Honest Hospice

“Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure the patient right to participate in decisions about their care, treatment, or services was respected. On review of all active patient records there was no documentation that the patient or caregiver was informed of the Patient Notification of Hospice Non-Covered Items, Services, and Drugs as this information could not be located on the record. The Administrator Designee was able to present the addendum form and review the process yet there was no indication the patients were given the information as required.”

“Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure the comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. On review of RRHV#1 the patient elected hospice in April and there was no psychosocial assessment documented at time of survey. There was documentation of a spiritual care assessment visit within 5 days yet no documentation of the assessment completed. In RRHV#2, and RRHV#3 there was no documentation of a psychosocial or spiritual assessment. The RN initial comprehensive assessment noted a psychosocial and spiritual screening and documented that a MSW and Spiritual visit was needed yet later orders noted services declined without a psychosocial/spiritual assessment documented. In RRNHV#4, and RRNHV#5 there was no documentation of a psychosocial assessment. These observations were reviewed with the Administrator Designee and the Administrator/DON.”

“Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure that a patient specific comprehensive assessment that identified the patient’s need for hospice care and services to include severity of symptoms was conducted. On review of RRHV#2 the patient record documentation noted multiple wounds to the heels, ankle, and buttocks. There was no documentation of a comprehensive wound assessment to include details such as size, color, drainage, odor, surrounding skin as required. In RRHV#3 the initial comprehensive assessment noted the patient was uncomfortable because of pain yet there was no comprehensive assessment conducted to assess details such as: type, location, frequency, character, and tolerable level. In RRNHV#5 and RRNHV#9 the patient indicated there was pain yet the pain was not assessed per policy to include highest level, lowest level and patient pain goal as required by policy. In RRNHV#7 there was documentation the patient had a wound yet no comprehensive assessment of the wound as required. In RRNHV#10 the patient was diabetic yet the initial comprehensive assessment the endocrine system assessment was left blank. Further, the plan of care noted orders for daily blood glucose monitoring yet the blood glucose monitoring assessment was not documented by nursing during May. These observations were reviewed with the Administrator Designee and the Administrator/DON.”

“Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the update of the comprehensive assessment was accomplished by the interdisciplinary group as frequently as the condition of the patient required but no less frequently that every 15 days. On review of RRHV#1 and RRHV#2 each IDG meeting every 15 days the updated to the comprehensive assessment was noted to be nearly identical verbiage each update and did not address patient’s progress toward desired outcomes nor reassessment of the patient’s response to care. In RRNHV#4, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, RRNHV#10 the most recent IDG meeting was incomplete as there was no update to the comprehensive assessment documented. On discussion with Administrator Designee it was noted the meeting was started but delay and would not be completed until Friday after survey leaving a 17 day gap in update to the comprehensive assessment. In RRNHV#9 there was a 42 day gap in documentation of RN visits from March to May. These observations were reviewed with the Administrator Designee, and the Administrator/DON.”

“Observed in Record Review. In 2 of 10 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 RRHV#1 there was documentation of visits by the RN being made with a date and time in and time out conducted in April and other visits conducted in May, per the leadership, but not yet entered into the system. The Initial spiritual assessment by the Chaplain there was visit note with a time in and time out yet the note was blank with no documentation of the assessment. In RRHV#2 the RN documentation for April and May were incomplete as notes had not been entered into the system at time of survey. Per the Administrator Designee the policy is that visit notes must be entered into the record within 72 hours of the visit. These observations were reviewed with the Administrator Designee and the Administrator/DON.”

“Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the individualized written plan of care is based on goals that are specific, measurable, and time bound. On review of RRHV#3 there were goals that were noted to not be specific and measurable such as: Pt will report BP within acceptable range. In RRNHV#4 an example was Promote rest status for pt/family/PCG and Blood sugar management for patient comfort. Further all goals were noted to have a target/achieve by date of the end of the certification period. In RRNHV#5 an example was Pt/Family/PCG will verbalize understanding that symptom is a part of the disease process and the limitations of treatments and Reduce discomfort with improved bowel elimination status. Further examples can be seen in RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, and RRNHV#10. These observations were reviewed with the Administrator Designee and Administrator/DON.”

“Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the patient/primary caregiver receive education and training as appropriate to their responsibilities for the care and services identified in the plan of care. On review of RRNHV#5 there was a pain medication Norco added yet there was no documentation in the record that the patient/caregiver was educated on the medication to include indication, dosage, frequency, route, and potential side effects. On review of RRNHV#9 the patient was prescribed Lactulose and Norco that were documented in a communication note yet there was no documentation that the patient/family was educated on the new medications. In RRNHV#10 the patient was diabetic and there were orders for blood glucose monitoring yet no documentation the patient was educated on diabetes, hypo and hyperglycemia or on blood glucose monitoring to include return demonstration. These observations were reviewed with the Administrator Designee and the Administrator/DON.”

“Observed in Record Review. In 5 of 10 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 RRHV#1 the nursing document noted that the patient was taking Acetaminophen 500mg for pain however there were no physicians orders for the medication noted on the patient’s plan of care. Further in RRHV#1 home observation there was a pressure dressing to the patient’s right antecubital space and when questioned the caregiver noted it was for a lab draw for a Divalproex level yet there were no physicians order nor was the lab indicated on the plan of care. In RRNHV#7 there was an order for wound care that was incomplete as it had no location indicated. Further, there was an order for diclofenac gel that did not have a dosage of location or where to apply the gel. In RRNHV#8 the patient was diabetic, and nursing was documenting blood glucose monitoring yet there were no orders on the plan of care for the monitoring. In RRNHV#9 there were multiple pain medications ordered as needed (Naproxen, Ibuprofen, and Norco) yet there were no specific instructions to guide the patient on when to use which medication. In RRNHV#10 the patient was ordered oxygen 2-5 lts as needed but no specific instruction of how to choose the liter flow. These observations were reviewed with the Administrator Designee and the Administrator/DON.”

“Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the ongoing sharing of information between all disciplines. In review of RRNHV#4 there was documentation in the record that the patient barely slept, and became loud and aggressive yet there was no documentation that the change in patient condition was reported to the physician. In RRNHV#5 on admission the documentation noted the patients pain 10/10 and indicated the current pain medication was not working yet there was no documentation the physician was informed of the patient’s pain. In RRNHV#8 the documentation from the RN noted a blood glucose of 356 but no documentation that the physician was informed of the issue. These observations were reviewed with the Administrator Designee.”

“Observed in Patient Home. In 1 of 1 home visits conducted, with the spiritual counselor, the organization failed to ensure the patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. On home observation with the spiritual counselor (SC) at RRHV#3 the visit was the SC’s first visit and was to conduct an initial spiritual assessment. On observation the SC provided prayer only and did not inquire with the caregiver to assess for any spiritual needs. This observation was reviewed with the Spiritual Counselor and the Administrator/DON.”

“Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure the medical director review the clinical information for each hospice patient and provide written certification. On review of RRHV#3 the Initial Certification of Terminal Illness (CTI) had not been completed with a written narrative to certify the patient’s life expectancy is six months or less if the illness runs its normal course. In RRNHV#6 the Initial CTI physician’s narrative lacked all required elements as it read Based on the MD Face to Face encounter and RN assessment, patient meets the LCD guidelines for hospice services and is appropriate for hospice services. Further decline is anticipated due to poor prognosis. Continue with the plan of care. Similar narratives that lacked required elements were seen in RRNHV#7, and RRNHV#10. In RRNHV#9 the physicians narrative read like a nursing note that noted services needed but lacked required elements to establish eligibility. These observations were reviewed with the Administrator Designee.”

“Observed in Patient Home. In 2 of 3 home visits conducted, where medication reconciliation was conducted, the organization failed to ensure the patient record contain all information to reflect the patient’s care, treatment, and services. On home observation of the medication reconciliation for RRHV#1 the medication profile did not match the profile and physicians orders per the hospice plan of care. In the plan of care the patient was taking Divalproex 125 mg daily, yet in the home and on home profile the patient was getting 2 tabs daily (1 in the AM and 1 in the PM). Quetiapine 50 mg was ordered daily at bedtime yet in the home the patient was getting 1/2 tab in the AM and 1 1/2 tab in the PM. In RRHV#3 during medication reconciliation there were medications that were being administered by the caregiver differently than that of the Plan of care. The caregiver noted the patient was no longer taking Calcium + D, and was taking Losartan 1 tab as opposed to 1/2 listed in the record. She also stated the Memantine was given 2 times a day and not daily as ordered. She noted the changes took place approximately 2 months ago. These observations were reviewed with the Administrator Designee, and The Administrator/DON.”

“Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure that all entries in the patient record were legible, clear, complete, and appropriately authenticated and dated in accordance with the organization’s policy and currently accepted standards of practice. In all active patient records reviewed it was noted that most all entries were in various stages of submission status and therefore not completed and were not electronically signed and dated as part of the record. In RRNHV#4 it was noted that the election of Benefits was signed by the patient representative and hospice representative yet was not dated. These observations were reviewed with the Administrator Designee.”

“Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to maintain complete and accurate patient records. On review of RRHV#3 the patient record noted the patient was a full code yet there was a signed POLST stating the patient was a DNR. In RRNHV#4 there was RN documentation that appeared nearly identical to the initial assessment documentation to include stating that the consents were signed during the visit however the visit took place 2 weeks after the admission start of care visit. These observations were reviewed with the Administrator Designee.”