Alleviate Hospice, Inc.

“Upon patient record review, 7 of 14 (Patient #1, 2, 3, 5, 7, 8, & 10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: Tylenol Extra Strength 500mg three times daily PRN “pain” present on the medication profile. Tramadol 50mg one tab every 8 hours as needed “Pain” also present. Neither medication indicates specific instructions for administration related to severity or intensity of pain. Also, Acetaminophen suppository 650mg every 6 hours as needed present on medication list. There are no indications listed on any of the medications for maximum daily dose of Acetaminophen/Tylenol for patient safety. Morphine Sulfate Concentrate found on medication profile with the instructions of, “every 4 hours as needed pain/sob” with no complete instructions on what pain severity or intensity would require administration of Morphine Sulfate rather than listed Tylenol or Tramadol. Patient 2: Oxygen concentrator present on DME and noted in home during home visit. No evidence of Oxygen therapy on medication record. Further, Acetaminophen suppository 650mg duplicated on medication record with order dates of 11/07/23 and 4/13/24. Patient 3: Ibuprofen 600mg tablet for arthritis pain, Acetaminophen 650mg suppository for mild pain/fever, Norco 5mg-325mg for moderate-severe pain are all present on the medication record, however, Morphine Sulfate 20mg/ml for pain/sob listed with no further indications on when to initiate comfort medication rather than other available options. Patient 5 & 8: Morphine Sulfate Concentrate as needed “pain/sob” and Acetaminophen 500mg as needed “pain” present on medication profile with no further instructions or indications on what severity or intensity would warrant administration of various medications. Patient 7: Duplicate medications present on medication record, “Bisac-Evac 10mg rectal suppository every 12 hour as needed” and, “Duoneb 3mg-0.5mg/3ml 1 solution every 6 hours as needed”. Further, Morphine Sulfate concentrate 20mg/ml every 4 hours as needed is duplicated as well. Patient 10: Medication record reveals Metamucil 3.4g powder twice daily with no instructions regarding liquid to reconstitute medication. Further, a second fiber powder, Benefiber, is present once daily with no further instructions on reconstitution of medication. Also, Morphine Sulfate Concentrate as needed “pain/sob” and Acetaminophen 500mg as needed “pain” present on medication profile with no further instructions or indications on what severity or intensity would warrant administration of various medications.”

“Upon patient record review, 1 of 14 (Patient #5) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 5: There is no RN visit documented since 4/30/24 for comprehensive assessment or update.”

“Upon patient record review, 1 of 14 (Patient #8) did not have evidence in the patient record that the hospice has 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 8: Oxygen use is documented per nursing notes with Oxygen instructions entered under “other” on the plan of care. However, there are no problems, interventions, or goals present for Oxygen therapy, respiratory status, or safe use and education r/t Oxygen.”

“Upon patient record review, 2 of 14 (Patient #7, &12) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 7 & 12: MSW frequency written as, “One-time then PRN” and spiritual care is written as “One-time then PRN”. There is no evidence of detailed scope and frequency to ensure patient needs are met.”

“Upon patient record review, 7 of 14 (Patient #1, 2, 3,5, 7, 8, & 10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: Tylenol Extra Strength 500mg three times daily PRN “pain” present on the Plan of Care. Tramadol 50mg one tab every 8 hours as needed “Pain” also present. Neither medication indicates specific instructions for administration related to severity or intensity of pain. Also, Acetaminophen suppository 650mg every 6 hours as needed present on Plan of Care. There are no indications listed on any of the medications for maximum daily dose of Acetaminophen/Tylenol for patient safety. Morphine Sulfate Concentrate found on Plan of Care with the instructions of, “every 4 hours as needed pain/sob” with no complete instructions on what pain severity or intensity would require administration of Morphine Sulfate rather than listed Tylenol or Tramadol. Patient 2: Acetaminophen suppository 650mg duplicated on Plan of Care with order dates of 11/07/23 and 4/13/24. Patient 3: Ibuprofen 600mg tablet for arthritis pain, Acetaminophen 650mg suppository for mild pain/fever, Norco 5mg-325mg for moderate-severe pain are all present on the plan of care, however, Morphine Sulfate 20mg/ml for pain/sob listed with no further indications on when to initiate comfort medication rather than other available options. Patient 5 & 8: Morphine Sulfate Concentrate as needed “pain/sob” and Acetaminophen 500mg as needed “pain” present on plan of care with no further instructions or indications on what severity or intensity would warrant administration of various medications. Patient 7: Duplicate medications present on plan of care, “Bisac-Evac 10mg rectal suppository every 12 hour as needed” and, “Duoneb 3mg-0.5mg/3ml 1 solution every 6 hours as needed”. Further, Morphine Sulfate concentrate 20mg/ml every 4 hours as needed is duplicated as well. Patient 10: Plan of Care reveals Metamucil 3.4g powder twice daily with no instructions regarding liquid to reconstitute medication. Further, a second fiber powder, Benefiber, is present once daily with no no further instructions on reconstitution of medication. Also, Morphine Sulfate Concentrate as needed “pain/sob” and Acetaminophen 500mg as needed “pain” present on plan of care with no further instructions or indications on what severity or intensity would warrant administration of various medications.”

“Upon patient record review, 2 of 14 (Patient #7 & 8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 7: Documentation and medication list reveal use of Oxygen by patient. An Oxygen concentrator and/or portable tanks are not found as ordered DME on the patient plan of care. Patient 8: Documentation reveals use of: mattress, hospital bed, walker, wheelchair, shower chair, nebulizer, oxygen concentrator, and e-tanks. No evidence of any of these items on patient plan of care.”

“Upon client record review, 4 of 14 (Patient #2, 4, 5, & 8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: MSW declined per MSW documentation at the time of initial assessment. Plan of Care contains frequency order at once at each recert. There are no clarification orders present to discontinue MSW services and no evidence of attempted or missed visits documented at the time of recert for third, fourth, or fifth recert periods. Patient 4: SC documents in -person visit to patient home on 5/4/24. Plan of Care frequency order for Spiritual Care services is marked as “declined”. Further documentation found in EMR of patient refusal of SC services. Also, nursing frequency listed as, “RN 1 per 2 weeks and SN 1 per week. RN visits completed as indicated per POC. SN frequency of 1 per week is not met for the weeks of 4/14/24, 4/21/24, and 5/12/24 with no evidence of missed or refused visits documented. Patient 5: SN frequency per plan of care is once weekly. There is one extra visit performed every other week. The weeks that an extra visit is performed, it appears an LVN and an RN are making a visit. The Plan of Care does not reflect the scope and frequency performed and has not been updated to reflect the patient’s apparent need. Patient 8: Plan of Care reveals MSW frequency of “per month and 2 PRN”. MSW is conducting visits at a frequency of once per certification period from the time of admission, 10/05/22.”

“Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: Aide instructions do not contain current Oxygen orders for aide knowledge. EMR has area for Oxygen LPM, Route, and for continuous or PRN to be specified for patient safety. Patient does have current Oxygen MD orders present on Plan of Care. Further, need for glasses due to decreased visual acuity not listed on aide instructions, and mechanical soft diet is not indicated as patient Plan of Care specifies, rather “as tolerated” is indicated on the current aide instructions.”

“Upon patient record review 2 of 14 (Patient #1 & 6) did not have evidence documentation in the patient record 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 by such hospice aide • Consistent with the hospice aide training Patient 1: Aide instructions effective 11/29/22 state vital signs to be obtained at each visit. Aide frequency twice weekly. No evidence of vital signs obtained at any aide visit for the current or prior certification period dating 1/30/24 - present date of 5/22/24. Patient 6: Aide documents “tidy patient’s room” on 5/15/24 visit, “light housekeeping done” on 5/8/24 visit, “changed soiled linens, removed trash and light housekeeping” documented at 4/29/24 visit. None of these actions are included on the aide instruction sheet (although completed by CHHA).”

“Upon patient record review 2 of 14 (Patient #6 & 7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 6 & 7: No evidence found of a hospice Aide supervisory visit completed by the RN since 5/6/24 as of current date of 5/23/24”

“Upon patient client record review, 7 of 14 (Patient #1, 6, 7, 8, 10, 13, & 14) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 1:No evidence found of the effective date of the hospice election, there is only a line for the date beside the patient or primary caregiver signature. This indicates the date the form was signed and does not specify the election date of services. There is no evidence of discussion and selection of the attending physician of patient choice. Patient 6, 7, 8, 10, 13, & 14: No evidence found on Election Statement of Date of Election of hospice services.”

“Upon patient client record review, 4 of 14 (Patient #1, 3, 8, & 10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: Nursing Re-cert Assessment with visit date 3/25/24 is completed in EMR but is not appropriately signed and dated by the clinician. All routine visit notes for SN and SC dated 3/5/24 through last documented visit, 5/15/24 are unsigned and undated by the appropriate completing clinician. Patient 3: Plan of Care frequency indicates nursing frequency as follows: RN 1 per week + 2 PRN visits, and SN 1x/week under “Frequency of Visit” section of the plan of care. In the “other” section of the POC, “Skilled nurse visits-1x/week” is free texted. It is unclear as to what frequency is desired by the patient and indicated as needed per patient acuity and MD order. Patient 8: Nursing recert visit dated 5/22/24 indicates need for hospice aide marked, “yes” with further tasks marked as a need “changing linen, grooming, light meal preparation, and other ADLs”. The nursing narrative note does not reveal discussion of hospice aide services discussed and accepted or refused. Prior documentation revealed pt had refused CHHA services. It is unclear if this is a new need and patient now agrees or this is the patient baseline with continued refusal. Patient 10: Plan of Care contains “Frequency of Visit” for CHHA as declined but under “Other” HA visits - 2x/week is listed. Is is unclear which frequency is valid and desired by patient.”