Aviva Hospice Inc.

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the Interdisciplinary Group (IDG) completed the initial comprehensive assessment within 5 calendar days after the election of hospice care. Agency policy, Submission of Documentation, no date, stated in part, “Initial Assessments must be documented in 24-72 hours.” Clinical Record 4: The patient elected the hospice benefit on 05/07/2024 for the diagnosis of heart failure. As of the date of record review on 05/16/2024, the initial psychological assessment and the initial spiritual assessment were not documented in the clinical record a total of 9 days and 4 days outstanding. Clinical Record 11: The patient elected the hospice benefit on 01/29/2024 for the diagnosis of chronic obstructive pulmonary disease. Clinical record review revealed the spiritual assessment was not documented for the patient. During an interview and joint record review on 05/16/2024, the Administrator/Director of Patient Care Services confirmed the assessments had not been documented in the clinical records. When discussing Clinical Record 4, it was stated “they [the assessments] had been completed but had not been documented yet and the staff had not followed the documentation policy.” Human Resources Policy “Submission of Documentation which stated in part: Initial Assessments must be documented in 24-72 hours”.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 3 (67%) home visit observations, the agency did not ensure the medication review process was completed when the drug profile did not include the patient’s current medications. Home Visit 1: The patient elected the hospice benefit on 02/02/2024 for the diagnosis of unspecified cirrhosis of the liver. The patient resided at a Skilled Nursing Facility (SNF). During the home visit observation with the Hospice Aide (Personnel Record 7), a medication review was completed by comparing the facility medication record to the hospice medication record. The facility medication record contained the following medications not listed on the hospice medication record, Vitamin C and Zinc dated 02/08/2024, Ciclodan solution dated 02/28/2024. The hospice medication record contained the following medications not listed on the facility medication record, Ativan and Zofran dated 2/19/2024 and Benadryl dated 04/30/2024. Home Visit 2: The patient elected the hospice benefit on 02/19/2024 for the diagnosis of atherosclerotic heart disease. The patient resided at a SNF. During the home visit observation with the Licensed Vocational Nurse (LVN) (Personnel Record 4), a medication review was completed by comparing the facility medication record to the hospice medication record. The facility medication record contained the following medication not listed on the hospice medication record; Vitamin C dated 04/16/2024. The hospice medication record contained the following medications not listed on the facility medication record, Ativan and Zofran dated 02/19/2024. During an interview and joint record review on 05/16/2024, the Administrator/Director of Patient Care Services confirmed the medications had not been reconciled.”

“It is required that the Interdisciplinary Group [IDG], in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure the interdisciplinary group reviewed, revised, and updated the individualized plan of care as frequently as the patient’s condition required. Clinical Record 3: The patient elected the hospice benefit on 04/01/2024 for the diagnosis of heart disease. The clinical record contained the following communication notes, “04/19/2024 SN [Skilled Nurse] report that patient has dry cough for a few days. Robitussin ordered. 04/20/2024 Call from son reporting that cough is not improving with Robitussin. Montelukast was ordered for wheezing. 04/22/2024 Continuous O2 therapy started.” The plan of care (POC) dated 04/01/2024 included the following: “Respiratory Problem: Potential for altered respiratory status. Goal: No SOB [shortness of breath] will be reported by the next IDG meeting.” The POC was not updated to include the new medications and treatments ordered for the patient’s change in respiratory status. Clinical Record 7: The patient elected the hospice benefit on 03/06/2024 for the diagnosis of Alzheimer’s disease. The POC dated 03/06/2024 included the following: “Safety Risk for falls. Mobility Potential risk of harm due to fall risk.” The nurse provided an on-call visit to the patient on 05/03/2024 for “fainting” and documented the caregiver said the patient was “weak and also fainted/fell yesterday due to tiredness and sleeplessness.” The nurse noted to continue the current plan of care and there were no updates to the POC after the patient experienced a fall and fainting episode. Clinical Record 11: The patient elected the hospice benefit on 01/29/2024 for the diagnosis of chronic obstructive pulmonary disease. The POC dated 01/29/2024 included the following: “Gastrointestinal: Altered elimination r/t constipation.” The nursing visit note dated 02/01/2024 included documentation that the patient had “uncontrolled diarrhea.” The POC was not updated when the patient experienced a change in their gastrointestinal assessment. Clinical Record 13: The patient elected the hospice benefit on 02/28/2023 for the diagnosis of acute respiratory failure. The POC dated 03/01/2023 included the following: “Gastrointestinal problem: potential for altered bowel movements. Neurological problem: potential for altered mental status. Respiratory problem: potential for altered respirations.” The nursing visit note dated 03/29/2023 included documentation that stated “Neuro: increase in agitation and confusion. New order for lorazepam. Very agitated during visit. Respiratory: depends on O2 at 3 LPM with upper airway gurgles. GI: 1 episode of vomiting. Nutrition no appetite last week.” The POC was not updated when the patient experienced a change in their neurological assessment, respiratory assessment, and gastrointestinal assessment. During an interview and joint record review on 05/15/2024, the Administrator/Director of Patient Care Services confirmed the plans of care had not been updated with patient condition changes.”

“It is required that nursing care and services are provided by and under the supervision of a Registered Nurse and per the patient plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure nursing services were provided per the plan of care. Clinical Record 1: The patient elected the hospice benefit on 02/02/2024 for the diagnosis of unspecified cirrhosis of the liver. The initial plan of care dated 02/02/2024 included an order for nursing frequency of visits twice a week. Clinical record review revealed for the week of 04/28/2024, the nurse provided one visit on 04/30/2024 and there was no documented evidence of a second nursing visit being provided for the week. Clinical Record 2: The patient elected the hospice benefit on 02/19/2024 for the diagnosis of atherosclerotic heart disease. The initial plan of care dated 02/19/2024 included an order for nursing frequency of visits twice a week. Clinical record review revealed for the week of 04/28/2024, the nurse provided one visit on 04/30/2024 and there was no documented evidence of a second nursing visit being provided for the week. Clinical Record 9: The patient elected the hospice benefit on 01/30/2024 for the diagnosis of atherosclerotic heart disease. The initial plan of care dated 01/30/2024 included an order for nursing frequency of visits twice a week. Clinical record review revealed for the week of 02/25/2024, the nurse provided one visit on 02/25/2024 and there was no documented evidence of a second nursing visit being provided for the week. During an interview and joint record review on 05/15/2024, the Administrator/Director of Patient Care Services confirmed the nursing visit frequency did not meet the frequencies ordered on the plans of care.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) bereavement records reviewed, the agency did not ensure the bereavement plan of care included the types of bereavement services to be offered and the frequency of service delivery. Clinical Record 13: The patient elected the hospice benefit on 02/28/2023 for the diagnosis of acute respiratory failure. The patient died on 04/02/2023. The bereavement plan of care did not include the types of bereavement services to be offered and the frequency of service delivery. Clinical Record 14: The patient elected the hospice benefit on 10/13/2023 for the diagnosis of malignant neoplasm of the bladder. The patient died on 10/23/2023. The bereavement plan of care did not include the types of bereavement services to be offered and the frequency of service delivery. During an interview and joint record review on 05/16/2024, the Administrator/Director of Patient Care Services confirmed the bereavement plans of care did not include the types of bereavement services to be offered and the frequency of delivery.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN [Registered Nurse] who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provided specific written patient care instructions for the hospice aide. Clinical Record 1: The patient elected the hospice benefit on 02/02/2024 for the diagnosis of unspecified cirrhosis of the liver. The Initial nursing assessment dated 02/02/2024 noted a “Stage III pressure ulcer left buttock.” The aide care plans dated 02/02/2024 and 04/26/2024 assigned the aide the task of bathing via shower chair, visualize skin, and peri care. The aide care plans did not notify the aide of the patient’s wound and did not include specific instructions for care of the wound during the assigned tasks. Clinical Record 3: The patient elected the hospice benefit on 04/01/2024 for the diagnosis of heart disease. The aide care plan dated 04/01/2024 assigned the aide the tasks of bathing via shower chair and shampooing. The nursing assessment dated 04/22/2024 included documentation that the patient was on continuous oxygen at 2 liters per minute. The aide care plan did not include the patient’s use of continuous oxygen and did not include instructions to the aide related to the patient’s use of oxygen while the aide provided care to the patient. Clinical Record 4: The patient elected the hospice benefit on 05/07/2024 for the diagnosis of heart failure. The initial nursing assessment dated 05/07/2024 included documentation that the patient was on oxygen at 3 liters per minute continuously. The aide care plan dated 05/07/2024 assigned that aide the tasks of shower chair and dressing the patient. The aide care plan did not include instructions to the aide related to the patient’s use of oxygen while the aide provided care to the patient. Clinical Record 5: The patient elected the hospice benefit on 04/25/2024 for the diagnosis of chronic obstructive pulmonary disease. The initial nursing assessment dated 04/25/2024 included documentation that the patient was on oxygen at 2 liters continuous. The aide care plan dated 04/25/2024 assigned the aide the tasks of bed bath and dressing the patient. The aide care plan did not include the patient’s use of continuous oxygen and did not include instructions to the aide related to the patient’s use of oxygen while the aide provided care to the patient. Clinical Record 13: The patient elected the hospice benefit on 02/28/2023 for the diagnosis of acute respiratory failure. The initial nursing assessment included documentation that the patient was on continuous oxygen at 3 liters per minute and had a coccyx wound covered with a foam dressing. The aide care plan dated 02/28/2024 assigned the aide the tasks of showering the patient and inspecting skin. The aide care plan did not notify the aide of the patient’s wound and did not include specific instructions for care of the wound during the assigned tasks. The aide care plan did not include the patient’s use of continuous oxygen and did not include instructions to the aide related to the patient’s use of oxygen while the aide provided care to the patient. During an interview and joint record review on 05/15/2024, the Administrator/Director of Patient Care Services confirmed the aide care plans did not include specific instructions for oxygen and wounds.”

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed with aide services provided, the agency did not ensure the aide provided services included in the plan of care. Clinical Record 13: The patient elected the hospice benefit on 02/28/2023 for the diagnosis of acute respiratory failure. The aide care plan dated 02/28/2023 assigned the aide the tasks of showering the patient. The aide documented on the aide visit notes dated 04/01/2023 “Patient awake and screaming for help, due to pain. Charge nurse notified. [Patient] refused shower, bed bath given from head to toe,” 03/28/2023 “Patient refused shower, bed bath given,” 03/25/2023 “[patient] refused shower, sponge bath given from head to toe,” 03/23/2023 “Patient refused shower, bed bath given,” 03/18/2023 “Patient refused shower, bed bath given,” 03/16/2023 “Patient screaming and yelling in pain. Refused shower, bed bath given,” 03/11/2023 “Patient was confused and bed bath given.” 03/9/2023 “Patient refused shower, bed bath given,” 03/4/2023 “Patient confused, screaming and yelling. Refused shower. Bed bath given.” The aide provided a bed bath at visits from 04/01/2023 through 03/28/2023 instead of a shower as assigned on the aide care plan. During an interview and joint record review on 05/15/2024, the Administrator/Director of Patient Care Services confirmed the aide did not follow the care plan and performed a bed bath instead of a shower.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, personnel record review, and interview. In 3 of 9 (33%) personnel records reviewed, the agency did not ensure competencies had been assessed on individuals providing care. Agency policy No 3-001, November 2020, stated in part, “all direct care personnel will establish and retest annually re-evaluate job-specific competencies.” Personnel Record 2: Administrator /Director of Patient Care Services /Registered Nurse date of hire 05/08/2023. Personnel record review revealed no documented evidence of Registered Nurse competency assessment for this staff member that does provide direct patient care. Personnel Record 3: Alternate Director of Patient Care Services /Registered Nurse date of hire 07/05/2023. Personnel record review revealed no documented evidence of Registered Nurse competency assessment for this staff member that does provide direct patient care. Personnel Record 4: Licensed Vocational Nurse date of hire 02/15/2023. Personnel record review revealed no documented evidence of Licensed Vocational Nurse competency assessment for this staff member that does provide direct patient care. During an interview and joint record review on 05/16/2024, the Administrator/Director of Patient Care Services confirmed the competencies were incomplete.”

“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 6 (17%) clinical records reviewed with recertification, the agency did not ensure the recertification of the terminal illness was completed by the physician no later than two calendar days after the first day of the benefit period and no more than 15 days before the next benefit period. Clinical Record 8: The patient elected the hospice benefit on 02/08/2024 for the diagnosis of Alzheimer’s disease. The patient was recertified for a second benefit period which started on 05/08/2024. As of the date of record review on 05/15/2024, the clinical record contained no documented evidence that the recertification of terminal illness had been signed by the hospice Medical Director, 7 days after the start of the benefit period and 5 days outstanding. During an interview and joint record review on 05/15/2024, the Administrator/Director of Patient Care Services confirmed the recertification of terminal illness had not been completed.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed of patients that reside in a Skilled Nursing Facility/Nursing Facility (SNF/NF), the agency did not ensure the hospice care was stated in a written plan of care established and maintained in consultation with SNF/NF. Clinical Record 1: The patient elected the hospice benefit on 02/02/2024 for the diagnosis of unspecified cirrhosis of the liver. The patient resided in a SNF. The clinical record contained no documented evidence that the written plan of care was established and maintained in consultation with SNF. Clinical Record 2: The patient elected the hospice benefit on 02/19/2024 for the diagnosis of atherosclerotic heart disease. The patient resided in a SNF. The clinical record contained no documented evidence that the written plan of care was established and maintained in consultation with SNF. Clinical Record 4: The patient elected the hospice benefit on 05/07/2024 for the diagnosis of heart failure. The patient resided in a SNF. The clinical record contained no documented evidence that the written plan of care was established and maintained in consultation with SNF. Clinical Record 13: The patient elected the hospice benefit on 02/28/2023 for the diagnosis of acute respiratory failure. The patient resided in a SNF. The clinical record contained no documented evidence that the written plan of care was established and maintained in consultation with SNF. During an interview and joint record review on 05/15/2024, the Administrator/Director of Patient Care Services confirmed a written plan of care between the hospice and SNF/NF had not been included in the clinical record.”