Hospice of Washington County

“Based on clinical record review the hospice failed to ensure the patient received information about the services covered under the hospice benefit for 11 of 11 sampled patients requesting the information (Patients #1, #2, #4, #5, #6, #7, #8, #9, #12, #13 and #14). 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: Clinical record review revealed a Medicare Hospice Election Statement form completed at the time of admission to hospice services. The form contained a section titled, Right to Request “;Patient Notification of Hospice Non-Covered Items, Services, and Drugs”, with the statements: 1. I would like to receive addendums by: a. mail or b. email. 2. I do not wish to receive addendums at this time. Patients #1, #2, #4, #5, #6, #7, #8, #9, #12, #13 and #14, completed the forms by checking the option “;I would like to receive addendums by mail or email”. During an interview on 4/16/24 at 2:45 PM, Staff C, Compliance Officer, reported Staff G, Social Worker (SW), is responsible for mailing/emailing out the form identifying hospice non-covered items. During an interview on 4/16/24 at 2:53 PM, Staff G, SW, reported the process to provide the hospice non-covered forms included mailing or emailing all interdisciplinary group (IDG) meeting notes to the patient and/or primary caregiver. Staff G reported all covered items are identified on the IDG meeting notes. During an interview on 4/17/24 at 4:03 PM, Staff C, Compliance Officer, reported that the agency was not doing the addendum right. The above findings were reviewed with the Administrator and Staff C, Compliance Officer. Hospice staff 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 (IDG) completed an accurate and complete Drug Regimen Review (DRR) for 4 of 14 sampled patients (Patients #4, #8, #12 and #13). Failure to ensure the IDG members involved in the assessment of patient needs identified actual or potential issues when performing the DRR with each update to the comprehensive assessment increased the risk of unidentified side effects and actual interactions of medications. Findings include: 3. Patient #8 had a hospice admission date of 3/27/2024 and received hospice services while residing in a skilled nursing facility (SNF). Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/27/2024 to 6/24/2024, included physician orders for duplicate antihypertensive medications (blood pressure) which included amlodipine (blood pressure), atenolol (blood pressure), and losartan (blood pressure). b. The initial comprehensive assessment completed by the Registered Nurse (RN) at the start of care, dated 3/27/24 included documentation the RN assessed the patient was not on any duplicate drug therapy. The DRR completed by the RN failed to identify any duplicate drug therapy. c. The initial DRR completed by the pharmacist, dated 3/28/24, assessed the patient was on duplicate drug therapy with multiple antidepressants, but failed to address the antihypertensive medications as being duplicates. The DRR completed by the pharmacist failed to identify any duplicate drug therapy with antihypertensive medications. 4. Patient #12 had a hospice admission date of 8/30/23 and a discharge date of 10/16/23, and received hospice services while residing in a skilled nursing facility (SNF). Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 08/30/23 to 11/25/23, included physician orders for duplicate pain relieving topical gels/creams including Asper creme (topical pain reliever) , lidocaine patch (topical pain reliever), and Cannabis Satavina lotion (topical pain reliever) . b. The initial comprehensive assessment completed by the Registered Nurse (RN) at the start of care, dated 6/27/24 included documentation the RN assessed the patient was not on any duplicate drug therapy. The DRR completed by the RN failed to identify any duplicate drug therapy. c. The initial DRR completed by the pharmacist, dated 8/30/24, assessed the patient was not on any duplicate drug therapy. The DRR completed by the pharmacist failed to identify any duplicate drug therapy. The above findings were reviewed with the Administrator and Compliance Officer. The hospice team did not provide any further information prior to the end of the survey. The hospice’s undated policy, titled Hospice of Washington County Compliance Process, identified the DRR is done at admission by the physician/pharmacist and is updated during regular visits or as needed to address any patient needs or concerns. The case manager provides a current medication list for review at each IDG. The medical director, in consultation with the patient’s primary care provider, and the pharmacist review the following: Effectiveness of drug therapy, possible side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with lab monitoring. On 4/16/24 at 9:30 AM, during an interview, the Clinical Manager reported the DRR is performed at admission, at IDG, and anytime a new medication is ordered. The DRR is documented in the patient’s clinical record. 1.Patient #4 had a hospice admission date of 3/30/24 and received hospice services while residing in a skilled nursing facility (SNF). Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/30/24 to 6/27/24, included physician orders for duplicate bowel medications including Bisacodyl (constipation) and Milk of Magnesia (constipation). b. The initial comprehensive assessment completed by the Registered Nurse (RN) at the start of care, dated 3/30/24 included documentation the RN assessed the patient was not on any duplicate drug therapy. The DRR completed by the RN failed to identify any duplicate drug therapy. c. The initial DRR completed by the pharmacist, dated 4/4/24, assessed the patient was not on any duplicate drug therapy. The DRR completed by the pharmacist failed to identify any duplicate drug therapy. 2. Patient #13 had a hospice admission date of 8/14/23, a death date of 1/7/24, and received routine hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 8/14/23 to 11/11/23, included physician orders for duplicate pain medications including Tylenol and Hydromorphone. b. The initial comprehensive assessment completed by the RN assessed the patient did not take any duplicate medications. The DRR completed by the RN failed to identify duplicate drug therapy. c. The initial DRR completed by the pharmacist, dated 8/17/23, assessed the patient was not on any duplicate drug therapy. The DRR completed by the pharmacist failed to identify any duplicate drug therapy.”

“Based on clinical record review, hospice policy review, and hospice staff review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or a complete order for all medications and treatments to meet the needs of the patient for 2 of 14 sampled patients (Patient #2 and #8). Failure to ensure the plan of care included complete orders for medications and treatments placed patients at risk to receive inappropriate treatment of symptoms and/or not meet the needs of the patients. Findings include: 2. Patient #8 had a start of care date of 3/27/24 and was receiving hospice services in her home. Review of clinical record revealed the following: a. The interdisciplinary group documentation (IDG), dated 4/11/24, indicated that an order was received from the physician on 4/8/24 for the medication prednisone, (steroid for increased breathing difficulties.) b The Plan of Care, (POC) dated 3/27/2024 to 6/24/2024, included physician orders for medications, treatments and services. The POC lacked the new medication order for prednisone 10 milligram (mg) by mouth daily. c. The medication profile printed on 4/22/2024 also lacked the new medication prednisone. The agency failed to update both the POC and the medication profile with new medication orders received. The above findings were reviewed with the Administrator and the Compliance officer, no additional information was presented prior to the end of survey. According to the hospice policy titled, Medication Management, last updated July 2023, a medication profile will be completed for each patient at the time of admission and updated to reflect any changes including new or discontinued medications. The profile will include over-the-counter drugs, nutritional, herbal remedies, vitamins, and minerals. The profile will be part of the patients Electronic Medical Record (EHR), and a hard copy of the profile should be available to the patient/representative. According to the hospice policy title, Coordination of Care, undated, the Plan of Care will include all services necessary for the palliation and management of the terminal illness and related conditions, including: drugs and treatment necessary to meet the needs of the patient. The hospice IDT (interdisciplinary team) (in collaboration with the individuals attending physician, if any) shall review, revise and document the individualized plan as frequently as the patients condition requires, at least every 15 days to include information from the patient’s updated comprehensive assessment and note progress toward outcomes and goals. In an interview on 4/17/24 at 2: 08 PM, Staff C, Compliance Officer, reported the medication list view may change depending on a computer setting and that she understood that the Plan of Care needs to be updated when medication changes occur. 1. Patient #2 had a hospice admission date of 4/1/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care dated 4/1/24 to 6/29/24 included an orders for 1-2 nursing visits per week and an order for potassium chloride 20 mEq (milliequivalents) oral tablet, extended release; Take 2 tab(s) orally 2 times a day for replacement Start Date: 04/01/2024. b. IDT Note on 4/18/24 included a nurse note from a visit that was held on 4/10/24 where the patient reported she no longer took potassium chloride tablets. c. IDT Note on 4/18/24 included a nurse note from a visit that was held on 4/12/24 of the following: with previous input from the Medical Director we reviewed her medications in attempts to reduce her pill burden and some changes were made and will be reflected in the medical profile. d. The Medication Profile included completed medications: calcium carbonate 600 mg oral tablet, chewable; Chew 2 tab(s) chewed once a day for supplement with a start date of 4/1/24 and a completed date of 4/15/24 and cetirizine 10 mg oral capsule; Take 1 cap(s) orally once a day for itching; At bedtime with a start date of 4/1/24 and a completed date of 4/15/24. e. The Plan of Care dated 4/1/24 to 6/29/24 failed to include the changes to the patients medications with the discontinued calcium carbonate and cetirizine. f. The Clinical Record failed to include orders from the medical director for which medications to specifically discontinue or that it was reported to the medical director that the patient was no longer taking potassium chloride.”

“Based on hospice clinical record review and hospice policy review, the hospice failed to ensure the Plans of Care (POC) for 2 of 14 sampled patients (Patient #4 and #13) identified all medical equipment and supplies necessary to meet identified patient needs. Failure to include all needed items of medical equipment and supplies the patient used on the POC placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: According to the undated hospice policy, titled Coordination of Care, the POC will include all services necessary for the palliation and management of the terminal illness and related conditions, including: durable medical equipment (DME) and medical supplies to meet the needs of the patient. 1.Patient #4 had a hospice admission date of 3/30/24 and received hospice services while residing in a skilled nursing facility (SNF). Review of the clinical record revealed the following: a. The POC, dated 3/30/24 to 6/27/24 identified the patient used the following DME and supplies: bed rails, bedside commode, gait/transfer belt, grab bars/safety rails, hand held shower, hospital bed, hoyer lift, nebulizer, overbed table, pressure release mattress, raised toilet seat, rolling walker, shoe/sock aid, shower chair, sliding board, wheelchair, wheelchair cushion, gloves-non sterile, gloves-sterile, and moisture barrier cream/ointment. b. The comprehensive assessment, dated 4/11/24, completed by Staff D, Registered Nurse (RN), identified the patient had alarms in place due to falls. c. The comprehensive assessment, dated 4/11/24, completed by Staff D, RN, identified the patient had incontinence briefs to help manage incontinence. d. The Interdisciplinary Group (IDG) note, dated 4/18/24, failed to identify the patient’s additional DME and supplies that included alarms and incontinence briefs. 2.Patient #13 had a hospice admission date of 8/14/23, a death date of 1/7/24, and received routine hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 11/12/23 to 2/9/24 identified the patient used the following DME and supplies: wheelchair, cane, pill cutter, and pill crusher. b. The hospice aide note, dated 11/14/23, completed by Staff E, Hospice Aide, identified the patient’s weight was obtained using the patient’s scale. The IDG update on 11/22/24 failed to identify the DME scale. c. The skilled nursing note, dated 12/1/23, completed by Staff F, RN, identified the patient had a new wound and it was treated by Staff F using wound cleaner, gauze, skin prep, triple antibiotic ointment, and a hydrocolloid dressing. The IDG update on 12/7/23 failed to identify the DME wound supplies. d. The skilled nursing note, dated 12/18/23, completed by Staff F, RN, identified the patient had recently tested her Lifeline button. The IDG update on 12/21/23 failed to identify the DME lifeline button. The above findings were reviewed with the Administrator and Compliance Officer. The hospice provided no 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 the Interdisciplinary Group (IDG) 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 (POC) for 1 of 4 patients with wounds (Patient #13). Failure of the hospice 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 POC increased the risk that patients did not receive services to meet assessed needs. Finding include: According to the undated policy, titled Interdisciplinary Group, the IDG is responsible for directing, coordinating, and supervising all care and services provided from admission through discharge. The IDG will ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are providing directly or under arrangement. Patient #13 had a hospice admission date of 8/14/23, a death date of 1/7/24, and received routine hospice services while residing in a private residence. Clinical record review revealed the following: a. The POC, dated 11/12/23 to 2/9/24, included physician orders for Complementary Therapies (Massage Therapy) 1 time a week for 13 weeks. The clinical record lacked any documentation of Massage Therapy visits from 11/12/23 through 1/7/24; patient’s death. On 4/17/24 at 4:04 PM, during an interview, the Compliance Officer noted the patient had canceled Massage Therapy services prior to the end of the last certification period and the POC was not updated with the change. b. The skilled nurse visit note, dated 12/1/23, identified the patient had a new wound to the left buttock and Staff F, Registered Nurse (RN), cleaned the wound, dried it with 4X4 gauze, placed triple antibiotic ointment on it, and covered it with a gauze dressing. The clinical record lacked physician communication and orders for wound care. The above findings were reviewed with the Administrator and Compliance Officer. The hospice team provided no further information prior to the end of the survey.”

“Based on clinical record review and hospice staff interview, the hospice failed to ensure the registered nurse (RN) developed hospice aide instructions for patient care that were specific and individualized to the patients needs for 7 of 12 sampled patients receiving hospice aide services (Patients #3, #8, #11, #5, #6, #7, and #9). Failure to identify specific tasks for the hospice aide to perform or a specific frequency for the task leads to the potential risk that patients may fail to receive necessary services ordered on the plan of care. Findings include: 4. Patient #5 had a start of care date of 3/1/24 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The POC, dated 3/1/24 to 5/29/24, included physician orders for hospice aide services for 1-3 visits per week with the hospice aide interventions that included the task to apply lotion, ointments or creams for skin care. b. The hospice aide visit note, dated 3/5/24, 4/4/24, 4/8/24, 4/9/24 and 4/11/24, identified the task apply lotion, ointments or creams for skin care had been completed. c. The hospice aide intervention apply lotion, ointments or creams for skin care failed to identify which item to apply to what area. 5. Patient #6 had a start of care date of 3/18/24 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 3/18/24 to 6/15/24, included physician orders for hospice aide services for 1-2 visits per week with the hospice aide interventions that included the task to ambulate with stand by assist and walker in room. b. The hospice aide visit note, dated 4/5/24, identified the task ambulate with stand by assist and walker in room as completed and the narrative note included documentation the patient was transferred with assist of one with walker and gait belt. c. The hospice aide interventions failed to identify the hospice aide was to use a gait belt with transfers. 6. Patient #7 had a start of care date of 2/1/24 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The POC, dated 2/1/24 to 4/30/24, included physician orders for hospice aide services for 1-2 visits per week with the hospice aide interventions that included the tasks to apply lotion/barrier creams and ointments for skin care needs. b. The hospice aide visit notes, dated 2/14/24, 2/16/24, 2/21/24, 2/23/24, 2/28/24, 3/6/24, 3/8/24, 3/13/24, 3/15/24, 3/20/24, 3/27/24, 4/3/24, 4/5/24 and 4/10/24, identified the task apply lotion/barrier creams and ointments for skin care needs had been completed. c. The hospice aide intervention apply lotion/barrier creams and ointments for skin care needs failed to identify which item to apply to what area. 7. Patient #9 had a start of care date of 2/22/23 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The hospice aide care plan, dated 8/16/23, included hospice aide interventions that included the task to apply lotion, barrier cream and/or ointments for skin care. b. The interdisciplinary group meeting note, dated 2/15/24, included physician orders for hospice aide services 1-2 visits per week. c. The hospice aide documentation, dated 2/26/24, 2/29/24, 3/6/24, 3/11/24, 3/14/24, 3/18/24, 3/21/24, 3/25/24, 3/28/24, 4/1/24, 4/4/24, 4/8/24 and 4/11/243/5/24, 4/4/24, 4/8/24, 4/9/24 and 4/11/24, identified the task apply lotion, barrier cream and/or ointments for skin care had been completed. d. The hospice aide intervention apply lotion, barrier cream and/or ointments for skin care failed to identify which item to apply to what area. The surveyor reviewed the above findings with the Administrator and Staff C, Compliance Officer. Hospice staff provided no further information prior to the end of the survey. 2. Patient #8 had a start of care date of 3/27/24 and received hospice services in long term care facility. Clinical record review revealed the following: a. The Plan of Care (POC), dated 3/27/2024 to 6/24/2024, included home health aide services for 1-2 visits per week with the home health aide interventions that included a bed bath, also indicated use of a shower chair. b. The home health aide documentation reviewed for the date of 4/5/24, indicated the patient received a shower after being transferred to the shower chair with a Hoyer lift and the assistance of a facility aide. a. The aide intervention failed to clearly instruct when and how the patient would receive a shower in the facility. 3. Patient #11 had a start of care date of 6/27/23 and a discharge date of 9/21/23, and received hospice services in the home. Clinical record review revealed the following: a. The Plan of Care, dated 6/27/23 to 9/24/23 included home health aide services for 1-2 visits per week with a home health aide intervention of may apply lotion, barrier cream and ointments for skin care needs. The care plan lacked any specific instructions related to what type of lotion, barrier cream and ointments as well as where to apply them. The Registered Nurse failed to develop hospice aide instructions for patient care that were specific and individualized to the patients needs. In an interview on 4/17/24 at 2:15 PM Staff C, Compliance Officer, reported that it makes sense that the aide intervention for bathing has to be more specific and list the type of bath the aide can provide and that the hospice does not have a policy related to this concern. 1. Patient #3 had a hospice admission date of 3/12/24 and resided in a long term care (LTC) facility. The Hospice Current Plan of Care (POC), dated 3/12/24 to 6/9/24, included orders for aide services 1-2 times per week. The aide interventions on the POC included may give one of facilities scheduled baths for patients/CG (caregiver) choosing. Review of the clinical record revealed the following: a. The aide intervention failed to specify which type of bath, tub or shower, the aide was to provide. In an interview on 4/17/24 at 2:15 PM Staff C, Compliance Officer, reported that it makes sense that the aide intervention for bathing has to be more specific and list the type of bath the aide can provide.”

“Based on clinical record review, nursing home medication records, hospice policy review, and hospice staff interview, the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the nursing home for 1 of 2 sampled patients with visits observed who resided at nursing homes (Patient #1) including a review of the patients nursing home residence medication records. The hospice reported a current census of 22 patients at the time of the survey, including 11 patients receiving hospice services while residing in nursing homes. Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: According to the hospice policy titled, Compliance Process, dated January 2023, the plan of care is initiated by the admitting RN (registered nurse) and then updated by the case manager. Medication review is done at admission by the physician/pharmacist, updated during regular visits or as needed to address any patient needs or concerns. The case manager provides a current medication list for review at each IDT (interdisciplinary team), the medical director (in consultation with the patients primary care provider), and the pharmacist will review at a minimum the following: effectiveness of drug therapy, possible side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy currently associated with lab monitoring, and any psychotropic medication therapy. In an interview on 4/17/24 at 2:08 PM, Staff C, Compliance Officer, reported that she was not aware that there were discrepancies between the medications on the patients plan of cares and the nursing home medication records because this was an issue a few years ago that she worked hard at correcting and had the understanding that it remained corrected. Patient #1 had a hospice admission date of 8/22/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The nursing homes medication and treatment administration record, dated 4/15/24, included the following order discrepancies when reconciled against the medications listed on the hospice Plan of Care dated 2/18/24 to 4/17/24: a. The following medications were on the hospice POC and not on the nursing home medication list: A&D ointment apply 2 times daily to right thigh abrasion until healed with a start date of 9/29/23, arnica topical ointment apply every 12 hours as needed for leg cramps with a start date of 8/22/23, and Paxlovid 300 milligrams (mg) - 100 mg dose pack for COVID start date of 3/13/24 and end date of 3/17/24. b. The hospice POC had an order Senna S 50 mg-8.6 mg take 2 tablets 2 times per day for constipation with a start date of 8/22/23. The nursing home medication list had an order for Senna S 1 tablet 2 times per day with a start date of 11/9/20. c. The hospice POC had an order for Paxlovid 300 mg - 100 mg dose pack for COVID. The nursing home medication list did not include an order for Paxlovid. The hospice RN failed to ensure coordination of medications with the nursing home staff. The Administrator and Compliance Officer received the above findings and hospice staff provided no further information prior to the end of the survey.”