Cardinal Hospice and Palliative Care

“It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which patients were live discharged for extended prognosis revealed the agency did not ensure patients were involved in the development of the plan of care at discharge. Clinical Record 6: The patient elected the hospice benefit on 3/20/2023 for the diagnosis of Alzheimer’s disease. They were discharged for extended prognosis on 2/19/2024. The Notice of Medicare Non-Coverage (NOMNC) was signed by the patient/family on the day of discharge, instead of the required 48 hours before discharge. Clinical Record 7: The patient elected the hospice benefit on 3/21/2023 for the diagnosis of Alzheimer’s disease. They were discharged to Home Health for extended prognosis on 4/10/2024. The NOMNOC was signed by the patient/family on the day of discharge, instead of the required 48 hours before discharge. During an interview and joint record review with the Administrator/Director of Patient Care Services on 6/13/2024, the administrator was unaware that the NOMNC needed to have been provided to patients for review/signature 48 hours prior to discharge.”

“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 clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure the initial comprehensive assessment was completed no later than 5 days after the election of hospice care. Clinical Record 2: The patient elected the hospice benefit on 5/8/2024 for the diagnosis of hypertensive heart disease. The initial social worker and spiritual counselor visits were declined, and the nurse did not complete the spiritual or social work assessment. Clinical Record 3: The patient elected the hospice benefit on 5/23/2024 for the diagnosis of Parkinson’s disease. The initial social worker assessment was declined, and the nurse did not complete the social worker assessment. Clinical Record 4: The patient elected the hospice benefit on 5/23/2024 for the diagnosis of hypertensive heart disease. The nurse did not complete the initial spiritual assessment and the spiritual counselor noted “SC reached out to family/caregiver for spiritual assessment and support. PCG nor the patient did not respond nor returned my call for any need of spiritual support.” During an interview and joint record review with the Administrator/Director of Patient Care Services on 6/13/2024, it was confirmed these clinical records did not contain completed comprehensive assessments.”

“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. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 3 (33%) home visits performed revealed the agency did not ensure the drug profile contained the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Clinical Record 1: The patient elected the hospice benefit on 2/3/2023 for the diagnosis of Alzheimer’s disease. During Home Visit 1 on 6/13/2024, the hospice medication profile was compared to the medications the caregiver/daughter was giving the patient. The hospice profile had Seroquel 12.5 mg dated 11/16/2023 1 tablet daily at bedtime. The daughter advised she did not have the medication in the house and had not been giving it to the patient. During an interview and joint record review with the Administrator/Director of Patient Care Services on 6/13/2024, it was confirmed the medication profile had not been reconciled.”

“It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure documentation visit frequency was performed following the plan of care. Clinical Record 1: The patient with a diagnosis of Alzheimer’s disease elected the hospice benefit on 2/3/2023. The plan of care dated 2/3/2023 ordered a visit frequency for skilled nursing of 2 visits per week. During the time frame of 5/14/2023 to 3/29/2024 skilled nursing visits were provided at a frequency of 1 visit per week, The plan of care was not updated to reflect the weekly skilled nurse visit frequency until 3/29/2024. Clinical Record 3: The patient with a diagnosis of Parkinson’s disease elected the hospice benefit on 5/23/2024. The plan of care ordered a visit frequency for skilled nursing of 1 visit per week. There was no documentation of a nursing visit the week of 6/3/2024. Clinical Record 13: The patient with a diagnosis of cirrhosis elected the hospice benefit on 5/5/2023. The plan of care ordered a visit frequency for skilled nursing of 2 visits per week. The week of 7/16/2023 was missing 1 visit. During an interview and joint record review with the Administrator/Director of Patient Care Services on 6/13/2024, it was confirmed the visit frequencies did not match those ordered in the plan of care.”

“It is required that the Interdisciplinary Group, 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. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the individualized plan of care was updated as frequently as the patient’s condition required. Clinical Record 9: The patient elected the hospice benefit on 9/10/2023 for the diagnosis of congestive heart failure. Social worker visit on 10/27/2023 noted “SW educating on keeping patient safe and at home.” Social worker visit on 11/11/2023 noted “No issues related to complicated grief, visiting monthly.” The plan of care did not include a routine visit frequency for the social worker nor a psychosocial plan of care, only an as-needed social worker frequency. Clinical Record 13: The patient elected the hospice benefit on 5/5/2023 for the diagnosis of cirrhosis. Nursing visits on the following dates noted “7/13/2023 PCG reports episodes of constipation but often relieved by increasing fluid intake. 8/5/2023 Patient continues to experience constipation, for which increasing fiber intake was advised. 8/10/2023 Severe constipation persists.” The Plan of Care dated 5/30/2023 for gastrointestinal had problems for hemorrhoids and incontinence. It was not modified to include the issues regarding constipation. During an interview and joint record review with the Administrator/Director of Patient Care Services on 6/13/2024, it was confirmed the plans of care had not been updates based on changes in the comprehensive assessments.”

“It is required that 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 5 of 9 (56%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific instructions for the hospice aide. Clinical Record 1: The patient elected the hospice benefit on 2/3/2023 for the diagnosis of Alzheimer’s disease. The initial nursing assessment dated 2/3/2023 included a physician order for “Keppra twice daily for seizures”. The hospice aide care plan dated 2/22/2023 included the relevant tasks of bathing via bed bath, peri care and visualize condition of skin and report to RN every visit. The aide care plan did not inform the aide of the seizure precautions. Clinical Record 9: The patient elected the hospice benefit on 9/10/2023 for the diagnosis of congestive heart failure. The initial nursing assessment dated 9/10/2023 noted the patient was on continuous oxygen at 5 liters per minute. The hospice aide care plan dated 9/13/2023 included the relevant tasks of showering and shampooing. It identified the patient as being on oxygen but did not provide the aide with specific instructions for the oxygen during tasks. Clinical Record 11: The patient elected the hospice benefit on 8/31/2023 for the diagnosis of hypertensive heart disease. The initial nursing assessment dated 8/31/2023 noted “wounds to sacral-coccyx and wounds to bilateral heels covered with foam dressing.” The hospice aide care plan dated 9/8/2023 included the relevant tasks of bathing via bed bath, peri care and visualize condition of skin and report to RN every visit. The aide care plan did not notify the aide of the wounds nor include specific instructions for protecting the wound dressing during tasks. Clinical Record 13: The patient elected the hospice benefit on 5/5/2023 for the diagnosis of cirrhosis. The initial nursing assessment dated 5/5/2023 noted “wounds on left heel, right 2nd toe and sacrol-coxxyx” The hospice aide care plan dated 5/12/2023 included the relevant tasks of bathing via bed bath, peri care and visualize condition of skin and report to RN every visit. The aide care plan did not notify the aide of the wounds nor include specific instructions for protecting the wound dressing during tasks. Clinical Record 14: The patient elected the hospice benefit on 2/6/2024 for the diagnosis of malignant neoplasm of the stomach. The initial nursing assessment dated 2/6/2024 noted patient was taking Keppra for seizures. The hospice aide care plan dated 2/6/2024 did not inform the aide of the seizure precautions. During an interview and joint record review with the Administrator/Director of Patient Care Services on 6/13/2024, it was confirmed the hospice aide care plans did not contain specific written instructions for the wounds, oxygen or seizure precautions.”

“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, interview and observation. In 1 of 9 (11%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the aide provided services included in the plan of care. Clinical Record 1: The patient elected the hospice benefit on 2/3/2023 for the diagnosis of Alzheimer’s disease. A hospice aide visit dated 5/15/2023 included in the comments section they performed the task of taking the vital signs of temperature, pulse, respiration, and blood pressure. The aide care plan dated 2/22/2023 did not include taking vital signs as a task. Home Visit 1: During Home Visit 1 on 6/13/2024, the hospice aide and the patient’s daughter discussed the aide shampooing the patient’s hair. The site Visitor asked the hospice aide how often she shampooed the patient’s hair and she replied “One time per week.” The daughter confirmed this. The task of shampooing the patient’s hair was not listed on the aide care plan. During an interview and joint record review with the Administrator/Director of Patient Care Services on 6/13/2024, it was confirmed the aide(s) had not followed the plan of care.”