Everystep

“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, Intervention to manage pain and symptoms, and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 26 (12%) clinical records reviewed it was revealed that the agency did not ensure that the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: The patient elected hospice services on 01/23/2025 with a diagnosis of Malignant neoplasm of lower-outer quadrant of right female breast. During the initial nursing assessment on 01/23/2025 the RN documented that the patient was having issues with getting her pain managed specifically “pain in upper right shoulder, shooting pain and into back also pain in torso.” On 01/30/2025 the RN documented “Tramadol not working well, states she has been using 2 tablets. Pain gets up to 7 or 8.” Medication changes were made on this visit to Dilaudid 2mg. On 02/02/2025 the RN documented “patient reports she started out taking a half tab of Dilaudid but is now taking a whole tablet about 2 to 3 times a day.” On 02/11/2025 the RN documented “pain reported down the right ribs, taking Dilaudid 2mg 3 times a day.” On 02/17/2025 the RN documented “patient would like a long-acting pain medication due to increased pain.” Morphine ER was started on this date. On 03/11/2025 the Morphine ER was discontinued and Fentanyl 15mcg was added. The problem of pain was identified on the plan of care however during interview and joint review with the VP of clinical services there was no evidence documented of specific measurable patient goals or interventions documented on the plan of care. The patient was also admitted to hospice services with a peritoneal dialysis catheter. She manages her own dialysis at night. During joint review of the clinical record and interview with the VP of clinical services it was revealed there was no documented evidence of any monitoring or care for the peritoneal catheter. During the interview with the VP of clinical services on 03/12/2025 she agreed that there should have been risk for peritonitis and the RN should have been monitoring for signs and symptoms of infection as well as fluid overload due to her kidney failure. CLINICAL RECORD 8: The patient elected hospice services on 12/10/2024 with a diagnosis of Malignant neoplasm of the prostate. The RN documented that the patient had a wound on her left buttock and right heel. During joint review of the clinical record and interview with the VP of clinical services on 03/12/2025 there was no documented evidence of any measurable goals for the patient’s wound. CLINCIAL RECORD 25: The patient was admitted to the IPU with uncontrolled pain and was receiving dilaudid. Pain was identified as a problem and there was no documented measurable goal to achieve to ensure the patient’s pain was managed.”

“It is required that Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) bereavement records reviewed it was revealed that the agency did not ensure that a bereavement plan of care was developed for the bereaved. CLINICAL RECORD 23: The patient elected the hospice benefit on 09/06/2024 and expired on 09/30/2024. A phone call was made to the family on 10/04/2024 by the bereavement coordinator and it was documented as, “condolence call - left voicemail - will reach out for the bereavement assessment in the next few weeks.” During joint review of the record and interview with the VP of Clinical services there was no documented evidence found that there were any follow up phone calls or bereavement services offered to this family.”

“Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to ensure the individualized plan of care was reviewed and revised based on the comprehensive assessment at least every 15 days for 1 of 6 sampled patients (Patient #3). Failure of the interdisciplinary group (IDG) to review and update the individualized plan of care at least every 15 days placed hospice staff at risk of not knowing what care and services to provide to meet the patient’s assessed needs and/or placed the hospice patients at risk for not receiving appropriate care to have their needs met. Findings include: Review of the hospice policy titled Care Coordination, Care Planning and IDG, dated 6/17/24, identified the IDG, in collaboration with the patient’s attending physician reviews, revises and documents the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. Patient #3 had a start of care date of 8/30/23 and received hospice services in a private home prior to moving to a skilled nursing facility on 9/26/24. Clinical record review revealed documentation of IDG meetings on 9/17/24 and 10/9/24, 22 days apart, which exceeded the requirement by 7 days. On 10/22/24 at 11:42 AM, during an interview, Staff A, Vice President of Clinical Services identified an IDG meeting was missed due to the patient moved into a skilled nursing facility which placed the patient on a different team with a different IDG meeting day. The above findings were shared with the Vice President of Clinical Services and the Quality Management Director.”

“Based on hospice policy review, clinical record review, and hospice staff interview, the hospice failed to ensure care and services were provided in accordance with the plan of care for 1 of 4 sampled patients (Patient #4). Failure of the hospice to maintain a system for communication and integration of patient care and services to ensure staff provide care in accordance with the plan of care placed patients at risk to not receive services and medications according to assessed needs and physician orders. Findings include: Review of the hospices policy, titled, Care Coordination, Care Planning, and IDG, dated 11/14/18, all care and services furnished to patients and their families follows the individualized written plan of care (POC) established by the Interdisciplinary Group (IDG) in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patients needs. The IDG, in collaboration with the patients attending physician, reviews, revises, and documents the individualized plan as frequently as the patients condition requires, but no less frequently than every 15 calendar days. Review of the hospices policy, titled, Physician Orders, dated 11/1/22, verbal orders are put in writing and signed and dated by qualified staff responsible for furnishing or supervising the care. 1. Patient #4 had a hospice admission date of 1/11/24 and received hospice services while residing at home. Review of the clinical record and interview with staff revealed the following: a. The POC, dated 1/11/24 to 4/6/24, included orders for Morphine Sulfate (MS) (concentrate) by mouth solution 20 milligrams (MG)/millileters (ML) 3 times a day by mouth per request as needed (PRN) for air hunger/pain. b. The Team Director (TD) phone call note, dated 1/15/24, revealed patients spouse was concerned about running out of MS. Spouse reported 15ml left in bottle. TD informed spouse that equates to about 30 doses so about 1 week of 0.5ml 4 times a day. Spouse indicated pulmonologist said patient could take MS 4 times a day but the chart still reads 3 times a day. TD reported the nurse visiting on Wednesday (1/17/24) would address this further. c. Staff C, Registered Nurse (RN), note dated, 1/17/24, did not indicate any changes in orders or POC to reflect patients current MS usage. d. Staff C, RN, visit note dated, 1/19/24, revealed collaboration regarding MS script and progress. The RN noted the doctors office returned call during visit and gave verbal confirmation previous requests received by RN and order in progress will be ready later today. e. The IDG notes dated, 1/24/24 and 2/7/24, revealed no updates to the POC regarding increased frequency of MS. f. The medical record lacked any written documentation of the verbal orders given regarding MS frequency being changed. g. During an interview on 2/14/24 at 3:12 PM, with agency Regional Director (RD), RD reported Staff C, RN, confirmed receipt of new verbal order for MS 20 mg/ml 4 times a day by mouth PRN for air hunger/pain, on 1/19/24. Staff C reported failure to enter the verbal order into patient record and Staff C failed to update the POC. The hospice agency failed to follow the plan of care and failed to update the plan of care with new physician orders. The above findings were reviewed with the hospice Regional Director. Hospice staff did not provide any additional information prior to end of the survey.”