American Hospice Connection

“Upon patient record review, 3 of 14 (Patient #6,7,8) 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 #6: Melatonin 5 mg 2 tabs HS for sleep. Discontinued for Trazadone per nurse, but medication profile not updated. Vitamin D3 5000 units 1 / day still on med profile, but patient stated it was discontinued. Patient #7: Med profile includes 9/24/24 Hydralazine 10 mg 1 tablet two times per day and also 7/9/24 Hydralazine 50 mg 3 times a day. Patient has 10 mg dose in home and states she is taking twice daily. Both meds show refilled for 10/15/24. In addition, patient has and says she is taking Metropolol 25 mg twice daily. It is not on the medication profile. Patient #8: Patient has Lovastatin 10 mg 1 tablet po qd in home that she is taking. Atorvastatin Calcium 20 mg 1 tab qd is listed also on med profile with order date of 10/14/24 . Patient does not have and is not taking.”

“Upon patient record review, 2 of 14 (Patient #1, 6) 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: Initial IDG Plan of Care for patient admitted with Cardiac Disease, requiring Oxygen therapy, includes Oxygen precautions, but rate is omitted from intervention documented as “safe use of oxygen at liters/min via nasal cannula or mask.” Patient #6: Patient documented as legally blind and with speech impairment related to brain tumor 5 years ago. There are no related problems, goals interventions, particularly for safety and effective communication.”

“Upon patient record review, 3 of 14 (Patient #4, 5,7) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patient #4: Patient admitted 7/16/24 with orders for MSW eval and 1x/month x3 months. The only documentation by MSW was September 30th regarding multiple attempts to schedule but no one answered phone. There was no documentation of individual attempts to contact patient, missed visits and there was no documented communication to other team members during IDG. Patient #5: IDG meetings were held on 8/9 and 9/6/24, greater than 15 calendar days. Patient #7: IDG meetings were held on 9/20 and 10/11/24. Staff interview states that 10/11/24 was recorded in error as no IDG was held that date, and it should read 10/4/24. Documentation shows greater than 15 calendar days.”

“Upon patient record review, 6 of 14 (Patient #1, 2, 3, 4, 6, 8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Patient admitted 7/17/24 with order for SC eval and then order r/t SC decline starting on 7/17/24. There was a visit documented 7/20/24 with plan for 1x/month and a subsequent visit documented 8/3/24, there is no visit documented for September. Patient #2: Admitted 7/8/24 with order for MSW 1mo3. There was no visit documented for August. Patient #3: Admitted 6/24/24 with order for SC eval and SC 1xm3. The only visit made was 6/28/24. SC frequency continued x 1/mo through September. Patient #4: Patient admitted 7/16/24 with orders for MSW eval and 1x/month x3 months. There was no visit documented for September. Patient #6: Patient admitted 7/4/24 with orders for SC eval and SC 1/mo for 3 months. Patient was seen 7/9, 8/5, 10/10. There was no documented visit for September. In addition, a MSW order for eval and 1/mo for 3 months, patient was seen 7/4 and 9/19. There was no documented visit for August. Patient #8: Patient admitted 5/2/24 with order for SC eval and SC 1/mo for 3 months. There was no documented visit for July. In addition, MSW order for 1/mo starting 7/31/24. There was no documented visit for August.”

“Upon patient record review, 1 of 14 (Patient #13) 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 #13: The patient bereavement assessment update was documented 01/05/24 with a death date of 01/07/24. It is not clear if the date of visits is accurate or was miswritten. Staff is unable to determine, as employee is no longer with agency. The care plan includes plan to follow up in 2 weeks. There is no further documentation other than one letter sent out post death. There is no documented evidence that bereaved declined bereavement services.”

“Upon patient record review, 8 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8) 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 Patients #1, 2, 3, 4, 6, 7, 8: RN marks tasks, but also has narrative listing tasks “as requested by the patient”. For example: shower, shampoo every visit as requested by the patient.” There is no documented statement of patient’s cognitive ability. Patients #3, 5: Aide assignment sheets have assigned tasks for both shower and bed bath. Patient #8: Has oxygen ordered at 2-5 LPM, with no flow specified on aide assignment sheet.”

“Upon patient record review 2 of 14 (Patient #3, 5)did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group1, 3, 5 • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3: Recertification Plan of Care 9/22/24 has no order frequency for hospice aide, (ended with prior recert) but visits made 9/27/24, 10/3/24, and 10/10/24. Patient #5: Initial orders for hospice aide 2xwk and as needed x3 starting 6/11/24. Has subsequent order for hospice aide 1/month effective 9/9/24, but no visits documented after 8/15/24.”

“Upon patient record review, 13 of 14 (Patient#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13) 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, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13: It is unclear whether or not patient requested or declined Notice of Non-Covered Items, Services Addendum. There is no documentation of patient’s choice to receive or not. Patient #5: Admission documents, including but not limited to consent form and election of hospice, were signed by patient, who is admitted with hospice diagnosis of Alzheimer’s Disease.”

“Upon patient record review, 7 of 14 (Patient #2, 7, 9, 10, 11, 12, 13) 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 #2: 10/6/24 CTI includes text “log in, sign/up, you said, Chat GPT said....create a recertification of terminal illness for a hospice patient . the patient has been dx with cirrhosis of the liver. : ...” However, the CTI meets requirements of 418.22. Patient #7: 7/10/24 MSW note is not signed although it says electronically signed. The note is grossly incomplete. Has date and time in and out, but minimal data and no signature. MSW no longer employed by agency. Patient #9: Patient admission Acknowledgment Form signed blank. There are no related deficiencies as acknowledgments verified other forms. Patient #10: 8/29/24 RN visit note not signed/authenticated with electronic signature. Patient #11, 12: DC summary inadvertently Checked Transferred to Bereavement, but patient revoked hospice participation. Patient #13: DOD 1/7/24. SC documented bereavement assessment and care plan 1/5/24 and electronically signed 1/6/24 but included death date of 1/7/24. Care plan says assess reaction to loss within 15 days of death. There is no evidence this occurred.”