Grace and Glory Hospice, Inc.

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the initial bereavement assessment was completed. Clinical Record 2: The patient elected the hospice benefit on 12/29/2023 with a terminal diagnosis of degenerative disease of the nervous system. Clinical record review revealed no documented evidence that the initial bereavement assessment had been completed as part of the comprehensive assessment and was not incorporated into the patient’s plan of care. During a joint clinical record review and interview on 01/18/2024, the Administrator /Director of Patient Care Services agreed the bereavement assessment was not present in the clinical record.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. 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 individualized plan of care included planned interventions based on problems identified in the comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 02/21/2023 with a terminal diagnosis of protein-calorie malnutrition. The plan of care dated 02/21/2023 contained no documented evidence of planned interventions based on the patient’s terminal diagnosis documented on the comprehensive assessment and plan of care. Clinical Record 2: The patient elected the hospice benefit on 12/29/2023 with a terminal diagnosis of degenerative disease of the nervous system. The plan of care dated 12/29/2023 contained no documented evidence of planned interventions based on the patient’s terminal diagnosis documented on the comprehensive assessment and plan of care. Clinical Record 3: The patient elected the hospice benefit on 06/13/2023 with a terminal diagnosis of Alzheimer’s dementia. The plan of care dated 06/13/2023 contained no documented evidence of planned interventions based on the patient’s terminal diagnosis documented on the comprehensive assessment and plan of care. During a joint clinical record review and interview on 01/18/2024, the Administrator /Director of Patient Care Services agreed problems for the primary diagnosis should have been added to the plan of care.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician 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 3 of 19 (16%) clinical records reviewed revealed the agency did not ensure the individualized plan of care was updated based on changes identified in the comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 06/13/2023 with a terminal diagnosis of Alzheimer’s dementia. Clinical record review revealed the skilled nurse documented on the nursing visit note dated 08/31/2023 the patient had a “left heel deep tissue injury (DTI) fully healed no eschar and pink dry healthy wound bed.” The nursing visit notes dated 10/26/2023 and 12/30/2023 documented the patient’s skin was “clean dry and intact.” Review of the patient’s plans of care from admission on 06/13/2023 through the current plan of care dated 12/10/2023 revealed no documented evidence that the patient’s plan of care was updated with assessed changes in the patient’s skin integrity and wound status. Clinical Record 8: The patient elected the hospice benefit on 11/08/2023 with a terminal diagnosis of pneumonia. The initial plan of care dated 11/08/2023 listed the patient as “imminently dying.” The problems, goals, and interventions on the plan of care suggested this would be within 24 to 48 hours. The plan of care was not updated as the patient status changed to reflect that the patient was no longer imminently dying. Clinical Record 11: The patient elected the hospice benefit on 10/17/2023 with a terminal diagnosis of malignant neoplasm of the left bronchus. The skilled nurse documented on the nursing visit note dated 11/06/2023 that “the patient is observed holding her abdomen and appears restless. Answer to pain controlled with current intervention: NO-Pain of 4.” The plan of care did not include a problem, goal or an intervention for pain and was not updated to include a pain intervention. During a joint clinical record review and interview on 01/19/2024, the Administrator /Director of Patient Care Services agreed the plans of care should have been updated.”

“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 who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 6 of 19 (32%) clinical records reviewed with aide services provided, the agency did not ensure specific written patient care instructions were provided for the hospice aides. Clinical Record 3: The patient elected the hospice benefit on 06/13/2023 with a terminal diagnosis of Alzheimer’s dementia. The nurse documented on the initial comprehensive assessment dated 06/13/2023 that the patient had a secondary diagnosis of seizures, and the patient was prescribed medications of Keppra and Depakote for seizures. The aide care plan assignment dated 06/13/2023 did not include information to the aide that the patient had a diagnosis of the seizures and should be on seizure precautions. Clinical Record 5: The patient elected the hospice benefit on 12/29/2023 with a terminal diagnosis of acute respiratory failure. The nurse documented on the initial comprehensive assessment dated 12/29/2023 that the patient was on continuous oxygen at 2 liters per minute. The aide care plan dated 12/29/2023 did not include specific instructions to the aide related to the patient’s need for oxygen during tasks. Clinical Record 8: The patient elected the hospice benefit on 11/08/2023 with a terminal diagnosis of pneumonia. The aide care plan assignment dated 11/13/2023 assigned the tasks of bed bath and dressing the patient. Review of the nursing visit note dated 12/28/2023 revealed documentation that the patient had “pressure wounds dressing changed frequently and getting better.” The aide care plan did not include information or instructions to the aide related to the patient’s wound(s) and how to care for the wound(s)/dressing(s) during assigned tasks. Clinical Record 9: The patient elected the hospice benefit on 11/06/2023 with a terminal diagnosis of pathological fracture of the right femur. The aide care plan assignment dated 11/06/2023 assigned the tasks of bed bath and dressing the patient. The skilled nurse documented on the nursing visit note dated 11/07/2023 that the patient had a wound on the right heel covered with adhesive foam dressing. The aide care plan assignment did not include instructions to the aide related to the patient’s wound and how to care for the wound and dressing during assigned tasks. Clinical Record 10: The patient elected the hospice benefit on 10/24/2023 with a terminal diagnosis of multiple sclerosis. The skilled nurse documented on the nursing assessment dated 10/24/2023 that the patient had “bilateral wounds in different stages of care, Calmoseptine, non-adhesive dressing wrapped with kerlix.” The aide care plan assignment dated 10/24/2023 did not notify the aide of the wounds and did not include instructions on how to care for the wound/dressing while providing care to the patient. Clinical Record 13: The patient elected the hospice benefit on 04/20/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. The aide care assignment dated 04/20/2023 assigned the tasks of shower and dressing patient. The skilled nurse documented on the nursing visit note dated 11/21/2023 that the patient had “left calf Unna boots and kerlix were applied to the patient.” The aide care plan assignment was not updated to include instructions to the aide on how to care for the wound/dressing while providing care to the patient. During joint clinical record review and interview on 01/18/2024, the Administrator /Director of Patient Care Services agreed these items had not been included in the aide care plans.”

“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 1 of 10 (10%) clinical records reviewed with patient recertification, the agency did not ensure the physician completed the recertification of the terminal illness in the required time frame. Clinical Record 15: The patient elected the hospice benefit on 07/07/2023 with a terminal diagnosis of Alzheimer’s disease. Clinical record review revealed the second benefit period started 10/05/2023 and the recertification for terminal illness was signed by the physician on 10/16/2023, 11 days after the recertification and 6 days outstanding. During joint clinical record review and interview on 01/18/2024, the Administrator /Director of Patient Care Services confirmed the recertification of terminal illness was signed outside of the required timeframe.”

“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 2 of 2 (100%) clinical records reviewed in which the patient revoked the hospice benefit, the agency did not ensure the attending physician was forwarded a copy of the discharge summary. Clinical Record 15: The patient elected the hospice benefit on 07/07/2023 with a terminal diagnosis of Alzheimer’s disease. The patient revoked the hospice benefit on 10/27/2023 to seek aggressive treatment. Clinical record review revealed no documented evidence that a copy of the discharge summary was sent to the attending physician. Clinical Record 16: The patient elected the hospice benefit on 08/09/2023 with a terminal diagnosis of nontraumatic hemorrhage of the brain. The patient revoked the hospice benefit on 08/21/2023 to seek aggressive treatment. Clinical record review revealed no documented evidence that a copy of the discharge summary was sent to the attending physician. During a joint clinical record review and interview on 01/18/2024, the Administrator /Director of Patient Care Services confirmed a copy of the discharged summary had not been faxed or otherwise sent to the attending physician.”

“It is required that the hospice discharge summary provided to the patient’s community attending physician upon hospice discharge includes at least the following, a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient discharge, the agency did not ensure the discharge summary included the patient’s current plan of care. Clinical Record 15: The patient elected the hospice benefit on 07/07/2023 with a terminal diagnosis of Alzheimer’s disease. The patient revoked the hospice benefit on 10/27/2023. Review of the discharge summary revealed no documented evidence that the patient’s current plan of care was included. Clinical Record 16: The patient elected the hospice benefit on 08/09/2023 with a terminal diagnosis of nontraumatic hemorrhage of the brain. The patient revoked the hospice benefit on 8/21/2023. Review of the discharge summary revealed no documented evidence that the patient’s current plan of care was included. During a joint clinical record review and interview on 01/18/2024, the Administrator /Director of Patient Care Services agreed the discharge summary did not include the required elements.”