Best Hospice Provider, Inc.

“Based on interview and record review, the Hospice Agency (HA) failed to notify the Physician (MD) regarding the wound for one (Patient 3) out of 4 sampled patients. This failure resulted in inconsistent wound care and inability to re-evaluate the plan of care. This failure also had the potential to result in unnecessary discomfort and decreased quality of life. During a review of Patient 3s “;Hospice Nursing Initial Comprehensive Admission Assessment,” for benefit period dated 7/25/24 to 10/22/24, the assessment indicated Patient 3 resided in an assisted living facility (ALF) and had a Start of Care (SOC) date with HA on 7/25/24 with multiple diagnoses including malignant neoplasm of rectosigmoid junction (cancer of the rectum) and pressure ulcer of sacral (tailbone area), stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). The admission assessment also indicated, “;Assess skin integrity...Coccyx (tailbone) pressure ulcer closed...Encouraged to reposition every 2 hours.” During a review of Patient 3s “;Hospice Nursing Clinical Note,” dated from 7/28/24 to 8/14/24, the notes indicated Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 assessed and provided different wound care to Patient 3s wound on tailbone area. RN 1 and LVN 1 did not notify or obtain wound care orders from MD. During a review of Patient 3s “;Home Health Agency Care Note (care communication form of ALF),” dated 7/29/24, 8/2/24 and 8/10/24, the notes indicated RN 1 provided wound care to Patient 3 and again did not notify MD. During a telephone interview on 10/4/24 at 11:00 a.m. with LVN 1, LVN 1 stated she observed Patient 3 had a new wound on sacrum upon removal of an old dressing. LVN 1 further stated there was no order for wound care on patient 3s electronic clinical record and decided to provide the wound care. LVN stated she was unable to recall whether she communicated Patient 3s wound to MD. During a telephone interview on 10/4/24 at 11:36 a.m. with RN 1, RN 1 stated she had been the primary RN case manager for Patient 3. RN 1 stated she sent the order obtained from MD through the agencys text communication application and office clinicians should have entered the order on patient 3s electronic record. During a concurrent interview and record review on 10/4/24 at 1:45 p.m. with Director Patient Care Services (DPCS), Patient 3s electronic clinical record was reviewed. DPCS stated she did not find wound care orders for Patient 3. DPCS also stated that she expected licensed nurses should notify and obtain wound care orders from the MD per agencys protocol. DPCS confirmed the agencys text communication was an application available on all clinicians (field licensed nurses, doctors, supervisors, and the office clinical team) phones, and field licensed nurses could obtain care orders from MD. During a review of retrieved information from the agencys text communication application, dated 7/25/24 until 8/17/24, the information indicated RN 1 and LVN 1 did not obtain order from MD and did not notify the office clinical team of Patient 3s wound care. During a concurrent interview and record review on 10/15/24 at 11:30 a.m. with Licensed Vocational Nurse (LVN) 2. A photocopy of communication between LVN 1 and LVN 2 was reviewed. LVN 2 stated receiving the text message from LVN 1 on 8/14/2024, regarding Patient 3s wound. LVN 2 further stated he called to obtain wound care order from Patient 3s MD. LVN 2 also stated he spoke with one of the clinical supervisors about the order, but he couldnt recall the name of the person he spoke with. LVN 2 did not document this communication in Patient 3s clinical record. During an interview on 10/15/24 at 12:00 p.m. with LVN 3 and RN 2, both stated they were unaware of Patient 3s wound or wound care needs and there was no physican order for wound care. They also stated that they did not receive a phone call from LVN 2 regarding Patient 3s wound care order on 8/14/2024. Additionally, RN 2 stated that LVN 1 only informed LVN 2 about Patient 3s wound because LVN 1 did not use the agencys text communication application.During a review of agencys policy and procedure (P&P) titled “;Skin Care/Wound Management Program Policy,” dated January 2024, the P&P indicated, “;Physician Orders for Wound Care...6. A physician order is required for any cleansing, medication, treatment, dressing, or a “;leave to open air”. Physician orders are input into the hospices medication administration record...After physician orders are received by the Skilled Nurse, the Plan of Care is updated with the newly acquired order.” During a review of agencys P&P titled, “;Verification of Physician Orders,” dated May 2023, the P&P indicated, “;To ensure that accurate physician orders are obtained in accordance with applicable law and regulation...Orders will be obtained from a licensed physician for care and services to be provided to hospice patients...2.All telephone orders...will be documented by the staff receiving the order, indicated by staff signature and credentials, and cosigned by the physician...3.Orders will be documented on a form provided by Best Hospice Providers Inc, dated and signed by the professional receiving the order.””

“Upon patient record review, 1 of 14 (Patient #11) did not contain evidence that the Hospice had developed an individualized written Plan of Care for each patient. The Plan of Care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The Plan of Care must include all services necessary for the palliation and management of the terminal illness and related conditions: Patient #11: The admitting RN documents in her 12/29/23 SOC Assessment that the patient has an indwelling Foley Catheter 16F/5cc balloon.” A verbal order was written on 12/29/23 for, “Foley 18 F/5cc. Change Q month.” Foley order was not updated to the next subsequent IDG note of 01/03/23; nor did the order delineate ‘who’ was to change such Foley Q month.”

“Upon patient record review, 2 of 14 (Patients #1 and 2) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #1: During Surveyor-attended home visit on 02/13/24 it was noted that the patient had the DME of: Hospital bed. This was not included on the POC. Patient #2: During Surveyor-attended home visit on 02/13/24 it was noted that the patient had the DME of: 1) Bed; 2) Walker; 3) Commode; and 4) Shower chair. These DME were not included on the POC.”

“Upon patient record review 1 of 14 (Patient #2) did not contain documented evidence that a Hospice Aide provided care/services only as are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2: During Surveyor-attended home visit on 02/12/24, the Aide was interviewed, and reported having assisted the patient, upon Aide arrival at the home, in Active/Passive Range of Motion; prior to the patient attempting to get out of bed and ambulate. This intervention was not assigned on the current Aide POC. The current Aide POC assigned a complete bed bath. The Aide provided a shower at this same home visit.”

“Upon patient record review, 1 of 14 (Patient #10) did not contain evidence that each patient record contained: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 There must be evidence that the Hospice Election Statement reflects that: The effective date of the Hospice Election, may be no earlier than the dated Election Statement. An individual/representative may not designate an effective date that is retroactive to the date the Hospice Benefit Election was signed up for: Patient #10: SOC was 12/28/23. However, the Election Statement was not dated by the patient’s representative until 01/12/24.”

“Upon Inpatient contract review, 1 of 1 (Sequoia Living GIP/RIP) did not contain evidence that it contained the contract requirements of: 1) The Hospice patient’s inpatient clinical record must include a record of all inpatient services furnished, and events regarding care that occurred at the facility; 2) That a copy of the Discharge Summary shall be provided to the Hospice at the time of discharge; and 3) That a copy of the inpatient clinical record is available to the Hospice at the time of discharge. This contract did not include: That a copy of the Discharge Summary shall be provided to the Hospice at the time of inpatient discharge.”