1st Choice Hospice

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 8 (12%) clinical records reviewed revealed the agency did not ensure the individualized written plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. Clinical Record 3: The patient elected the hospice benefit on 06/19/2024 for the diagnosis of malignant neoplasm of bronchus or lung. Site Visitor observed Staff 6 SC (Spiritual Counselor) during Home Visit 3 on 07/02/2024. The patient’s husband and daughter both described the support the SC had been providing for the patient and family since admission. The house had walls painted with biblical verses and the daughter pointed out to the Site Visitor that the patient “had painted the walls to honor her beliefs.” The daughter also advised that “she had been struggling with the idea her mother was going to a better place and that the SC had been helping her with her relationship with God.” A spiritual counselor visit on 06/21/2021 noted “Spirituality seems to be an important priority. SC asked the patient her favorite passage from bible and she turned to book of 1 Kings and handed her bible to SCC.” Upon review of the Clinical Record, it was revealed there was not a written plan of care that included the detailed scope and frequency of the spiritual counselor’s visits, interventions, patient and family goals, or outcomes. Interviewed the Spiritual Counselor after Home Visit 3 on 07/02/2024 who stated he was visiting the patient and family weekly to support them but had not entered a written plan of care in the clinical record. During an interview and joint record review with the Director of Patient Care Services (DPCS) and Administrator on 07/02/2024, the last visit frequency entered for the Spiritual Counselor had been entered upon admission (6/19/2024) was 1 time per month and 2-3 as-needed visits for spiritual support. It had not been updated to reflect the 1x per week. It was confirmed there was not a written plan of care regarding spiritual support problems, goals, or interventions. The DPCS stated she “didn’t know how to word spiritual support problem, goals or interventions.””

“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. but no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 2 of 8 (25%) clinical records reviewed revealed the agency did not ensure the individualized care plan was revised as frequently as the patient’s condition required. but no less frequently than every 15 days. Clinical Record 2: The patient elected the hospice benefit on 06/06/2024 for the diagnosis of paroxysmal atrial fibrillation. The initial plan of care dated 06/06/2024 included a “Problem: Potential for Impaired Skin Integrity.” On 6/20/2024 an on-call nursing visit noted: “called out for small cut on the leg, covered and dressed with Xerofoam.” The plan of care was not updated from the “impaired skin integrity problem” to reflect the actual wound/cut on the leg. Clinical Record 5: The patient elected the hospice benefit on 05/16/2024 for the diagnosis of Alzheimer’s disease. An on-call nursing visit for a “change of condition” dated 05/23/2024 noted “daughter reported patient having seizures. Obtained new orders for Keppra and Valium”, The plan of care was not updated to include a problem, goals, or interventions for the seizures. During an interview and joint record review with the Director of Patient Care Services (DPCS) and Administrator on 7/2/2024, it was confirmed neither plan of care had been updated after the updated comprehensive assessments. The Administrator stated “It appeared to be a communication or process issue as both visits were on-call””

“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 4 of 7 (57%) 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 2: The patient elected the hospice benefit on 06/06/2024 for the diagnosis of paroxysmal atrial fibrillation. An on-call nursing visit on 6/20/2024 noted the patient to have “a small cut to her right calf. Cleansed and covered with Xerofoam dressing.” The wound was still present on 7/2/2024 as the Site Visitor observed Staff 4, a licensed vocational nurse, care for the wound during Home Visit 2. The hospice aide care plan dated 6/6/2024 included the relevant tasks of “bathing via bed bath, dressing, and checking skin/pressure areas.” The aide care plan was not updated to notify the aide of the wound nor provide specific instructions for care of the dressing during tasks. Clinical Record 4: The patient elected the hospice benefit on 06/14/2024 for the diagnosis of heart failure. The initial nursing assessment dated 06/14/2024 noted the patient was on continuous oxygen at 2 liters per minute. The hospice aide care dated 06/14/2024 included the relevant tasks of “bathing via bed bath, shampoo hair, dressing patient and assist with transfers” and identified the patient as being on oxygen but did not provide the aide with specific instructions for the oxygen during tasks. Clinical Record 5: The patient elected the hospice benefit on 05/16/2024 for the diagnosis of Alzheimer’s disease. The initial nursing assessment dated 05/16/2024 noted the “patient to have a history of seizures.” An on-call nursing visit for a “change of condition” dated 05/23/2024 noted “daughter reported patient having seizures. Obtained new orders for Keppra and Valium” The hospice aide care plan dated 05/16/2024 included the relevant tasks of “bathing via bed bath and dressing.” The aide care plan did not notify the aide of the seizure precautions or include instructions for the aide to notify the nurse if the patient had a seizure. Clinical Record 7: The patient elected the hospice benefit on 12/14/2023 for a malignant neoplasm of the rectum. The initial nursing assessment dated 12/14/2023 noted the patient had a “rectal tumor covered with dry dressing.” The hospice aide care plan dated 12/14/2023 included the relevant tasks of “bathing via bed bath and check pressure areas.” The aide care plan was not updated to notify the aide of the wound nor provide specific instructions for care of the dressing during tasks. During an interview and joint record review with the Director of Patient Care Services (DPCS) and Administrator on 07/02/2024, the DPCS stated “it made sense to add the specific instructions for the wounds to the aide care plans” after review of Clinical Records 2 and 7. During the interview regarding Clinical Record 4 and the oxygen, it was agreed that the aide needed to be given specific written instructions and those were not present in this record. During the interview with the DPCS regarding Clinical Record 5 and the seizure precautions, the DPCS stated “The nurses were not updating care plans as changes occurred”.”

“It is required that a patient clinical record contains correct clinical information available to the patient’s attending physician and hospice staff, including, at a minimum, any advance directives. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records reviewed revealed the agency did not ensure the clinical record contained copy of the patient’s advance directives. Clinical Record 6: The patient elected the hospice benefit on 6/6/2024 for the diagnosis of multiple myeloma. The initial nursing assessment noted the patient “was not ready to sign the POLST (physician order of life-sustaining treatment) and wanted to look it over and think about it and they would remain a full code” There was a later notation that the “POLST had been completed” but it was not attached to the clinical record. During an interview and joint record review with the Administrator on 07/02/2024, it was confirmed the POLST had not been added to the Clinical Record and it was not able to be located during the Site Visit.”