Virtue Hospice Care

“Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met as follows: 1. The hospice agency failed to ensure care and interventions needed for one of 14 sample patients (Patient 6), who had difficulty breathing was provided. This deficient practice resulted to the delay of care and had the potential to cause respiratory complications leading to the patients discomfort and poor-quality nursing care. (Refer to L539). 2. The hospice agency failed to notify the physician regarding the current medical condition for one of 14 sample patients, (Patient 6). This failure had the potential to cause the patients discomfort and a poor quality nursing care that can affect the quality of end of life care the patient deserved. (Refer to L556). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services.”

“Based on observation, interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to assess one of fourteen sampled patients (Patients 8) for hospice care and services by failing to conduct a comprehensive assessment (an evaluation of the patient’s physical, psychosocial [mental, social, and spiritual aspects], and emotional status related to the terminal illness [illness with a prognosis of having six months of life or less to live]) to help develop and implement an individualized plan of care to address Patient 8’s right and left posterior heel stage 2 pressure ulcers (injury to the skin and underlying tissue from pressure). These failures had a potential to result in lack of care and services to meet the patient’s needs and care goals. A review of Patient 8’s Patient Profile indicated a start of care (SOC) date 11/17/2023 with a primary diagnosis of Alzheimer’s disease (a progressive disease where brain cells degenerate and die, destroying memory and other important mental functions). A review of Patient 8’s Plan of Care (POC), dated 11/17/2023, indicated a Hospice Aide (HA) was to visit three times per week and a Skilled Nurse (SN) was to visit twice per week and additional of visits as needed (PRN) for any change of condition, and symptom control and management. A review of Patient 8’s electronic medical record revealed a communication log dated 11/17/2023 indicated the Administrator/Director of Nursing (Admin/DON) wrote: WOUND: upon initial face to face, doctor referred patient to wound consult for a deep tissue injury (pressure ulcers are defined as purple or maroon localized area of discolored intact skin or blood‐filled blister due to damage of underlying soft tissue from pressure and/or shear) on foot. Family and facility notified. A review of the initial visit note from the wound care specialist (WCS) on 11/28/2023, indicated that Patient 8 is an 84 year old male, presents with multiple wounds on the following areas: 1. Chronic non-healing pressure ulceration of the left superior buttocks. The wound has been present for approximately 30 days and is for initial evaluation. Previous treatments included Daily dressing changes and Off­loading. The patient’s underlying comorbidities are being managed by the agency’s primary care physician. The goal is to facilitate complete closure of the patient’s chronic wound. Because of numerous comorbidities, the aim is also to prevent the progression of the wound, prevent infection, as well as prevent hospitalization. The pre-procedure area was prepped in the usual aseptic manner. Local anesthesia was not administered. The chronic non-healing ulceration was debrided by mechanical methods. Devitalized tissue was removed to the level of healthy bleeding tissue which included slough. The instruments used included gauze scrub with cleanser. The debridement area extended down to the level of subcutaneous tissue. All surrounding peri-wound hyperkeratotic skin was also removed as required. Hemostasis was achieved by the usage of compression. The estimated blood loss was less than 3 ccs. The post-debridement measurements were as follows: W:2.15 x L:2.03 x D:0.12. The debridement area was cleansed with wound cleanser then dressed with a non-adherent dressing. The patient tolerated the procedure well and there were no complications. The patient, caregiver and or patient coordinator were provided detailed post-procedure instructions. A follow-up appointment will be scheduled for approximately 1 week. Follow-up visit is scheduled for 12/05/2023. Treatment Orders/Addendum: Cleanse the wound with cleanser and pat dry with gauze. Apply topical antibiotic spray to the wound bed, followed by oil emulsion gauze. Cover with hydrocolloid dressing 3x weekly and PRN for soiled or loose dressing. Use bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing. 2. Chronic non-healing pressure ulceration of the right superior buttocks. The wound has been present for approximately 30 days and is for initial evaluation. Previous treatments included Off-loading and Daily dressing changes. The patient’s underlying comorbidities are being managed by the agency’s primary care physician. The goal is to facilitate complete closure of the patient’s chronic wound. Because of numerous comorbidities, the aim is also to prevent the progression of the wound, prevent infection, as well as prevent hospitalization. The pre-procedure area was prepped in the usual aseptic manner. Local anesthesia was not administered. The chronic non-healing ulceration was debrided by mechanical methods. Devitalized tissue was removed to the level of healthy bleeding tissue which included slough and necrotic tissue. The instruments used included gauze scrub with cleanser. The debridement area extended down to the level of subcutaneous tissue. All surrounding peri-wound hyperkeratotic skin was also removed as required. Hemostasis was achieved by the usage of compression. The estimated blood loss was less than 3 ccs. The post-debridement measurements were as follows: W:4.23 x L:2.83 x D:0.12. The debridement area was cleansed with wound cleanser then dressed with a non-adherent dressing. The patient tolerated the procedure well and there were no complications. The patient, caregiver and or patient coordinator were provided detailed post-procedure instructions. A follow-up appointment will be scheduled for approximately 1 week. Follow-up visit is scheduled for 12/05/2023. Treatment orders/Addendum: Cleanse the wound with cleanser and pat dry with gauze. Apply topical antibiotic spray to the wound bed, followed by oil emulsion gauze. Cover with hydrocolloid dressing 3x weekly and PRN for soiled or loose dressing. Use bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing. 3. A developing pressure ulceration of the right posterior heel which is not associated with the admitting diagnosis. The patient will be prescribed a wound dressing protocol. Next Consultation: 12/05/2023 Referral Recommendation: Offloading, Elevation . Referral Ancillary Consultations: None Note: The wound was cleansed and inspected. There is a deep tissue pressure injury noted with no break in tissue. Recommended heel pillow, offloading, and elevation to avoid opening of the wound and future pressure ulcer / complications. Will follow-up, continue to monitor weekly at visit for patients’ other wounds and can start advanced wound care if needed. Note: Recommended dressing changes as described above in addition to frequent positional changes and use of positioning devices for prevent prolonged pressure to bony prominences, keep the head of the bed as low as possible to reduce risk of shearing. Treatment plan: Cleanse Wound: The wound was lavaged with wound cleanser. Dressings Ordered: Dressing Intervals: Cleanse the wound with cleanser and pat dry with gauze. 4. A pressure ulceration of the left posterior heel which is not associated with the admitting diagnosis. The patient’s wound had healed upon evaluation, will follow up to evaluate status of healed wound. Treatment Plan: The wound was cleansed. Once slough tissue was removed there was noted to be 100% epithelial tissue across the wound bed. Recommendations: Recommended heel pillow. Recommended offloading. Recommended elevation to avoid re-opening of wound and avoid future pressure ulcer/complications. Contacted agency and discussed recommendations. Note: Recommended dressing changes as described above in addition to frequent positional changes and use of positioning devices for prevent prolonged pressure to bony prominences, keep the head of the bed as low as possible to reduce risk of shearing. Spoke with hospice agency regarding recommendations. Daughter at bedside, discussed recommendations. A review of the WCS “Progress Report” dated 1/2/2024 indicated that the wound on the left superior buttocks was healed and has reopened. Advised to continue with dressing regimen. Will assess the patient in person. Visit Addendum: Cleanse the wound with cleanser and pat dry with gauze. Apply topical antibiotic spray to the wound bed, followed by oil emulsion gauze. Cover with hydrocolloid dressing 3x weekly and PRN for soiled or loose dressing. Use bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing. The wound on the right superior buttocks was healed and has reopened. Advised to continue with dressing regimen. Cleanse the wound with cleanser and pat dry with gauze. Apply topical antibiotic spray to the wound bed, followed by oil emulsion gauze. Cover with hydrocolloid dressing 3x weekly and PRN for soiled or loose dressing. Use bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing. A review of the WCS “Progress Notes” dated 1/9/2024 indicated the Right posterior heel ,The chronic non-healing ulceration was debrided by mechanical methods. Devitalized tissue was removed to the level of healthy bleeding tissue which included slough. The instruments used included gauze scrub with cleanser. The debridement area extended down to the level of subcutaneous tissue. All surrounding peri-wound hyperkeratotic skin was also removed as required. Hemostasis was achieved by the usage of compression. The estimated blood loss was less than 3 ccs. The post-debridement measurements were as follows: W:1.4 x L:1.7 x D:0.2. The debridement area was cleansed with wound cleanser then dressed with 4x4 gauze pads. The patient tolerated the procedure well and there were no complications. The patient, caregiver and or patient coordinator were provided detailed post-procedure instructions. A follow-up appointment will be scheduled for approximately 1 week. Follow-up visit is scheduled for 01/16/2024. Cleanse the wound with cleanser and pat dry with gauze. Apply topical antibiotic spray to the wound bed, followed by oil emulsion gauze. Cover with bordered gauze 3x weekly and PRN for soiled or loose dressing. Note: The supplies used was from patient’s supplies. On 1/13/2024 at 12:38 p.m., a home visit was conducted with License Vocational Nurse (LVN 1) at Patient 8’s board and care (B&C) facility. Patient 8 was observed sitting on a recliner in the living room watching tv, non-verbal, uses a Hoyer lift provided by the agency, On concurrent interview with the administrator(Admin) B&C stated he has wound on the heels, and the nurse visits the patient 2x a week. B&C admin stated that Patient 8 is a feeder, sometimes hard to swallow puts thickener on liquids, sleeps good, always been combative, no medications for the combative behavior and is manageable at this time. B&C admin stated he does not have problems sleeping. B&C admin stated that he has on and off wound for about a year now and the WCS comes every week. On 1/13/2024 at 12:38 p.m., during an concurrent interview with LVN 1 stated that she is not the current follow up nurse who visits the patient regularly. LVN 1 stated that the other nurse visits twice a week. LVN 1 checked the dressing of the right and left heel and stated that the wound care specialist (WCS) comes in once a week and provides the treatment for the patient. LVN 1 did not perform wound treatment on this home visit. A review of the HA’s documentation on Patient 8’s electronic medical record on 1/14/2024 revealed that the HA had no evidence of wound care coordination with the wound care specialist regarding his treatment orders since 12/5/2023. Skilled nursing home visit notes revealed the visiting nurse was not performing follow up wound care on the following dates: 12/5/2023, 12/7/2023, 12/12/2023, 1/2/2024, 1/4/2024 and 1/9/2024. The Registered Nurse (RN) assessment revealed that the RN did not conduct a wound assessment, no wound care provided on her visit on 12/15/2023 and 12/29/2023. During an interview with the Admin/DON on 1/14/24 at 12:24 p.m., Admin/DON stated that she spoke to the RN asking about the wound care orders and the Admin stated that she needs to call the WCS for orders and ask the doctor and the agency should follow the treatment. Admin/DON stated that the nurse still did not call the WCS to confirm the wound care orders for Patient 8. Admin/DON stated that not coordinating with the WCS will result in ineffective treatment of the wound and the plan of care will not be updated and followed. A review of the HA’S policy titled “ Ongoing Assessments” revised 5/2022, indicated that during each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. A review of the HA’s policy titled “ Comprehensive Assessments” revised 5/2022, indicated During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient’s clinical record, including at least the following information, as relevant: G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patient’s terminal illness, R. Interdisciplinary group assessment of needs, W. Measurable outcomes anticipated from implementing and coordinating the plan of care. 8. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes.10. Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service.A review of the HA’s policy titled “ The Plan of Care” revised 5/2022 indicated , A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. This plan of care must be initiated at start of care.1. The Case Manager ( or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care after the consent forms are signed. 2. The Case Manager ( or admitting registered nurse) will then notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs. The plan of care will be reviewed prior to care being delivered. 3. Orders for the start of care will be verbally received by the Case Manager (or hospice registered nurse) from the attending physician ( or other authorized independent practitioner) and documented on the plan of care/physician order form.4. The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals and outcome achievement.5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care.”

“Based on interview and record review, the hospice agency failed to ensure care and interventions needed for one of 14 sample patients (Patient 6), who had difficulty breathing was provided. This deficient practice resulted to the delay of care and had the potential to cause respiratory complications leading to the patients discomfort and poor-quality nursing care. During a review of Patient 6’s admission record, the admission record indicated a start of care date (SOC) of 5/6/2023, with a terminal diagnosis of arteriosclerotic heart disease ( build up of fats, cholesterol and other substances in and on the artery walls). During a review of Patient 6’s Physician’s order dated 5/6/2023, the physicians order indicated to perform oxygen saturation (the amount of oxygen in the bloodstream with normal range of 95-100%) check every visit and notify physician of oxygen saturation below 85 percent in room air; to administer oxygen two to four liters via nasal cannula (a device that delivers extra oxygen through a tube into the nose) and may increase oxygen to five liters via mask for respiratory distress /shortness of breath if saturation level less than 92 percent; to administer Morphine Sulfate (pain medicine) liquid 20 mg (milligrams) 0.25 mg under the tongue every 2 hours as needed for shortness of breath and moderate to severe pain. During a review of Patient 6’s Plan of Care (POC)/Interdisciplinary Group (IDG - a team responsible for the holistic care of the hospice beneficiary) form dated 7/24/2023, indicated the frequency of visits for skilled nurse (SN) was two per week plus one prn (as needed) visits for symptom management and support and for any change of patients condition. During a review of Patient 6’s License Vocational Nurse (LVN) Visit Note dated 8/3/2023, indicated Patient 6 was non-responsive except to pain stimuli only, pupil sluggish to light, with shallow and labored breathing, lung sounds were diminished (reduced) with occasional crackles (a lung sound that indicate a person’s lungs have fluid inside or are not inflating correctly) through auscultation (method used to listen to the sounds of the body during a physical examination by using a stethoscope [a medical instrument]). The patient also had shortness of breath with oxygen saturation of 78 percent (normal saturation is 95% and higher), with oxygen therapy at four to five liters via nasal cannula. The patient developed having mottled (spot) skin on bilateral (both) lower extremities and cyanosis (bluish) lips. The patient appeared comfortable with no signs of pain but breathing was fast and shallow. The visiting nurse administered Roxanol (pain medication) 5 mg (milligrams) sublingually. However, there was no documented evidence the visiting nurse had provided comfort measures to relieve Patient 6’s existing troubled breathing and notified the physician regarding the patient’s new existing condition during the visit. On 1/12/2024, at 12 p.m., during a phone interview with Family Member (FM 1), FM 1 complained that on the last nursing visit, Patient 6 had a change of condition wherein she was struggling to breathe and was grasping for air, but the visiting nurse did not provide a mask nor provided comfort measures to ease down the patient’s difficulty in breathing. He also stated the patient died the following day. FM1 further stated he was very upset that the agency did not provide comfort and palliative care during the patient’s end of life transition. On 1/14/2024, at 1:30 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS agreed that Patient 6 had a sudden crisis situation that required continuous care level of care and the hospice agency failed to provide this level care to Patient 6. A review of the undated hospice agency’s policy and procedure (P&P), titled “Interdisciplinary Group Membership Responsibilities”, the P&P indicated the interdisciplinary group will collaborate with the patient’s attending physician to develop an individualized written plan of care. When there is more than one (1) interdisciplinary group, the hospice will designate in advance the group responsible for program oversight and the establishment of policies that govern the day-to-day provision of hospice care and services. The hospice interdisciplinary group membership includes at a minimum: Physician, Registered Nurse, Social Worker and Pastoral or other counselor. A review of the undated hospice agency’s policy and procedure (P&P), titled “Continuous Care Services”, the P&P indicated the crisis situations that may require continuous care include uncontrolled, severe symptoms, e.g., pain, dyspnea, nausea and vomiting which require continuous skilled assessment, intervention, and evaluation.”

“Based on interview and record review, the hospice agency failed to notify the physician regarding the current medical condition for one of 14 sample patients, (Patient 6). This failure had the potential to cause the patients comfort and a poor quality nursing care that can affect the quality of end of life care the patient deserved. During a review of Patient 6’s admission record, the admission record indicated a start of care date (SOC) of 5/6/2023, with a terminal diagnosis of arteriosclerotic heart disease ( build up of fats, cholesterol and other substances in and on the artery walls). During a review of Patient 6’s Physician’s order dated 5/6/2023, the physicians order indicated to perform oxygen saturation (the amount of oxygen in the bloodstream with normal range of 95-100%) check every visit and notify physician of oxygen saturation below 85 percent in room air; to administer oxygen two to four liters via nasal cannula (a device that delivers extra oxygen through a tube into the nose) and may increase oxygen to five liters via mask for respiratory distress /shortness of breath if saturation level less than 92 percent; to administer Morphine Sulfate (pain medicine) liquid 20 mg (milligrams) 0.25 mg under the tongue every 2 hours as needed for shortness of breath and moderate to severe pain. During a review of Patient 6’s Plan of Care (POC)/Interdisciplinary Group (IDG - a team responsible for the holistic care of the hospice beneficiary) form dated 7/24/2023, indicated the frequency of visits for skilled nurse (SN) was two per week plus one prn (as needed) visits for symptom management and support and for any change of patients condition. During a review of Patient 6’s License Vocational Nurse (LVN) Visit Note dated 8/3/2023, indicated Patient 6 was non-responsive except to pain stimuli only, pupil sluggish to light, with shallow and labored breathing, lung sounds were diminished (reduced) with occasional crackles (a lung sound that indicate a person’s lungs have fluid inside or are not inflating correctly) through auscultation (method used to listen to the sounds of the body during a physical examination by using a stethoscope [a medical instrument]). The patient also had shortness of breath with oxygen saturation of 78 percent (normal saturation is 95% and higher), with oxygen therapy at four to five liters via nasal cannula. The patient developed having mottled (spot) skin on bilateral lower extremities and cyanosis (blue) lips. The patient appeared comfortable with no signs of pain but breathing was fast and shallow. The visiting nurse administered Roxanol (pain medication) 5 mg (milligrams) sublingually. However, there was no documented evidence the visiting nurse had provided comfort measures to relieve Patient 6’s existing troubled breathing and notified the physician regarding the patient’s new existing condition during the visit. On 1/12/2024, at 12 p.m., during a phone interview with Family Member (FM 1), FM 1 complained that on the last nursing visit, Patient 6 had a change of condition wherein she was struggling to breathe and was grasping for air, but the visiting nurse did not provide a mask nor provided comfort measures to ease down the patient’s difficulty in breathing. He also stated the patient died the following day. FM1 further stated he was very upset that the agency did not provide comfort and palliative care during the patient’s end of life transition. A further review of Patient 6’s clinical record indicated no documented evidence the visiting nurse notified the physician regarding the patient’s existing condition on her visit on 8/3/2023. On 1/14/2024, at 1:45 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated she was not aware of Patient 6’s change of condition, that if the visiting nurse have told her about it, she could have sent a nurse to provide continuous care to achieve palliation. She also stated that she could not find any documented evidence that the visiting nurse notified the physician of patient’s sudden change of condition. A review of the facilitys undated policy and procedure titled, “Monitoring Patient’s Response/Reporting To Physician,” indicated during each hospice visit, the clinician will notify the patient’s physician or the hospice medical director on the same day when there are changes in the patient’s condition.”

“Based on interview and record review, the hospice agency failed to ensure a performance improvement projects (PIP, a concentrated effort on a particular problem in one area of the facility or facility wide involving gathering of information systematically to clarify issues or problems, and intervening for improvements) conducted every year. This failure had the potential to affect the highest quality of care provided to all the patients under agency’s care. A request was made on 1/14/2024, at 11:30 a.m., to the Administrator/Director of Nursing (ADM/DON) for the performance improvement projects (PIP) derived from the data collected from the Quality Assurance and Performance Improvement (QAPI, the coordinated application of two mutually‑reinforcing aspects of a quality management system. QAPI takes a systematic, comprehensive, and data‑driven approach to maintaining and improving safety and quality of patient care) program. On 1/14/2024 at 11:30 a.m., during an interview with the ADM/DON, ADM/DON stated she is aware of the requirement, but she is not in charge of the QAPI and PIP. ADM/DON stated that she requested the QAPI/PIP to the owners of the hospice agency on the first day of the validation survey, but none was forwarded to her. ADM/DON stated that she does not have access to that particular part of the program and the owners of the agency had not sent the details of their QAPI/PIP. ADM/DON understood the outcome of not providing any evidence of past projects. The agency’s policy and procedure titled “Quality Assessment and Performance Improvement Plan and Program”, indicated the agency will have an organized system assessing and improving the quality of care and services. This system shall be designed to improve performance on a systematic and continuous basis. The policy indicated there should be coordination of performance improvement activities.”

“Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verified patients’ clinical information, necessary for initial certifications for two of 14 sampled patients (Patient 7 and Patient 13) which used to support diagnosis of the patients terminal illnesses and to qualify them for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attends to their emotional and spiritual needs at the end of life) care. This deficient practice resulted in the hospice using the CTI (Certification of terminal Illness, a brief narrative summary based on the clinical judgment of the hospice physician and the individuals attending physician (if the patient has one) or the medical director of the hospice regarding the normal course of the individuals illness) of another hospice for their clinical record and the medical director and/or the hospice attending physician certified the patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses which could result to lack of care and inappropriate care provided to the patients. 1. A review of Patient 7s “;Personal Information” sheet, indicated a start of care on 6/27/2023, with the diagnosis of atherosclerotic heart disease (the usual cause is the buildup of plaque which causes coronary arteries to narrow, limiting the blood flow to the heart causing damage or disease in the heart’s major blood vessels). The sheet indicated Patient 7 was transferred from another hospice. A review of the hospice agency’s (HA) document titled “CTI - Certification of Terminal Illness” for the period of 6/10/2023 to 8/8/2023, indicated that this was the documentation of Patient 7’s CTI from the former hospice agency. 2. A review of Patient 13s “;Personal Information” sheet indicated a start of care on 6/15/2023, with the diagnosis of Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions). Patient 13 was transferred from another hospice. A review of the hospice agency’s (HA) document titled “CTI - Certification of Terminal Illness” for the period of 5/15/2023 to 7/13/2023, indicated that this was the documentation of Patient 13’s CTI from the former hospice agency. During an interview on 1/14/2024 at 12:35 p.m., with the Administrator/Director of Nursing (ADM/DON), ADM/DON confirmed that Patient 7 and Patient 13 were transferred from another hospice agency and stated that the agency followed the CTI from another agency for the admission. ADM/DON stated that she did not know that the agency had to conduct their own assessments on the CTI instead of putting the old CTI from the other agency. ADM/DON stated that the medical director should conduct their own assessment for the CTI. A review of facilitys policy and procedure titled, “;Physician Services – Medical Director”, revised 7/2023, indicated “;The hospice Medical Director will have overall responsibility for the medical component of the hospice program. The duties and responsibilities of the Medical Director will include, but not limited to the following: Providing overall medical direction to the program including supervision of all hospice physician employees and contract hospice physicians. Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to 3rd and subsequent benefit periods. Providing written certification and narrative of the terminal illness for all subsequent benefit periods, will perform home visits, patient assessment and provide interventions as requested by IDG. May provide a face-to-face encounter visit with the patient prior to 3rd and subsequent benefit periods. Attending interdisciplinary group meetings and working in a team approach with the group. In conjunction with the attending physician and interdisciplinary group, reviewing and updating the plan of care every 15 days, or more frequently as needed. Documenting care provided in the patients clinical record, providing evidence of progression of the end stage disease process. A review of facilitys policy and procedure titled, “;Certification of Terminal Illness”, revised 7/2023, indicated “;Patients who elect the hospice ... will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director... Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification... Both the attending physicians and Medical Directors signed and dated initial certification forms must be on file prior to billing the first claim... Tools such as the fiscal intermediarys Local Coverage Determination, along with other supporting documentation, can be used to provide guidance in determining and documenting terminal prognosis.” A review of facilitys form titled, “;Job Title/Position: Hospice Medical Director Alternate” dated 2018, indicated “;The hospice Medical Director will have overall responsibility for the medical component of the hospice program. The duties and responsibilities of the Medical Director will include...: Adhering to requirements, terms, and conditions required by Medicare Conditions of Participation, accrediting body, and federal and state statutes governing the provision of services... Reviewing patients medical eligibility for hospice services... Providing written certification of the terminal illness... Documenting care provided in the patients clinical record, providing evidence of progression of the end-stage disease process.””

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure clinical records included assessments and clinical notes for seven out of 14 sampled patients (Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) were complete. This deficient practice had the potential for the lack of coordination of Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14’s clinical information and continuity of care services provided to the patients certified to receive the hospice care benefits. 1. A review of Patient 7s “;Personal Information” sheet indicated a start of care on 6/27/2023, with the diagnosis of atherosclerotic heart disease (the usual cause is the buildup of plaque which causes coronary arteries to narrow, limiting the blood flow to the heart causing damage or disease in the heart’s major blood vessels). A review of Patient 7s record titled, “;POC Summary” for the certification period from 12/7/2023 to 2/4/2024, indicated the skilled nurse was to visit patient once a week. Continued review of the EMR (electronic medical record) indicated the nurse did not submit weekly nursing notes for 12/27/2023. 2. A review of Patient 8’s “;Personal Information” sheet indicated a start of care on 11/17/2023, with the diagnosis of Alzheimers disease (a disease that destroys memory and other important mental functions) and wound care stage 3 (a full thickness ulcer that might involve the subcutaneous fat) on the right posterior heel and stage 1 (erythema of the skin) on the left posterior heel. A review of Patient 8s record titled, “;POC Summary” for the certification period from 1/16/2024 to 3/15/2024, indicated the skilled nurse was to visit patient once a week. Continued review of the EMR (electronic medical record) indicated the skilled nurse did not submit weekly nursing notes for 12/21/2023 and 12/28/2023. 3. A review of Patient 9’s “;Personal Information” sheet indicated a start of care on 9/9/2023, with the diagnosis of heart disease (refers to multiple conditions of the heart that affects its function in the body). A review of Patient 9s record titled, “;POC Summary” for the certification period from 12/31/2023 to 2/28/2024, indicated the skilled nurse was to visit patient once a week. Continued review of the EMR (electronic medical record) indicated the skilled nurse did not sign weekly nursing notes for the following dates: 10/21/2023, 12/30/2023, and 1/9/2024. 4. A review of Patient 10’s “;Personal Information” sheet indicated a start of care on 5/1/2023, with the diagnosis of atherosclerotic heart disease of native coronary arteries. A review of Patient 10s record titled, “;POC Summary” for the certification period from 12/7/2023 to 2/4/2024, indicated the skilled nurse was to visit patient once a week and hospice aide (HA) once a week. Continued review of the EMR (electronic medical record) indicated the skilled nurse did not sign weekly nursing notes for the following dates: 11/7/2023, 11/14/2023, 12/19/2023, 12/20/2023, 1/1/2024, 1/2/2024,1/4/2024, 1/8/2024, 1/9/2024, and 1/11/2024. 5. A review of Patient 11’s “;Personal Information” sheet indicated a start of care on 7/1/2023, with the diagnosis of Parkinson’s disease. A review of Patient 11s record titled, “;POC Summary” for the certification period from 12/8/2023 to 2/25/2024, indicated the skilled nurse was to visit patient once a week and hospice aide (HA) twice a week. Continued review of the EMR (electronic medical record) indicated the skilled nurse did not sign weekly nursing notes for the following dates: 12/5/2023, 1/1/2024, 1/2/2024, 1/3/2024, 1/4/2024, 1/8/2024, 1/9/2024, 1/10/2024, and 1/12/2024. 6. A review of Patient 12’s “;Personal Information” sheet indicated a start of care on 5/24/2023, with a diagnosis of Alzheimer’s disease. A review of Patient 12s record titled, “;POC Summary” for the certification period from 1/5/2024 to 3/4/2024, indicated the skilled nurse was to visit patient twice a week and hospice aide (HA) twice a week. Continued review of the EMR (electronic medical record) indicated the skilled nurse did not sign weekly nursing notes for the following dates: 12/16/2023, 12/19/2023, 12/21/2023, 12/28/2023, 1/2/2024, 1/4/2024, and 1/9/2024. During an interview on 1/14/2023, at 11:30 a.m., with the intake coordinator (IC), IC stated that the triangle is a notation in the electronic medical record that means the document was pending review from QA (Quality Assurance) and the (X) is a notation that indicates that the note was plotted by the visiting nurse, but had not submitted for review. IC stated that QA people work remotely. IC stated the QA personnel are in contract with the agency and review the chart. IC stated that the QA sends the report every two weeks and the Administrator/Director of Nursing (ADM/DON) reviews the report. IC further stated if the notes were unsigned in the EMR, the notes has not been completed and reviewed. During an interview with the ADM/DON on 1/14/2024 at 12:35 p.m., ADM/DON stated that she calls the QA and calls the caregivers and field staff to complete their notes for QA review. Admin stated that the field staff are required to submit their notes within 48 to 72 hours after their home visit. ADM/DON stated the QA will review the notes and will resend the noted to the field staff for signature. ADM/DON further stated that it has been an ongoing problem that the staff were not submitting their notes on time for the QA to review it. ADM/DON further stated she does the QA for the agency’s electronic medical record. ADM/DON stated the agency has a consultant QA that reviews the nurses notes. ADM/DON further stated that if the nurses does not submit their notes on time, there will be no continuity and updates for the plan of care. A review of facilitys policy and procedure titled, “;Clinical/Service Data Collection”, revised 5/2022, indicated “;A clinical/service record will be initiated and maintained for each patient... and will include at a minimum: Pertinent medical history... Current patient status and progress toward goals... Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided... Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. The clinical/service note will include: the date the service was provided... signature of clinician/technician and his/her credentials.””