First Priority Hospice, Inc.

“Upon patient record review, 1 of 5 (Patient #5) 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 5: Medication list contains order for Calmoseptine ointment with instructions: 2Gm Apply thin layer 4 times daily to treat and prevent skin irritation. There is no evidence of application site for this medication. Medication list contains order for A and D ointment 2 Gm topical ointment with instructions: Apply topically twice daily PRN for dry skin. There is no evidence of application site for this medication.”

“Upon patient record review, 1 of 5 (Patient #5) 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 5: Plan of care contains order for Calmoseptine ointment with instructions: 2Gm Apply thin layer 4 times daily to treat and prevent skin irritation. There is no evidence of application site for this medication. Plan of care contains order for A and D ointment 2 Gm topical ointment with instructions: Apply topically twice daily PRN for dry skin. There is no evidence of application site for this medication.”

“Upon patient record review, 1 of 5 (Patient 1) 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 1: COS-Aide care plan written with the following task frequencies noted as PRN: change linen, make bed.”

“Upon patient record review 12 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 14) 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, 4, 5 no evidence of an initial psychosocial or spiritual assessment. Patient 2, 3, 6, 7, 8, 9, 11, 12, 14 no evidence of an initial psychosocial assessment.”

“Upon patient record review, 6 of 14 (Patient #2, 3, 4, 5, 8, 9) 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 2, 3, 4 oxygen ordered as a treatment 2-5LPM NC. No evidence of oxygen on medication profile. Patient 5 Lidocaine patch 4% daily prn, no evidence of application site. Patient 8, 9 oxygen ordered 2-4 LPM NC no evidence of oxygen on the medication profile.”

“Upon patient record review, 8 of 14 (Patient #1, 4, 5, 6, 9, 11, 12, 14) 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 #1, 14 no evidence of an initial bereavement risk assessment. Patient 4 admitted 1/16/24, initial bereavement risk assessment completed on 7/17/24. Patient 5 admitted 4/23/24, initial bereavement risk assessment completed on 7/25/24. Patient 6 admitted 4/16/24, initial bereavement risk assessment completed on 7/18/24. Patient 9 admitted 2/22/24, initial bereavement risk assessment completed on 8/9/24. Patient 11 admitted 10/3/23, initial bereavement risk assessment completed on 6/1/24. Patient 12 admitted 2/13/24 initial bereavement risk assessment completed on 5/15/24.”

“Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 RN visit 5/15/24 and additional visits document patient chokes easily, no evidence of aspiration precautions. Patient received IV infusions weekly for the first 8 weeks, no evidence of a care plan for the IV. PT ordered no evidence of a care plan for PT. Patient 2 nursing visits document patient as aspiration precautions & dysphagia, no evidence of aspiration precautions. Admitted with terminal diagnosis of Parkinson’s, oxygen orders, nebs ordered, fall risk, documented fall risk, nausea & vomiting, spiritual care, massage therapy and physical therapy are seeing the patient. No evidence goals and interventions for identified problems. Patient 3 terminal diagnosis of Lewy Bodies, oxygen ordered, high risk falls, dysphagia, high risk for skin impairment, incontinence, and dizziness. No evidence of goals and interventions for the identified problems. Patient 4 has Foley/suprapubic, oxygen ordered, PT ordered. No evidence of a care plan to address PT, respirator or oxygen safety. Patient 5 oxygen ordered, no care plan for respiratory or oxygen safety. Patient 6 spiritual care seeing patient monthly and PT ordered 2x week, no care plans for SC or PT. Patient 7 oxygen ordered, aspirin, and medications for constipation. No evidence of goals and interventions for identified problems. Patient 8 PT, spiritual care and massage therapy ordered, no evidence of goals and interventions for identified problems. Patient 9 ordered oxygen, suction, PT. No evidence of goals and interventions for identified problems. Patient 10 on aspirin, medications for constipation, suctioning, being seen by PT, MSW, SC and massage therapy. No evidence of goals and interventions for identified problems.”

“Upon patient record review, 2 of 14 (Patient #7, 9) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient 7 initially admitted as inpatient level of care for anxiety continues on Ativan, on Morphine and Tylenol for pain, no evidence of a care plan for pain and/or anxiety. Patient 9 Morphine, Haldol and Ativan ordered, no evidence of a care plan to manage pain and/or anxiety.”

“Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1, 2, 3, 4, 5 IPOC included PT/OT/ST 2x week and initial admission ordered included PT 2x week. Patient 6, 7, 8, 10 IPOC included PT/OT/ST 1x week and initial admission ordered included PT 1x week. Patient 1 order 5/15/24 for SC 1x month and prn without a frequency. Patient 2 order 6/28/24 for SC 1x month and prn, SN 2x week and as needed without a frequency. Patient 6 order 7/15/24 SC 1x per period and prn, SN 1x week and prn without a frequency. Patient 7 IPOC SC declined and initial admission order has SC as 1x month and prn without a frequency. Order for massage therapy 1x week and as needed for comfort without a frequency. Patient 8 IPOC SC 1x month and 1 prn without a frequency, initial order SC 1x month and prn without a frequency. 6/23/24 recert POC orders PT/OT/ST 1x week, order is for PT only. Patient 9 IPOC SN 1x week and 1prn without a frequency. Aide states yes no frequency, SC 1x month and 1prn without a frequency. Volunteer 3x week and 1 prn without a frequency and PT/OT/ST eval and 1x week. Initial order SN, Aide and SC as 1x week and prn without a frequency. Volunteer as declined, PT as eval and 2x week. Patient 10 IPOC SW yes and no frequency, SC as declined, SN 1x week and 1prn. Initial order SN 1x week and prn without a frequency. SW/SC 1x per period and prn.”

“Upon patient record review, 7 of 14 (Patient #2, 3, 4, 5, 6, 8, 9) 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 2 volunteer frequency 2x week, all items on volunteer care plan are ordered as requested such as relief sitting, letter/book reading, friendly visit, companionship, caregiver respite, patient emotional support, family emotional support without indicator for PRN. Buspirone 5mg 2 tabs daily anxiety may repeat as needed during the night, no frequency for how often to repeat. Lorazepam 0.5mg 1 tab Q4H prn anxiety/sleep. Order does not specify when to take Buspirone or Lorazepam for anxiety. IPOC included Oxygen 2-5LPM NC prn, no indication for prn. Patient 3 IPOC included Oxygen 2-4LPM NC prn, no indication for prn. In addition, nursing visit 6/22/24 documents honey thickened liquids, no evidence of an order for honey thick liquids. Patient 4 IPOC included ordered for 16Fr foley with __ (blank) balloon change Q30 days and prn, no size of the balloon and no indication for prn changes. POC 7/14/24 included suprapubic change every 4 weeks monitor for S/S infection, order did not include size of catheter. Volunteer care plan 7/15/24 included all tasks as requested such as meals, housekeeping, relief sitting, companionship, caregiver respite, patient emotional support, caregiver emotional support, family emotional support, grocery and pharmacy errands without indicator for PRN. Patient 5 order 5/29/24 Lidocaine patch 4% daily prn pain, no location to apply the patch. Volunteer care plan 7/24/24 included tasks as requested such as light meal, housekeeping, chores, relief sitting, friendly visit, social support, companionship, caregiver respite, patient/caregiver/family emotional support without indicator for PRN. Patient 6 volunteer care plan included tasks as requested such as light meal, housekeeping, chores, relief sitting, friendly visit, shopping, pharmacy, companionship, caregiver respite, patient/caregiver/family emotional support without indicator for PRN. Patient 8, 9 Volunteer care plan 4/2/24 included all tasks as requested under the three sections meal/housekeeping, social support and grocery/pharmacy without an indicator for PRN,”

“Upon patient record review, 9 of 14 (Patient #1, 2, 3, 4, 5, 6, 8, 9, 10) 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 aide care plan includes the use of a cane, no evidence of cane ordered as DME. Patient 2 utilizing Albuterol nebs, no evidence of a nebulizer ordered as DME. Nursing visits 6/25/24 and 7/1/24 document the use of a wheelchair, no evidence order for wheelchair DME. Nursing visit on 7/4/24 documents the use of a hospital bed, no evidence of DME order. Patient 3, 4 IPOC includes Oxygen, no evidence of an order for Oxygen DME. Patient 5 utilizing Albuterol nebs, no evidence of a nebulizer ordered as DME. Order for Oxygen 2-4LPM, no DME order for Oxygen. Patient 6 IPOC includes an order to suction the patient, no DME orders for suction. Nursing visit 7/11/24 documents use of OBT, no DME order for OBT. Patient 8 IPOC includes an order to suction the patient, no DME orders for suction. Order for Oxygen 2-4LPM, no DME order for Oxygen. Patient 9 IPOC includes an order to suction the patient, no DME orders for suction. Nursing visit 8/5/24 documents current DME including nebulizer, wheelchair, oxygen concentrator, no evidence of a DME order for these. Patient 10 IPOC includes an order to suction the patient, no DME orders for suction. Nursing visit on 6/28/24 documents bedside commode, no evidence of DME order for bedside commode.”

“Upon patient record review, 5 of 14 (Patient #1, 4, 5, 6, 9) 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 1 6/19/24 Ondansetron ordered, and Lasix change in dose to manage edema. Cardiac care plan did not address interventions for edema and no evidence of a care plan for N&V. Wound care being provided to patient, no evidence of a care plan for skin care or wound care. Patient 4 Docusate and Senna ordered, Lorazepam for anxiety, no evidence of a care plan to address constipation or anxiety. Patient 5 Nursing visits throughout July and August document constipation, no evidence of a care plan for constipation. Patient 6 massage therapy ordered 7/23/24, no evidence of a care plan for massage therapy. Patient 9 Zofran ordered 8/13/24, no evidence of a care plan for N&V.”

“Upon client record review, 5 of 14 (Patient #1, 2, 3, 4, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1 initial order, and order 7/8/24 orders PT as 2x week, PT visits were weekly from 5/11/24 to current. No evidence of an order to change the frequency. Initial orders included D5NS 500ml & MVL 10ml/500ml via PIV 1x week for 8 weeks D/C 7/6/24. Only nursing visit that documented D5NS IV infusion provided was on 5/22/24, 24g angio no evidence of an order for peripheral IV insertion. Nursing visit 5/15/24 documented inserted 24g angio L forearm for PIV Albumin infusion, no evidence of an order to place PIV. Nursing visit 5/30/24 documented wound care as clean with NS, applied calmoseptine, and applied form dressing. No evidence of an order for wound care or form dressing. Patient 2 6/28/24 volunteer frequency ordered 2x week, no evidence of visits from 6/28/24-7/8/24. Patient 3 IPOC included SN 0 x week 1 and then begin 1x week starting week 2. Nursing visit on 6/22/24 and there is not an order for this visit. Patient 4 Nursing visit on 6/25/24 documents suprapubic catheter changed and does not document how the patient tolerated the change. Order to change suprapubic every 4 weeks, no documented evidence the suprapubic was changed from 6/25/24 to current. DCPS stated it was changed on 7/13/24 however there was not a nursing visit completed on 7/13/24. Patient 6 initial order for wound care to cleanse with NS pat dry apply zinc oxide barrier daily. Nursing visit on 7/18/24 documented Mepilex applied to wound, no evidence of an order for Mepilex.”

“Upon patient record review, 2 of 14 (Patient #13, 14) 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 bereavement plan of care states letters to be sent at 1, 3, 6, 12 months, along with calls and 1:1 support, it doesn’t specify the calls or 1:1 support. Visit completed on 9/13/23. Patient 14 bereavement plan of care stated bereavement would be provided as per policy. Policy stated that bereavement contact would be at 3, 6, 9, 12 months (doesn’t specify the contact). Cards were sent on 8/15/23, 9/14/23, 11/14/23 and 5/14/24, patient died 8/14/23.”

“Upon personnel record review, 1 of 16 (Personnel #6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 6 competency completed on 8/14/23 all tasks were verbally verified, no evidence that any of the tasks were completed with a patient.”

“Upon patient record review, 7 of 14 (Patient #1, 5, 6, 7, 8, 9, 11) 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 1 aide care plan included electric shave as needed. Patient 5 ordered oxygen, no evidence of oxygen on aide care plan. Aide care plan included the following tasks as requested: feed, setup, offer oral supplement, change linen, make bed, straighten room, laundry, and shopping. Patient 6 aide care plan included complete bed bath and assist bath chair both as every visit. Patient 7 aide care plan included clean and file nails as needed. Patient 8 ordered oxygen and identified as high risk for aspiration on care plan, no evidence of oxygen or aspiration precautions on aide care plan. Patient 9 on aspirin for blood thinner, no evidence of bleeding precautions on aide care plan. The following tasks were listed as requested: clean/file nails, make bed, straighten room, laundry, and shopping. Patient 11 aide care plan included several tasks as requested some including: shower, shampoo, dressing, mouth care, nail care, and peri care.”

“Upon patient record review 1 of 14 (Patient #6) 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 6 aide visits documented NA for several tasks that were to be completed every visit. Visit on 7/5/24 NA for ambulation, meals, mouth care, nails. Visit on 7/8/24 NA for mouth care, nails, soak feet. Visit for 7/12/24 NA for meals, ambulation, mobility, activity. Visits on 8/1/24, 8/5/24, and 8/8/24 NA for ambulation, mobility, meals, and nails.”

“Upon patient record review 2 of 14 (Patient #5, 8) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 5 no evidence of aide supervision on any visits from 7/1/24-8/12/24. Patient 8 aide supervisory visit completed on 6/19/24 and no evidence of supervision after that through the last visit on 7/31/24.”

“Upon patient client record review, 2 of 14 (Patient #4, 10) 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 4 nursing visits completed 6/25/24 and 7/9/24 by KP, the electronic signature did not include the credentials. Patient 10 aide supervision documented on all nursing visits from 7/15/24-8/6/24, no evidence of any aide visits ordered or completed.”