Medline Quality Hospice, Inc.

“Upon patient record review, 1 of 5 (Patient #4) 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 4: 8/20/24 initial assessment documents presence of right chest port a cath. The plan of care does not contain any instructions for the care and/or maintenance of the device.”

“Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient’s Rights and Responsibilities in a language and manner that the patient understands. Patient 2: The medical record contained nursing documentation stating the patient is Spanish speaking. There was no evidence of the Patient’s Rights and Responsibilities provided in Spanish. Patient 3: The medical record contained nursing documentation stating the patient is Spanish speaking. There was no evidence of the Patient’s Rights and Responsibilities provided in Spanish.”

“Upon patient record review 6 of 17 (Patient #1,#2,#3,#4,#5,#17) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #1: Upon review of record, the initial assessment completed on 05/02/24 did not address any spiritual needs of the patient or family. Patient #2: Upon review of the record, there was no evidence of an initial comprehensive spiritual assessment. Patient #3: Upon review of the record, there was no evidence of a psychosocial or spiritual comprehensive assessment completed. Patient #4: Upon review of record, there is no evidence of spiritual initial comprehensive assessment being completed. Patient #5: Upon review of record, an initial assessment was completed by RN on 9/28/22, however no spiritual needs we assessed or addressed. Patient #17: Upon review of record, there is no evidence of initial psychosocial needs. The patient also reported numerous falls, however there was no evidence of fall safety being addressed on the plan of care.”

“Upon patient record review, 5 of 17 (Patient #1,#6,#9,#10,#17) 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: There was no evidence of an order on medication profile for oxygen. Patient #6: The medication profile contained Voltaren 1% gel topical three times a day, however, there was no defined area for application. Patient #9: The medication profile is not up to date. On 02/09/24 there is an order for patient to receive comfort medications only. None of the routine or daily meds had been discontinued. Patient #10: The medication profile contained an order for calasoothe to be applied topically, however there was no defined area for application. Patient #17: The medication profile contained an order for Miralax, however there were no instructions for dilutant when preparing this medication.”

“Upon patient record review, 3 of 17 (Patient #3,#4,#9) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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 is considered in the bereavement plan of care. Patient #3: The patient was admitted on 9/19/23. There was no evidence of an initial bereavement assessment being completed. Patient #4: The patient was admitted on 05/31/23. There was no evidence of an initial bereavement assessment being completed. Patient #9: The patient was admitted on 01/26/24. There was no evidence of an initial bereavement assessment being completed.”

“Upon patient record review, 2 of 17 (Patient #4,#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 #4: Upon review of the record, there was no evidence of a comprehensive assessment between 08/22/23 and 09/19/23. Patient #5: Upon review of the record, there was no evidence of a comprehensive assessment completed after 8/22/23. The patient passed on 09/12/23.”

“Upon patient record review, 9 of 17 (Patient #1,#4,#5,#6,#7,#8,#9,#11,#12) 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 #1: Upon review of the record, there was no evidence of a care plan for spiritual or psychosocial problems, goals, or interventions. Patient #4: Upon review of the record, there was no evidence of a care plan for psychosocial problems, goals, or interventions. The record indicates patient was being treated and monitored for diagnosis of insulin dependent diabetes. There is no evidence of care plan for endocrine problems, goals, or interventions. Patient #5: The record indicated the patient was at high risk for falls. There is no evidence of care plan for safety and fall prevention. It was noted that patient had a “landing pad”. The record indicated patient has dysphagia, however there is no care plan with problems, goals, or interventions on dysphagia. Patient #6: Upon review of the record, there was no evidence of a care plan for psychosocial problems, goals, interventions. Patient #7: The record indicates the patient is at risk for aspiration and skin impairment. There is no evidence of care plan for problems, goals, or interventions on aspiration precautions or risk for skin impairment. Patient #8: Upon review of the record, there was no evidence of a care plan for psychosocial problems, goals, or interventions. Patient #9: Upon review of the record, there was no evidence of a care plan for psychosocial problems, goals, or interventions. Patient #11: The record indicates the patient was admitted with a diagnosis of ill-defined heart disease. There is no evidence of care plan with problems, goals, or interventions for cardiac dysfunction. Patient #12: The record indicates that the patient had dysphagia on admit. There is no evidence of care plan with problems, goals, or interventions on dysphagia.”

“Upon patient record review, 4 of 17 (Patient #1,#6,#10,#17) 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: The record indicates the patient was on Oxygen 2lpm continuous. There was not evidence of an order. The record indicates the patient was ordered daily wound care. There was no evidence of who was to perform care. The record indicates an order for lidocaine to be applied topically. There is no evidence of a defined area for application. The record indicates patient to receive Biotene. There is no evidence of a frequency, the order states per manufacturer recommendation. The record indicates patient to have thin liquids on 06/11/24 and on 5/27/24 documentation indicates patient to have nectar thick liquids. There is no evidence that the order was updated. Patient #6: The record indicated for Voltaren 1% gel apply topically three times a day. There is no evidence of a defined area for application. Patient #10: The recorded indicated for calasoothe for topical application. There is no evidence of a defined area for application. Patient #17: The record indicated patient has a coccyx wound stage 2 reported on admit. There is no evidence of a wound care order.”

“Upon patient record review, 9 of 17 (Patient #1,#3,#4,#5,#6,#7,#9,#11,#17) 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 #1: The record indicates patient having a bed, bedside table, shower chair, hoyer lift, and oxygen. There is no evidence of orders for equipment. Patient #3: The record indicates the patient having a walker per initial assessment. There is no evidence of orders for equipment. Patient #4: The record indicates the patient having a bed, overbed table, wheelchair, shower chair, geri chair, nebulizer, suction, oxygen , e tank, floor mat, and hoyer lift. There is no evidence of orders for equipment. Patient #5: The record indicates the patient having a bed, over bed table, wheelchair, shower chair, hoyer lift, geri chair, suction, oxygen concentrator, e-tank, and landing pad. There is no evidence of orders for equipment. Patient #6: The record indicates the patient having a shower chair and wheelchair. There is no evidence of orders for equipment. Patient #7: The record indicates the patient having an air mattress, overbed table, shower chair, hoyer lift, and o2 concentrator. There is no evidence of orders for equipment. Patient #9: The record indicates the patient has a geri chair, shower chair, walker, and a nebulizer. There is no evidence of orders for equipment. Patient #11: The record indicates patient has a bed, bedside table, walker, shower chair, oxygen concentrator, and hoyer lift. There is no evidence of orders for equipment. Patient #17: The record indicates the patient has a bed, over bed table, wheelchair, oxygen concentrator, nebulizer, suction, shower chair, and hoyer lift. There is no evidence of orders for equipment.”

“Upon patient record review, 3 of 17 (Patient #3,#4,#6) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #3: The record indicated patient had 1-2 falls in last 2 months, however there is no care plan for safety/fall prevention. Patient #4: The record indicates on 9/05/23 that the patient was found on the floor and was at high risk for skin impairment. There is no evidence that the plan of care was updated to include goals/interventions or progress on fall safety or risk for skin impairment. Patient #6: The record indicates on 05/02/24 per the RN that patient is at high risk for skin impairment. There is no evidence of an update to care plan for goals/interventions or progress on risk of skin impairment.”

“Upon client record review, 3 of 17 (Patient #8,#9,#12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8: The nurse visit frequency is two times per week. Between the dates of 2/15/24 - 2/27/24 daily nurse visit were made. The spiritual care visit frequency is one time per month. Two spiritual care visits were made for the month of February. One on 2/20/24 and the second one on 2/26/24. Patient #9: The nurse visit frequency is two times per month and three PRN visits. The week of 1/29/24 four scheduled nurse visits were made. The week of 2/5/24 four scheduled nurse visits were made. There is no evidence of visits being PRN. Patient #12: The record indicates the nurse visit frequency is two time a week. There were five visit made the week of admit (1/16/24).”

“Upon patient record review, 8 of 17 (Patient #8,#9,#10,#11,#12,#14,#16,#17) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #8: Upon review of bereavement plan of care, there was no evidence of the 1 month letter, 3 month letter, and sympathy card being completed. Patient #9: Upon review of the record, there is no evidence of an updated bereavement risk assessment after the passing of the patient. There was no evidence of a bereavement plan of care. There was no evidence of support being offered to bereaved. There was no evidence that bereavement support or services were declined. Patient #10: Upon review of record, there was no evidence of a bereavement plan of care. There was no evidence of support being offered to bereaved. There was no evidence that bereavement support or services were declined. Patient #11: Upon review of the record, there is no evidence of an updated bereavement risk assessment after the passing of the patient. There was no evidence of a bereavement plan of care. There was no evidence of support being offered to bereaved. There was no evidence that bereavement support or services were declined. Patient #12: Upon review of the record, there is no evidence of an updated bereavement risk assessment after the passing of the patient. There was no evidence of a bereavement plan of care. There was no evidence of support being offered to bereaved. There was no evidence that bereavement support or services were declined. Patient #14: Upon review of the record, there is no evidence of an updated bereavement risk assessment after the passing of the patient. There was no evidence of a bereavement plan of care. There was no evidence of support being offered to bereaved. There was no evidence that bereavement support or services were declined. Patient #16: Upon review of bereavement plan of care, there was no evidence of the 1 month letter, 3 month letter, and sympathy card being completed. Patient #17: Upon review of the record, there is no evidence of an updated bereavement risk assessment after the passing of the patient. There was no evidence of a bereavement plan of care. There was no evidence of support being offered to bereaved. There was no evidence that bereavement support or services were declined.”

“Upon patient record review, 4 of 17 (Patient #1,#2,#3,#4) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient’s conditions unrelated to the terminal illness Patient #1: The initial CTI did not contain a physician narrative that was specific to patient or the disease process. Patient #2: The initial CTI did not contain a physician narrative that was specific to patient or the disease process. Patient #3: The initial CTI did not contain a physician narrative that was specific to patient or the disease process. Patient #4: The initial CTI did not contain a physician narrative that was specific to patient or the disease process.”

“Upon patient client record review, 7 of 17 (Patient #2,#4,#5,#8,#9,#10, #12) 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 #2: Upon review of the record, there was no evidence of an addendum being provided. On the election of benefit, the addendum was both elected and declined. There is no evidence of clarification or communication with the patient or family. Patient #4: Upon review of client record, the addendum was not elected nor declined on the election of benefit form. There was no evidence of any follow up or communication with patient or family. Patient #5: Upon review of record, there was no evidence of the addendum being provided to the patient. The election of benefit did indicate that that they wished to receive the addendum. Patient #8: Upon review of record, the election of benefit indicated the the daughter listed 2 different physicians as her choice for attending physician. There was no documentation found that indicates that this was addressed or clarified with the POA as to which doctor she wanted as the attending physician. Patient #9: Upon review of record, there was no evidence of the addendum being provided to the patient. The election of benefit did indicate that that they wished to receive the addendum. Patient #10: Upon review of record, there is no evidence of the addendum being provided to. On the election of benefit the addendum was both elected and declined. There was no evidence of clarification or communication documented to follow up on the wishes of the patient or family. Patient #12: Upon review of record, there was no evidence of the addendum being provided to the patient. The election of benefit did indicate that that they wished to receive the addendum.”

“Upon client record review, 4 of 17 (Patient #2,#3,#4,#5) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient’s attending physician: • A copy of the hospice discharge summary • The patient’s clinical record, if requested Patient #2: The record indicates the patient revoked on 10/04/23 to go to the hospital for emergency treatment. There is no evidence of coordination of care, recent orders, summary of patient care and current condition, or plan of care being sent or communicated to attending or hospital for continuity of care. Patient #3: The record indicates the patient discharged to go to hospital on 09/25/23. There is no evidence of coordination of care, recent orders, summary of patient care and current condition, or plan of care being sent or communicated to a physician or hospital for continuity of care. Patient #4: The record indicates the patient was discharged on 09/20/23. There is no evidence of a discharge summary or this was sent to attending or not requested. Patient #5: The record indicates this patient was discharged on 09/12/23 for no longer meeting eligibility. There is no evidence of summary, records, orders, or plan of care sent to a physician or not requested.”

“Upon client record review, 3 of 17 (Patient #2,#3,#5) did not have evidence that the discharge summary includes all required information. Patient #2: The record indicates the patient revocated on 10/04/23 to go to the hospital for emergency treatment. There is no evidence the discharge summary included information regarding coordination of care, recent orders, current plan of care, or communication/coordination for continuity of care. Patient #3: The record indicates the patient discharged to go to hospital on 09/25/23. There is no evidence the discharge summary included information regarding coordination of care, recent orders, current plan of care, or communication/coordination for continuity of care. Patient #5: The record indicates this patient was discharged on 09/12/23 for no longer meeting eligibility. There is no evidence the discharge summary included information regarding coordination of care, recent orders, current plan of care, or communication/coordination for continuity of care.”

“Upon client record review, 3 of 17 (Patient #1,#2,#17) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #1: The nurse visit frequency is one time per week. The record indicates that every other week there were two nurse visits made. Patient #2: The nurse visit frequency is one time per week and three PRN visits. The week of 9/25/23 two nurse visits were made. There was no evidence of any PRN visits. Patient #17: The record indicates the nurse frequency is 1 time per week and RN visit once every 14 days. There were two nurse visits the week of admit and four nurse visits the week of 6/23/24.”

“Upon client record review, 3 of 17 (Patient #1,#3,#11) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #1: The record indicates patient has orders for wound care. There is no evidence on who is to provide the wound care. This patient resides in a SNF. Patient #3: The record indicates the patient had a PleurX drain, however the care plan did not indicate who was responsible for the care of the PleurX drain. The patient was in a SNF. Patient #11: The record indicates patient being treated for wounds to coccyx and left heel. There is no indication of who is responsible for the wound care. The patient resides at a SNF.”