Adoration Hospice

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by interview and observation. In 3 of 22 (14%) clinical records reviewed and home visits observed, the hospice did not ensure that the patient’s drug profile included current medications or that the drug profile was updated at each comprehensive assessment. Clinical Record 1/Home Visit 1: The patient elected hospice care on 12/10/2020. During the home visit on 02/05/2024, a medication reconciliation was completed with the patient’s primary caregiver, which revealed these medications documented on the agency’s medication profile as active medications were no longer in use: Cephalexin 250mg by mouth 3 times a day for UTI (urinary tract infection) was ordered for the patient on 5/10/2023; Hycodan (with homatropine) 5mg - 1.5mg/5mL take 10mL every 4 hours as needed for cough was ordered on 9/19/2023; and amoxicillin/potassium (pot) clavulanate 875mg/125mg by mouth 2 times a day for upper respiratory vs. aspiration. In an interview, the patient’s primary caregiver confirmed the patient was no longer taking this medication. The caregiver stated the patient was taking Macrodantin 50mg by mouth daily and Sertraline 100mg by mouth daily. Clinical Record 3/Home Visit 3: The patient elected hospice care on 06/01/2023 and resided in a skilled nursing facility (SNF). A medication reconciliation was completed with the facility staff on 02/06/2024 during the home visit. The SNF medication list documented: Albuterol Sulfate Inhalation Nebulization Solution (2.5mg/3mL) 0.083% (Albuterol Sulfate) 1 vial inhale orally every 4 hours as needed for wheezing or SOB, effective 10/22/2023; Opcon-A Ophthalmic Solution 0.027-0.315% (Naphazoline w/Pheniramine) instill 1 drop in both eyes as needed for redness, allergies, effective 07/18/2023; and Tussin DM Oral Syrup 10-100mg/5mg (Dextromethorphan-Guaifenesin) Give 10ml by mouth every 4 hours as needed for s/s infection/cough effective 10/24/2023. The hospice medication profile did not include documentation of the medications. During an interview on 02/06/2024, the medication technician confirmed that all the medications on the SNF medication list are active and being given to the patient. Clinical Record 4/Home Visit 4: The patient elected hospice care on 03/15/2023 and resided in a SNF. A medication reconciliation was completed with the facility staff on 02/06/2024 during the home visit. The SNF medication list documented as active: Sertraline HCI Oral 25mg Give 1 tablet by mouth at bedtime for depression effective 4/3/2023. This medication was not documented on the hospice medication profile. During an interview, the SNF staff confirmed that the patient’s medications were active and current. During an interview and a review of the medication discrepancies on 2/6/2024, the Clinical Manager stated, “I am not surprised it is hard to keep up with the medications in the facilities.””

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The assessment update is completed: as frequently as the condition of the patient requires; [and] no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 22 (5%) clinical records reviewed, the hospice did not ensure the Registered Nurse (RN) completed an update to the comprehensive assessment at least every 15 days. Clinical Record 9: The patient elected hospice care on 03/13/2023 with a diagnosis of senile degeneration of the brain. The RN documented comprehensive assessments in the visit notes dated 01/17/2024 and 02/02/2024, 16 days later. A review of the clinical record revealed that between these visits, the patient was seen by the Licensed Practical Nurse (LPN) and the Hospice Aide; there were no additional RN visits. On 2/6/2024, the Administrator stated, “This is my fault; the RN called in sick, and I sent the LPN; I didn’t realize we went over the 15 days.””

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 22 (9%) clinical records reviewed, the hospice did not ensure the plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 7: The patient elected hospice care on 07/21/2023 with a diagnosis of Amyotrophic Lateral Sclerosis (ALS). The initial comprehensive assessment completed by the Registered Nurse (RN) on 07/21/2023 documented “Decreasing oral intake due to chewing and swallowing difficulties.” The initial certification of terminal illness signed 07/26/2023 documented a diagnosis of dysphagia. The recertification for terminal illness completed by the physician, signed 01/22/2024, documented “Worsening dysphagia...his diet was changed to pureed due to the potential of dysphagia and choking hazard.” The plan of care, dated 07/21/2023 to present, did not include documentation of problems, goals, or interventions related to dysphagia, aspiration precautions, or dietary modifications. Clinical Record 15: The patient elected hospice care on 12/21/2023 with a diagnosis of Congestive Heart Failure. The initial comprehensive assessment dated 12/21/2023 documented, “He had a Pleurx drain placed on 12/19/2023 and has required frequent paracentesis for fluid removal in abdomen.” The admission notes documented that the Pleurx remained intact at the time of the hospice admission, and “wife states next draining would need to be on Saturday.” The plan of care, dated 12/21/2023 through discharge on 01/02/2024, did not include documentation of problems, goals, or interventions related to the ascites or the Pleurx drain. During an interview and a joint record review on 02/07/2024, the Clinical Manager confirmed, “They did not include the dysphagia, diet change, or the Pleurx drain,” and the care plan for the patient still on services had been “fixed.””

“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 the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by interview and observation. In 2 of 22 (9%) clinical records reviewed, the hospice did not ensure that the patient’s plan of care included drugs and treatment necessary to meet the needs of the patient. Clinical Record 3/Home Visit 3: The patient elected hospice care on 06/01/2023 and resided in a skilled nursing facility (SNF). A medication reconciliation was completed with the facility staff on 02/06/2024 during the home visit. The SNF medication list documented: Albuterol Sulfate Inhalation Nebulization Solution (2.5mg/3mL) 0.083% (Albuterol Sulfate) 1 vial inhale orally every 4 hours as needed for wheezing or SOB, effective 10/22/2023; Opcon-A Ophthalmic Solution 0.027-0.315% (Naphazoline w/Pheniramine) instill 1 drop in both eyes as needed for redness, allergies, effective 07/18/2023; and Tussin DM Oral Syrup 10-100mg/5mg (Dextromethorphan-Guaifenesin) Give 10ml by mouth every 4 hours as needed for s/s infection/cough effective 10/24/2023. During an interview on 02/06/2024, the medication technician confirmed that all the medications on the SNF medication list are active and being given to the patient. The hospice plan of care for the benefit period dated 01/27/2024 through 03/26/2024 did not include documentation of the medications. Clinical Record 4/Home Visit 4: The patient elected hospice care on 03/15/2023 and resided in a SNF. A medication reconciliation was completed with the facility staff on 02/06/2024 during the home visit. The SNF medication list documented as active: Sertraline HCI Oral 25mg Give 1 tablet by mouth at bedtime for depression effective 4/3/2023. During an interview, the SNF staff confirmed that the patient’s medications were active and current. Sertraline HCI was not documented on the hospice plan of care for the benefit period dated 01/09/2024 through 03/08/2024. During an interview and a review of the medication discrepancies on 2/6/2024, the Clinical Manager stated, “I am not surprised it is hard to keep up with the medications in the facilities.””

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. 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 2 of 19 (11%) clinical records reviewed in which aide services were accepted, the hospice did not ensure the Registered Nurse (RN) provided the Hospice Aide (HA) specific information to meet the patient’s personal care needs. Clinical Record 2: The patient elected hospice care on 12/12/2023 with a diagnosis of Cirrhosis of the Liver. The initial assessment completed by the RN on12/12/2023 documented that the patient was sent home from the hospital on 12/11/2023 with a Pleurx drain in the right upper quadrant. The HA care plan, effective as of 12/12/2023, assigned the HA the relevant tasks of bathing (tub bath), bathing (shower), and skincare. The HA care plan did not alert the HA that the patient had a Pleurx drain in place or instructions on what to do if the dressing was wet or fell off. Clinical Record 15: The patient elected hospice care on 12/21/2023 with a diagnosis of Congestive Heart Failure. The initial nursing assessment completed by the RN on 12/21/2023 documented, “He had a Pleurx drain placed on 12/19/2023 and has required frequent paracentesis for fluid removal in abdomen.” The admission notes documented that the Pleurx remained intact at the time of hospice admission, and “wife states next draining would need to be on Saturday.” The HA care plan, effective from 12/21/2023 to the patient’s discharge on 01/02/2024, assigned the HA the relevant tasks of bathing (bed/bath), skin care (apply lotion), and turn and position in bed. The HA care plan did not alert the aide that the patient had a Pleurx drain in place or instructions on what to do if the dressing was wet or fell off. During an interview on 02/07/2024, the Administrator and Clinical Manager (Personnel Record 3) confirmed that the HA care plans did not address the Pleurx drains. Per the clinical manager, “It makes sense, but we hadn’t thought to add them.””

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed of patients receiving Hospice Aide services, the hospice did not ensure that the Hospice Aide (HA) provided services included in the care plan. Clinical Record 12: The patient elected the hospice benefit on 06/02/2023 with a diagnosis of Neurocognitive Disorder with Lewy Body. The plan of care dated 11/14/2023 ordered Hospice Aide visits three (3) times a week for one (1) week and five (5) times a week for eight (8) weeks, effective 11/29/2023. The HA care plan written by the RN for the certification period dated 11/29/2023 through 01/27/2024 documented “Shampoo twice a week on Monday and Fridays.” The HA documented HA visits on 01/15/2024, 01/16/2024, 01/17/2024, 01/18/2024, and 01/19/2024. The HA documented that a shampoo was completed during all five (5) visits. During an interview and a joint record review on 02/06/2024, the Clinical Manager confirmed that the shampoo was completed on all five (5) visits and should not have been.”

“It is required that hospice aides are supervised by a registered nurse who makes 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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed in which Hospice Aide (HA) services were accepted, the hospice did not ensure the HA was supervised by the Registered Nurse (RN) no less frequently than every 14 days. Clinical Record 9: The patient elected hospice care on 03/13/2023 with a diagnosis of senile degeneration of the brain. The HA plan of care dated 01/07/2024 to 03/06/2024 ordered HA services two times per week. HA visits were documented on 01/18/2024, 01/22/2024, 01/25/2024, 01/20/2024, and 02/01/2024. The RN documented HA supervisory visits on 01/17/2024 and 02/02/2024, with 16 days outstanding. During an interview on 02/06/2024, the Administrator confirmed that there were 16 days between RN visits, and thus, the supervisory visit was late.”

“It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #6-022.1 “Clinical/Service Data Collection” (last revised 01/15/2021) stated in relevant parts, “4. Entries into the clinical/service record will be legible...13. Errors in documentation will be corrected as follows: Draw a line through the entry, date and initial.” In 1 of 22 (5%) clinical records reviewed, the hospice did not ensure that all entries in the patient’s record contained legible information. Clinical Record 16: A review of the patient’s signed “The Notice of Medicare Non-Coverage” (NOMNC) form revealed the dates were scribbled and written over. In the form section labeled: “The effective date coverage of your current hospice period,” the year was written over multiple times, making it illegible. In the form section labeled: “Hospice Services will end on this date,” the month and year were crossed out with multiple lines, and the numbers were written over each other, making the date illegible. The form was signed and dated 01/08/2024, with the effective date for hospice services to end identified as 01/21/2024. During an interview and a joint review of the record on 02/06/2024, the Administrator agreed that the corrections made to these dates did not follow the agency policy and made the dates illegible.”