Physicians Hospice Group

“Upon patient record review, 2 of 19 (Patient #13,14) 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 13: Patient has physician’s order in the medication list for diclofenac 1 percent topical gel, with instructions to apply one application topically daily as needed for pain relief. There is no evidence of statement of amount of application. There is no evidence of application site for this medication. Patient has physician’s order in the medication list for lidocaine 4 percent maximum strength topical patch, with instructions to apply one patch daily as needed. On for 12 hours and off for 12 hours. There is no evidence of application site for this medication. Patient 14: Patient has two physician’s orders in the medication list for Levaquin 500mg. the first order was written 03/04/2024. The second order was written 03/27/2024. Both have instructions: one tablet by mouth twice daily for 5 days. Patient has physician’s order for benzonatate 100mg by mouth twice daily for 5 days. This order was written 03/27/2024. There is no evidence of stop date for these orders in the medication list.”

“Upon patient record review, 2 of 19 (Patient #6,13) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 6: Patient has fall documented as incident on 09/23/2024. There was a SN visit made to patient this same date. There is no documentation of a falls assessment, safety assessment made on this date. Further, assessment question, “any fall/incident/occurrence to report today?” was answered, “no”. The next documented SN visit was made 09/27/2024, with same above-noted assessment findings observed in the medical record. Hospice’s policy states that an immediate visit/assessment should be made by SN with each fall. Patient 13: Patient has documented falls as incidents: 09/28/2024, 10/02/2024, 10/07/2024. SN visits documented 10/04/2024, 10/10/2024. This is outside hospice’s policy for follow up SN visits re: falls.”

“Upon patient record review, 9 of 19 (Patient #2,3,4,6,9,11,12,13,14) 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 2: Patient with evidence of puree diet in the plan of care. There is no evidence of aspiration precautions plan of care with problems, goals, and interventions. COS Patient 3: Patient with evidence of physician’s order for oxygen in the plan of care. Patient’s respiratory plan of care has intervention for oxygen that reads, “oxygen as ordered via ___@___L/min.” There is no evidence of an individualized intervention for oxygen in the respiratory plan of care. COS Patient 4: Patient with assessed Braden score of 10. There is no evidence of an integumentary plan of care with problems, goals and interventions. COS Patient 6: Patient with evidence of thickened liquids in the plan of care. There is no evidence of aspiration precautions plan of care with problems, goals, and interventions. COS Patient 9: Patient with assessed Braden score of 10. There is no evidence of an integumentary plan of care with problems, goals and interventions. Patient with assessed fall score of 16/10. There is no evidence of a fall plan of care with problems, goals and interventions. In patient’s ADL plan of care, there is an intervention that reads, “instruct pt/pcg on safety of bed-bound status using transfer techniques, use of SR, trapeze, hoyer lift.” There is no evidence of a physician’s order for these DME in the plan of care. All COS Patient 11: Patient with assessed fall score of 19/10. There is no evidence of a fall plan of care with problems, goals and interventions. Patient has physician’s order for oxygen in the plan of care. There is no evidence of oxygen as an intervention in the respiratory plan of care. In patient’s mobility plan of care, there is an intervention that reads, “instruct pt/pcg on safety of bed-bound status using transfer techniques, use of SR, trapeze, hoyer lift.” There is no evidence of a physician’s order for these DME in the plan of care. All COS Patient 12: Patient assessed as high risk of aspiration during comprehensive assessment. There is no evidence of aspiration precautions plan of care with problems, goals, and interventions. Patient has physician’s order for oxygen in the plan of care. There is no evidence of oxygen as an intervention in the respiratory plan of care. Patient 13: . Patient’s respiratory plan of care has intervention for oxygen that reads, “oxygen as ordered via ___@___L/min.” There is no evidence of an individualized intervention for oxygen in the respiratory plan of care. In patient’s ADL plan of care, there is an intervention that reads, “instruct pt/pcg on safety of bed-bound status using transfer techniques, use of SR, trapeze, hoyer lift.” There is no evidence of a physician’s order for these DME in the plan of care. Patient 14: Patient has physician’s order for oxygen in the plan of care. There is no evidence of oxygen as an intervention in the respiratory plan of care.”

“Upon patient record review, 2 of 19 (Patient #13,14) 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 13: Patient has physician’s order in the plan of care for diclofenac 1 percent topical gel, with instructions to apply one application topically daily as needed for pain relief. There is no evidence of statement of amount of application. There is no evidence of application site for this medication. Patient has physician’s order in the plan of care for lidocaine 4 percent maximum strength topical patch, with instructions to apply one patch daily as needed. On for 12 hours and off for 12 hours. There is no evidence of application site for this medication. Patient 14: Patient has two physician’s orders in the plan of care for Levaquin 500mg. the first order was written 03/04/2024. The second order was written 03/27/2024. Both have instructions: one tablet by mouth twice daily for 5 days. Patient has physician’s order for benzonatate 100mg by mouth twice daily for 5 days. This order was written 03/27/2024. There is no evidence of stop date for these orders in the plan of care.”

“Upon patient record review, 11 of 19 (Patient #1,2,3,4,6,9,10,11,12,13,14) 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: Patient has physician’s order for the following DME with no evidence of DME on the plan of care: hospital bed, overbed table oxygen. COS Patient 2: Patient has physician’s order for the following DME: Hospital bed, overbed table, wheelchair, hoyer lift, nebulizer, BRODA chair. There is no evidence of DME on the plan of care: Hospital bed, overbed table, wheelchair, hoyer lift, nebulizer. COS Patient 3: Patient has physician’s order for the following DME: wheelchair, oxygen. There is no evidence of DME on the plan of care: wheelchair. COS Patient 4: Patient has physician’s order for the following DME with no evidence of DME on the plan of care: hospital bed, walker, wheelchair, oxygen, nebulizer, overbed table, chair alarm. COS Patient 6: Patient has physician’s order for the following DME: hospital bed, overbed table, shower chair, oxygen. There is no evidence of DME on the plan of care: hospital bed, overbed table. COS Patient 9: Patient has physician’s order for the following DME: hospital bed, overbed table, shower chair, oxygen, walker, wheelchair, bedside commode. There is no evidence of DME on the plan of care: overbed table, walker. COS Patient 10: Patient has physician’s order for the following DME: hospital bed, overbed table, wheelchair. There is no evidence of DME on the plan of care: hospital bed. COS Patient 11: Patient has physician’s order for the following DME with no evidence of DME on the plan of care: overbed table, nebulizer, suction, oxygen concentrator, oxygen e-tank. COS Patient 12: Patient has physician’s order for the following DME: hospital bed, overbed table, oxygen. There is no evidence of DME on the plan of care: overbed table. Patient 13: Patient has physician’s order for the following DME with no evidence of DME on the plan of care: walker, bedside commode, oxygen concentrator, oxygen e-tank, wheelchair, shower chair, nebulizer. Patient 14: Patient has physician’s order for the following DME with no evidence of DME on the plan of care: hospital bed with half rails, oxygen, overbed table, Hoyer lift.”

“Upon observation 3 of the 3 home visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: during home visit, it was observed that aide did not cleanse hands upon entering patient’s room at the nursing facility. Additionally, she did not wash hands while preparing to bathe patient. Based upon hospice’s infection control policy, hands should be cleansed at these times. Patient 2: during home visit, it was observed that RN did not cleanse hands upon entering patient’s room at the nursing facility. Additionally, she did not wash hands before initially entering bag. Per hospice’s bag technique/infection control policy, employees are to wash hands before initially entering bag for supplies. Also, employees are to cleanse hands with alcohol-based hand rub with each subsequent time they enter the supply bag. RN was not observed performing hand hygiene until the end of the visit, when she doffed gloves. When RN returned her vital signs tools to bag, she did so with the following steps: removed soiled tool from dirty barrier. Cleansed tool with approved antimicrobial wipe. Returned tool to same barrier. Removed next tool. Cleansed tool with approved antimicrobial wipe. Returned tool to same barrier. This process was repeated for all of the vital signs tools. Lastly, it was observed that the RN obtained the patient’s blood pressure with a faulty Sphygmomanometer. The balloon portion was not fully inside the apparatus. It was observed that the RN noticed this and used the Sphygmomanometer anyway. Patient 4: during home visit, it was observed that chaplain did not cleanse hands upon entering patient’s room at the nursing facility.”

“Upon patient record review, 3 of 19 (Patient #2,4,5) 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 2: Patient with aspiration precautions on the plan of care. There is no evidence of aspiration precautions on the aide care plan COS Patient 4: Patient with aspiration precautions on the plan of care. There is no evidence of aspiration precautions on the aide care plan. Patient with physician’s order for oxygen on the plan of care. There is no evidence of oxygen order/precautions on the aide care plan. All COS Patient 5: Patient with physician’s order for oxygen on the plan of care. There is no evidence of oxygen order/precautions on the aide care plan. It is observed that there is no evidence that aide care plan updated since patient’s condition worsened/actively dying AEB toileting task still reads “bathroom” and patient is still to be a 1-person transfer. Patient was actively dying at beginning of survey, ultimately expiring on 10/16/2024.”

“Upon patient record review 2 of 19 (Patient #1,7) 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: Physician’s visit frequency order is twice weekly. Documented visit dates are 10/07/2024 and 10/14/2024. There is no evidence of second visit made week of 10/07/2024. Patient 7: During visit dates 09/30/2024, 10/07/2024, 10/14/2024, aide tasks shampoo hair and comb hair not completed. On 10/10/2024, aide visit was refused. There is instruction in the aide care plan to notify case manager of any refusals. There is no evidence of documentation that the case manager was notified of above refusals.”

“Upon patient client record review, 2 of 19 (Patient #2,3) 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: Patient’s notice of Medicare election consent indicated they wished to receive notification of non-covered items, services, drugs. There is no evidence in the medical record that patient received this notification. COS-upon being notified of this deficiency, hospice Executive Director contacted patient/family and made them aware of above and notification provided however, this is still outside allowed timeframe. Patient 3: Patient’s admission notice of Medicare election consent has an area for non-covered items, services, drugs. Patient can opt in/out by choosing a check box yes or no. This patient’s notice of election did not have a choice made, as both options were left blank.”