visitor the number of wounds had healed from 18 to 11. The care home owner advised she had given the patient pain medication in “advance of the aide visit to ensure he was comfortable during the bath.” The wound dressings covered large portions of the patient’s body, especially the coccyx, hips, heels, and shoulders. Staff 7 advised she was “nervous as this was not normally her patient and she didn’t know about all these wounds,” The aide care plan did not include specific written instructions for the aide regarding the wounds, including notification of the wound location(s) or to notify the nurse if the dressings became soiled, dislodged or wet. Clinical Record 5: The patient elected the hospice benefit on 06/13/2024 for the diagnosis of Parkinson’s disease. The hospice aide care plan dated 06/13/2024 included the relevant task of “checking vitals every visit” without including specific parameters of when the aide should notify the nurse. Clinical Record 6: The patient elected the hospice benefit on 06/13/2024 for the diagnosis of Alzheimer’s disease. The hospice aide care plan dated 06/13/2024 included the relevant task of “checking vitals every visit” without including specific parameters of when the aide should notify the nurse. Clinical Record 7: The patient elected the hospice benefit on 06/5/2024 for the diagnosis of malignant neoplasm of the right breast. A physician order dated 06/5/2024 stated “Malignant wound on right breast, extending from right chest to mid abdomen and left chest wall. Do not wash or get chest area/cancer site wet per patient request.” The hospice aide care plan dated 06/5/2024 included the relevant tasks of bathing via a bed bath and visualize condition of skin and report to nurse. It did not notify the aide of the wound on the right breast or chest area or the patient’s specific request. During an interview and joint record review with the Director of Patient Care Services on 07/31/2024, she stated “We normally don’t have the aides take vital signs, but parameters should have been added if we request they take vital signs. I didn’t do those admissions (Clinical Records 5 and 6).” When discussing the wounds, she agreed the aides needed to be aware “to notify the nurse regarding the dressing needing to be replaced.””

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 2 of 7 (29%) clinical records reviewed in which the patient was recertified, revealed the agency did not ensure the recertification of the terminal illness was completed by the physician no later than two calendar days after the first day of the benefit period and no more than 15 days before the next benefit period. Clinical Record 3: Clinical record review revealed the 15th benefit period started on 07/23/2024. The recertification of terminal illness was not signed by the hospice medical director at the time of record review on 07/31/2024, 8 days after the start of the benefit period and 6 days outstanding. There was not a verbal order present. Clinical Record 10: Clinical record review revealed the 3rd benefit period started on 07/23/2024 and the recertification of terminal illness was not signed by the hospice medical director at the time of record review on 08/01/2024, 9 days after the start of the benefit period and 7 days outstanding. There was not a verbal order present. During an interview and joint record review with the Director of Patient Care Services on 08/01/2024, she stated “I do not know why these have not been signed by the physician or a verbal order put in.””

“It is required that if a patient revokes the election of hospice care, the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed in which a patient revoked the election of hospice care revealed the agency did not ensure the attending physician received a copy of the discharge summary. Clinical Record 12: The patient elected to revoke their hospice benefit for aggressive treatment on 09/04/2023. The clinical record did not contain evidence that the discharge summary had been forwarded to the attending physician. During an interview and joint record review with the Director of Patient Care Services on 07/31/2024, she stated they had not faxed or sent a copy of the discharge summary to the attending physician.”