Primecare Hospice & Palliative, Inc.

“It is required that each patient’s individualized written plan of care reflects patient and family goals and 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, document review and interview. In 2 of 14 (14%) records reviewed the agency did not ensure that each patient’s individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments PC. P55 Hospice Plan of Care-Content read in part, ‘The hospice must develop an individualized plan of care for each patient. The plan of care must reflect patient and 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 including the following: f. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. h. Drugs and treatments necessary to meet the needs of the patient.’ Clinical Record 8: The hospice election of benefit was dated 02/07/2024. The 02/07/2024 hospice plan of care included an aide frequency of ‘2week12.’ Aide visits were provided at the ordered frequency 02/07/2024 through 04/29/2024. The 02/07/2024 initial and the 02/21/2024, 03/06/2024, 03/20/2024, 04/04/2024, and 04/17/2024 updated comprehensive assessments identified the patient’s ‘self-care deficit’ and agreement to the provision of aide services ‘to assist with ADL’s.’ At the time of the review on 02/24/2024, the hospice plan of care did not contain aide interventions or goals. Clinical Record 11: The hospice election of benefit was dated 12/28/2023. The 12/28/2023 hospice plan of care included an aide frequency of ‘3week12.’ Aide visits were provided at the ordered frequency 01/02/2024 through 01/26/2024. The 12/28/2023 initial and the 01/03/2024, 01/10/2024, 01/17/2024 and the 01/21/2024 updated comprehensive assessments identified the patient’s ‘self-care deficit’ and agreement to the provision of aide services ‘to assist with ADL’s.’ At the time of the review on 02/24/2024, the hospice plan of care did not contain aide interventions or goals. During interview 05/24/2024, the Administrator reviewed the associated records and stated that the aide interventions and goals had been inadvertently omitted and staff education would be provided to ensure compliance moving forward.”

“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, document review and interview. In 1 of 14 (7%) records reviewed the agency did not ensure that each patient’s individualized written plan of care: Included a detailed statement of the scope and frequency of services ordered. PC. P55 Hospice Plan of Care-Content read in part, ‘The hospice must develop an individualized plan of care for each patient. The plan of care must reflect patient and 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 including the following: f. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. h. Drugs and treatments necessary to meet the needs of the patient.’ Clinical Record 1: The election of hospice was dated 04/15/2024. The 04/15/2024 hospice plan of care included a frequency that read ‘SC 4 prn and MSW 4 prn.’ The 04/16/2024 social work initial evaluation and the 04/17/2024 chaplain evaluation included a planned visit frequency that read ‘1week4.’ At the time of the review on 05/23/2024, the 04/15/2024 hospice initial and the 04/17/2024, 05/05/2024 and the 05/17/2024 updated plans of care did not contain a social work or chaplain visit frequency. During interview 05/24/2024, the Administrator reviewed the associated record and stated that the original frequencies had been inadvertently omitted and had since been corrected.”

“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 drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) the agency did not ensure that each patient’s individualized written plan of care: Included the drugs and treatments necessary to meet the needs of the patient. PC.P55 Hospice Plan of Care-Content read in part, ‘The hospice must develop an individualized plan of care for each patient. The plan of care must reflect patient and 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 including the following: f. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. h. Drugs and treatments necessary to meet the needs of the patient.’ Clinical Record 3: The election of hospice was dated 05/09/2024. The 05/15/2024 physician’s order entered by the registered nurse read, ‘May place foley catheter if needed.’ At the time of the review on 05/22/2204, the order did not contain catheter or care specific instructions. Clinical Record 4: The hospice election of benefit was dated 12/02/2023. The 03/31/2024 hospice plan of care for the 03/31/2024 hospice episode of care read ‘Medi honey topically daily wound care start 04/03/2024.’ At the time of the review on 05/22/2024, the wound care order did not include the wound location. Clinical Record 11: The 12/29/2023 hospice plan of care read ‘Ulcer left lower buttock Stage 2 cleanse wound with wound cleanser/NS or soap and water, apply zinc oxide barrier cream, cover with band aid or apply hydrocolloid using aseptic technique. Dispose of old dressing. SN may teach family/CG to perform.’ At the time of the review on 05/24/2024, the wound care order did not contain a provision frequency. During interview 05/23/2024, the Administrator reviewed the associated records and stated that the incomplete orders had since been corrected.”

“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. In 5 of 14 (36%) records reviewed the agency did not ensure that all entries were appropriately authenticated by the person performing the care. Agency Policy PC.D25 Documentation Requirements read in part, ‘12. All documentation is signed using complete first and last name, credentials and title.’ Clinical Record 1: The 04/17/2024 aide visit note documentation did not contain a signature, credentials or date at the time of the review on 05/23/2024. Clinical Record 2: The 05/09/2024, 05/14/2024, and the 05/16/2024 registered nurse visit note documentation did not contain a signature, credentials or date at the time of the review on 05/22/2024. Clinical Record 3: The 05/12/2024, 05/15/2024, and the 05/20/2024 registered nurse visit note documentation did not contain a signature, credentials or date at the time of the review on 05/22/2024. Clinical Record 8: The 05/01/2024 aide and the 02/23-24/2024 volunteer visit note documentation did not contain a signature, credentials or date at the time of the review on 05/24/2024. Clinical Record 13: The 11/07/2023 and the 12/12/2023 volunteer visit note documentation did not contain a signature, credentials or date at the time of the review on 05/24/2024. During interview 05/24/2024, the Administrator reviewed the associated records and sated the missing signatures, credentials and dates had since been corrected.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) discharged records reviewed the agency did not ensure the patient’s attending physician was forwarded a copy of the hospice discharge summary. Clinical Record 8: The hospice discharge date was documented as 04/30/2024 due to patient no longer terminally ill. The 04/302/024 discharge registered nurse visit documentation read in part, ‘primary care appointment 05/15/2024 and physician office notified of discharge.’ The 04/30/2024 discharge summary. completed by the registered nurse, had a blank check box next to ‘discharge summary sent to physician.’ At the time of the review on 05/24/2024, there was no documented evidence of the agency sending a discharge summary to the physician assuming care of the patient post hospice discharge. During interview 05/24/2024, the Administrator reviewed the associated record and stated that the discharge summary had since been sent to the attending physician.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 10 (30%) discharge records reviewed the agency did not ensure the discharge summary included the patient’s current plan of care and the patient’s latest physician orders. Clinical Record 8: The patient was discharged from hospice on 04/30/2024 due to ‘no longer terminally ill.’ At the time of the review on 05/24/2024, the 04/30/2024 discharge summary completed by the registered nurse did not include the hospice plan of care nor any physician orders. Clinical Record 12: The patient was discharged from hospice on 04/28/2024 due to ‘revocation-seeking aggressive treatment.’ At the time of the review on 05/24/2024, the 04/28/2024 discharge summary completed by the registered nurse and forwarded to the receiving physician, did not include the hospice plan of care nor any physician orders. Clinical Record 13: The patient was discharged from hospice on 12/30/2023 due to ‘no longer terminally ill’ At the time of the review on 05/24/2024, the 12/30/2023 discharge summary completed by the registered nurse and forwarded to the receiving physician, did not include the hospice plan of care nor any physician orders. During interview 05/24/2024, the Administrator reviewed the associated records and the CHAP standard and stated was unaware of the requirement to include physician orders and the plan of care. Stated would provide staff education to ensure future compliance.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by interview and personnel record review. In 3 of 10 (30%) records reviewed the agency did not ensure a criminal background check was obtained on all hospice employees who have direct patient contact or access to patient records. Agency Policy: Personnel Policy and Procedure Background Checks read in part, ‘Agency Hospice and Palliative Inc requires all employees to have a criminal background check.’ Personnel Record 3: The Director of Patient Care Services (DPCS) personnel date of hire was 12/11/2023. At the time of the review on 05/23/2024 there was no evidence of a criminal background check. Personnel Record 4: The registered nurse (RN) personnel date of hire was 03/13/2024. At the time of the review on 05/23/2024 there was no evidence of a criminal background check. Personnel Record 10: The Medical Director personnel date of hire was 09/01/2023. At the time of the review on 05/23/2024 there was no evidence of a criminal background check. During interview 05/24/2024, the Administrator reviewed the policy and stated that the criminal background checks had been inadvertently omitted and have since been obtained.”