Hospice of Dubuque

“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 update of the comprehensive assessment includes Information on the patient’s progress toward desired outcomes and assessment of the patient’s response to care. 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, document review and interview. In 2 of 23 (9%) records reviewed the agency did not ensure that the updated comprehensive assessment included Information on the patient’s progress toward desired outcomes and assessment of the patient’s response to care. Document 3: Initial and Comprehensive Assessments Version 8 Effective 01/25/2024 read in part, “The comprehensive assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related medical conditions and includes screening for and assessment of: h. Review of the drug profile, including prescription and over the counter drugs, herbal remedies, and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy currently associated with laboratory monitoring. Updates to the Comprehensive Assessment 1. 1. Complete an update of the comprehensive assessment as frequently as the condition of the patient requires, but no less frequently than every 15 days 2. The Update to the Comprehensive assessment includes a. changes that have taken place since the first comprehensive assessment and most recent update to the comprehensive assessment (this includes developments listed previously under #6 of the Comprehensive Assessment Policy b. progress toward desired outcomes c. patients’ response to care.” Clinical Record 9: The 12/27/2023 hospice plan of care included daily wound care for documented sacral wound and read in part, “Hospice nurse to assess sacral wound 1xweek.” There were no weekly measurements documented for the nursing visits for the weeks of 12/30/2023, 01/26/2024, 01/25/2024, and 01/30/2024. The corresponding interdisciplinary team meeting notes dated 01/03/2024, 01/10/2024, 01/24/2024, and 02/07/2024 did not contain updated wound measurements and thus did not contain relevant information related to wound healing/treatment progress at the time of the review on 02/07/2024. Clinical Record 11: The 01/03/2024 hospice plan of care included daily wound care for documented Stage II coccyx wound and read in part, “Hospice nurse to assess coccyx wound weekly.” There were no weekly measurements documented for the nursing visits for the weeks of 01/08/2024, 01/11/2024, 01/16/2024, 01/22/2024 and 01/30/2024. The corresponding interdisciplinary team meeting notes dated 01/10/2024, 01/24/2024, and 02/07/2024 did not contain updated wound measurements and thus did not contain relevant information related to wound healing/treatment progress at the time of the review on 02/07/2024. During interview 02/08/2024, the Director of Compliance reviewed the associated records and agreed weekly measurements had not been performed and that the team meeting notes did not contain relevant wound data. Stated that remedial education would be provided to the clinical staff.”

“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 4 of 23 (17%) records reviewed the agency did not ensure that the individualized written plans of care included complete treatment orders necessary to meet the needs of the patient. Document 2: Plan of Care Version 4 effective 12/27/2023 read in part, ‘3. The POC includes d. Goals based upon the problem identified in the interdisciplinary assessments g. Drugs, treatments necessary to meet the patient’s needs.’ Clinical Record 1: The hospice election of benefit was dated 09/07/2023. The 12/06/2023 hospice plan of care for the 12/06/2023 hospice episode of care read in part, ‘Facility nurse will apply Opti foam 4x4 dressing to arch of right foot as needed if skin opens up or becomes sore. May change dressing every 3 days and as needed.’ There were no as needed qualifiers at the time of the review on 02/06/2024. Clinical Record 7: The hospice election of benefit was dated 01/10/2024. The 01/10/2024 hospice plan of care read in part, ‘Flush implanted port with 20cc 0.9%NS and 5cc Heparin 100u/ml monthly and as needed.’ There were no as needed qualifiers at the time of the review on 02/06/2024. Clinical Record 10: The hospice election of benefit was dated 01/04/2024. The 01/04/2024 hospice plan of care read in part, ‘wash wound with soap and water with warm wash cloth daily and as needed.’ There were no as needed qualifiers at the time of the review on 02/07/2024. Clinical Record 19: The hospice election of benefit was dated 11/03/2023. The 12/06/2023 hospice plan of care read in part, ‘monitor for patency of 16Fr 10cc Foley catheter and change as needed.’ There were no as needed qualifiers at the time of the review on 02/08/2024. During interview on 02/08/2024, the Director of Compliance reviewed the associated records and stated that the missing as needed qualifiers had since been corrected.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) records reviewed that included the provision of aide services, the agency did not ensure the aide provided services as per the plan of care. Clinical Record 5: The 12/08/2023 hospice plan of care included an aide frequency of 2xweek. The 12/18/2023 updated hospice aide plan of care included a task frequency of 1xmonth for soak feet trim/file toenails. At the time of the review on 02/06/2024, the aide visit note documentation for the week of 01/04/2024 dated 01/04/2024 and 01/08/2024, included completion of the aforementioned task at each visit instead of at the frequency ordered. Clinical Record 6: The hospice election of benefit was dated 10/29/2023. The 01/27/2024 hospice plan of care for the 01/27/2024 hospice episode of care included an aide frequency of 2xweek. The 01/29/2024 updated hospice aide plan of care included a task frequency of 1xweek for sweep and vacuum. At the time of the review on 02/06/2024, the aide visit note documentation for the week of 01/30/2024 dated 01/30/2024 and 02/02/2024, included completion of the aforementioned task at each visit instead of at the frequency ordered. Clinical Record 15: The hospice election of benefit was dated 10/05/2023. The 01/03/2024 hospice plan of care for the 01/03/2024 hospice episode of care included an aide frequency of 2xweek. The 012/04/2023 updated hospice aide plan of care included a task frequency of 1xweek for shave and did not include nail care. At the time of the review on 02/07/2024, the aide visit note documentation for the week of 01/08/2024 through 01/25/2024 included completion of the aforementioned tasks at each visit instead of at the frequency ordered. During interview 02/08/2024, the Director of Compliance reviewed the associated records and stated that remedial education would need to be provided to the associated staff moving forward. Stated the Supervising registered nurses would address aide documentation misalignment.”

“It is required that if laboratory testing is performed by hospice staff—and it is other than assisting an individual in self-administering a test with an appliance that has been approved for that purpose by the FDA—such testing complies with all applicable state and federal law and regulation. If the hospice refers specimens for laboratory testing to a reference laboratory, the reference laboratory is currently certified in the appropriate specialties and subspecialties of services in accordance with the applicable requirement of Clinical Laboratory Improvement Amendments (CLIA) certification and state law requirements. This standard was not met as evidenced by clinical record review and interview. The agency did not ensure that the reference laboratory referred for specimen laboratory testing was currently certified. Clinical Record 8: The 12/29/2024 physician order read ‘collect urine spearmen for urine C&S via clean catch or straight cath.’ The 12/29/2023 registered nurse visit note documentation included specimen collected as ordered. The 01/02/2024 registered nurse visit documentation read in part, ‘laboratory results back and medication ordered due to UTI.’ The laboratory results in the patient record from the 12/29/2023 documented sample collection was from a reference lab. During interview on 02/07/2024, the Director of Compliance stated she was unaware of need to obtain CLIA from the reference laboratory and had since collected and would retain with organizational records. The agency did not ensure that the reference laboratory referred for specimen laboratory testing was currently certified.”