Gundersen Palmer Lutheran Hosp and Clinics-Hospice

“Based on clinical record review the hospice failed to ensure the patient received information about the services covered under the hospice benefit for 1 of 2 sampled patients (Patient #4). The hospice reported a current census of 24 patients. Failure of the hospice to ensure the patient received information about the services covered under the hospice benefit increased the risk that patients did not receive appropriate services to meet assessed needs. Findings include: Patient #4 had a hospice admission date of 11/20/23 and received hospice services while residing in a nursing facility. Review of the clinical record revealed the following: Review of the patient’s Medicare Benefit Election Form, dated 11/20/23, identified the patient elected to receive the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” which must be furnished within 5 days as it was requested at the start of care. The hospice failed to include documentation the patient was provided with the addendum listing the non-covered items, services, and drugs. The above information was reviewed with the Clinical Manager and Charge Nurse. The hospice provided no further information prior to the end of the survey.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 3 of 7 sampled patients with missed visits (Patients #6, #12 and #13). Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. 3. Patient #12 had a hospice admission date of 5/6/23, and received hospice services while residing in a private home. Clinical record review revealed the following: a. POC, dated 5/6/23 to 8/3/23, included physician orders for volunteer visits one time a week, hospice aide visits 2 times a week, skilled nurse visits one time a week, and complementary therapy (massage therapy) visit one time a week. b. IDG updates to the POC, dated 5/17/23, 5/31/23, and 6/14/23 included IDG direction to provide volunteer visits one time a week, hospice aide visits 2 times a week, skilled nurse visits one time a week, and complementary therapy (massage therapy) visit one time a week. c. Volunteer visits were missed on 5/23/23, 6/1/23, 6/5/23, and 6/12/23, identified volunteer visit patient refused/not home. d. Hospice aide visits were missed on 5/23/23, 5/26/23, 6/9/23, 6/13/23, 6/15/23, 6/20/23 identified HHA patient refused or not home. Hospice aide visit on 5/30/23 included that the patient reported that he already showered and refused the visit with the HHA supervisor made aware. e. Skilled nurse visits were missed on 5/26/23, 6/15/23 and 6/20/23 identified RN patient refused/not home. f. Massage therapy visits were missed on 5/8/23, 5/15/23, 5/30/23, and 6/19/23 identified MT (massage therapy) Pt (patient) refused/not home. g. The IDG updates to the POC, dated 5/17/23, 5/31/23, and 6/14/23, lacked documentation the IDG was notified of missed volunteer, skilled nurse, complementary therapy, chaplain, and hospice aide visits. The hospice failed to provide volunteer and hospice aide visits as ordered per the IDG updates to the POC. The above findings were reviewed with Staff B, Clinical Manager and Staff C, Charge Nurse. The hospice team did not provide any further information prior to the end of the survey. Findings include: Review of the hospice policy, titled Interdisciplinary Team, dated 1/2024, identified the hospice must develop and maintain a system of communication and integration, in accordance with the hospices own policies and procedures, to ensure care and services are provided in accordance with plan of care and provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. During an interview on 4/24/24 at 3:48 PM, Clinical Manager reported the missed visits are documented in the electronic medical record and should automatically flow over to the IDG notes. She is unsure why this process is not working. 1. Patient #6 had a hospice admission date of 2/23/24, and received hospice services while residing in a private home. Clinical record review revealed the following: a. POC, dated 2/23/24 to 4/20/24, included physician orders for volunteer visits one time a week and hospice aide visits 2 times a week. b. IDG updates to the POC, dated 3/6/24, 3/20/24, 4/3/24 and 4/17/24, included IDG direction to provide one volunteer visit per week and two hospice aide visits per week. c. Volunteer visit notes, dated 3/1/24, 3/8/24, 3/15/24 and 4/3/24, identified volunteer visit patient refused/not home. d. Hospice aide visit note, dated 3/5/24, included documentation the patient was sleeping and nurse did not want aide to wake patient up, supervisor notified of visit not provided. e. The IDG updates to the POC, dated 3/6/24, 3/20/24, 4/3/24 and 4/17/24, lacked documentation the IDG was notified of missed volunteer and hospice aide visits. The hospice failed to provide volunteer and hospice aide visits as ordered per the IDG updates to the POC. 2. Patient #13 had a hospice admission date of 2/27/24, a death date of 3/27/24, and received hospice services while residing in an assisted living facility. Clinical record review revealed the following: a. POC, dated 2/27/24 to 5/26/24, included physician orders for complementary therapy (massage therapy) visits one time a week and hospice aide visits one time a week for one week and then 2 times a week. b. IDG updates to the POC, dated 3/6/24 and 3/20/24, included IDG direction to provide one volunteer visit per week, one hospice aide visit for one week and two hospice aide visits per week. c. Complementary therapy (massage therapy) visit notes, dated 3/4/24 and 3/18/24, identified patient refused/not home. d. Hospice aide visit note, dated 3/1/24, included documentation unable to contact the patient, supervisor notified of visit not provided. e. The IDG updates to the POC, dated 3/6/24 and 3/20/24, lacked documentation the IDG was notified of missed complementary therapy (massage therapy) and hospice aide visits. The hospice failed to provide volunteer and hospice aide visits as ordered per the IDG updates to the POC.”

“Based on clinical record review and hospice policy review, the hospice failed to ensure hospice aides provided care to the patients as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 2 of 8 sampled patients receiving hospice aide services (Patients #5 and #8). Failure to ensure the hospice aide services are provided as ordered by the physician and according to the hospice aide care plan increased the risk of patients’ personal care needs not being adequately met. Findings include: According to the agency policy titled, Home Care Aide Services, dated 2/2024, hospice aides provide services that are ordered by the physician and included in the plan of care. Hospice aides must be members of the IDG, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records. 1.Patient #5 had a hospice admission date of 1/2/24 and received services while residing in an assisted living facility. Clinical record review revealed the following: a. The plan of cares (POC) dated, 1/24/24 to 3/31/24 and 4/1/24 to 6/29/24, included written instructions for the hospice aide to complete the following tasks: ambulate patient using wheelchair if going outside client room, fall precautions, catheter care, remind patient to call 800# for questions/concerns, standard precautions, ambulate patient using assistive device of stand by assist and walker when in client room, recognize and report skin changes, empty foley catheter, change adult diapers, shave (electric), skin care (lotion), clean bathroom, shower, shampoo, and assist patient with dressing. b. The hospice aide visit note, dated 2/19/24, identified the tasks of skin care and shampoo hair as done. The narrative on the bottom of the visit note identified the patient refused lotion and shampoo. c. The hospice aide visit note, dated 2/23/24, identified the task of skin care as done. The narrative on the bottom of the visit note identified the patient refused lotion. d. The hospice aide visit notes, dated 2/21/24 and 3/6/24, identified the tasks of skin care, shave, and shampoo hair as done. The narrative on the bottom of the visit note identified the patient refused lotion, shave, and shampoo. e. The hospice aide visit note, dated 3/8/24, identified the tasks of skin care and shave as done. The narrative on the bottom of the visit note identified the patient refused lotion and shave. f. The hospice aide visit notes, dated 2/28/24, 3/1/24, 3/22, 3/25, 4/5/24, and 4/12/24, identified the task of shave as done. The narrative on the bottom of the visit note identified the patient refused shave. g. The hospice aide visit notes, dated 3/11/24, 3/15, 3/20, 3/27, 4/1/24, 4/3, 4/8, and 4/10/24, identified the tasks of shave and shampoo as done. The narrative on the bottom of the visit note identified the patient refused shave and shampoo. 2.Patient #8 had a hospice admission date of 4/8/24 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The POC dated, 4/8/24 to 7/6/24, included written instructions for the hospice aide to complete the following tasks: standard precautions, skin care lotion to extremities and back, assist patient with dressing, assist with transfers, fall precautions, apply calmoseptine to coccyx, clean bathroom, empty foley catheter, remind patient/caregiver to call 800# for questions, shampoo, recognize and report changes in skin condition to Registered Nurse (RN), shave, change adult diapers, shower, and catheter care. b. The hospice aide visit notes, dated 4/11/24 and 4/15/24, identified the task of shave as done. The narrative on the bottom of the visit note identified the patient refused shave. c. The hospice aide visit note, dated 4/22/24, identified the tasks of shave and apply calmoseptine to coccyx as done. The narrative on the bottom of the visit note identified the patient refused shave and calmoseptine not applied on bottom so nurse could assess. The hospice aide failed to appropriately document in the patients’ clinical records. The above information was reviewed with the Clinical Manager and Charge Nurse. The hospice provided no further information prior to the end of the survey.”

“Based on review of written contracts and staff interview, the hospice failed to ensure the written agreement between hospice and durable medical equipment was complete with each required provision for 1 of 2 contracts reviewed. The hospice reported a current census of 24 patients. Failure to include all required provisions for a contract increased the potential that Hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care. Findings include: Review of the contract between hospice and their durable medical equipment supplier dated 1/5/15 identified the contract lacked the following provisions: Hospice retains administrative management. Hospice retains financial management. Hospice retains oversight of staff and services. All services authorized by the hospice. All services are furnished in a safe and effective manner by qualified personnel. All services delivered in accordance with the patients plan of care. In an interview on 4/24/24 at 11:15 AM, Staff D, Compliance Officer, reviewed the contract and agreed all the information was not in the contract. The above findings were reviewed with Staff B, Clinical Manager and Staff C, Charge Nurse. The hospice team did not provide any further information prior to the end of the survey.”

“Based on clinical record review, hospice policy review, and staff interview, the hospice failed to ensure timely signed documentation for all patient services for 3 of 14 patients reviewed. The hospice reported a current census of 24 patients. Failure to ensure all clinical record documentation was authenticated timely decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients. 3.Patient #11 had a hospice admission date of 2/15/23, a revocation date of 6/21/23, and received services while residing in a private residence. Review of the clinical record revealed the following: a. The massage therapist visit note, dated 5/8/23, signed completed on 5/10/23 (1 day late). b. The massage therapist visit note, dated 5/30/23, signed completed on 6/1/23 (1 day late). c. The massage therapist visit note, dated 6/1/23, signed completed on 6/3/23 (1 day late). d. The massage therapist visit note, dated 6/5/23, signed completed on 6/7/23 (1 day late). e. The social worker visit note, dated 5/11/23, signed completed on 5/13/23 (1 day late). f. The social worker visit note, dated 6/9/23, signed completed on 6/11/23 (1 day late). The hospice clinical record failed to include timely documentation. The above information was reviewed with the Clinical Manager and Charge Nurse. The hospice provided no further information prior to the end of the survey. Findings include: According to the hospice policy titled, Documentation and Signatures on Charts last revised January 2024, documentation must be completed within the following timeframes: a. Comprehensive Assessments per CMS Reference sheet. Conference Center entries will be made in exceptions with documentation to support. b. Verbal orders should be documented the day the order is received by the individual taking the orders. c. Admission related paperwork, progress notes, flow sheets, recertification and discharge summaries, and discharge related paperwork should all be completed prior to billing. In an interview on 4/24/24 at 2:44 PM, Staff B, Clinical Manager reported that the expectation is to have documentation signed within 24 hours unless they contact the office and give a reason. This is the expectation for all disciplines. Patient #12 had a hospice admission date of 5/6/23 and received services while residing in a private residence. Review of the clinical record revealed: POC, dated 5/6/23 to 8/3/23, included physician orders for complementary therapy (massage therapy) visit one time a week. IDG updates to the POC, dated 5/17/23, 5/31/23, and 6/14/23 included IDG direction to provide complementary therapy (massage therapy) visits one time a week. Massage therapy visits were signed longer than 24 hours as follows: 5/8/23 was signed on 5/10/23, visit on 5/15/23 signed on 5/17/23, missed visit on 5/30/23 was signed on 6/1/23, and the missed visit on 6/5/23 was signed on 6/7/23. 2. Patient #14 had a hospice admission date of and received services while residing in hospital. Review of the clinical record revealed: POC dated 12/21/23 to 3/19/23 included physician orders for Medical Social Worker (MSW) to visit on 12/22/23. The MSW visit on 12/22/23 was signed on 12/24/23.”