Keystone Hospice

“Upon patient record review, 3 of 19 (Patients #1, 9, 14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/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. Patient #1: In the POC, the alternative therapies pathway does not include separate interventions and goals for massage therapy versus acupressure therapy versus music therapy. Patient #9: There is no evidence of interventions and goals for the use of oxygen in the plan of care. Patient #14: The patient is on service for cancer of the larynx. There are complaints for shortness of breath as well as medications provided for that symptom. The patient is a smoker. There are no interventions or goals related to smoking in the plan of care.”

“Upon patient record review, 4 of 19 (Patients #3, 7, 10, 14) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #3: The Social worker is ordered to see the patient 0/month with 8 prn visits. PRN visits cannot stand alone. Patient #7: The social worker is ordered for frequency of 0/month and 2 prn visits. The SC is ordered for 0/month and 2 prn visits. Alternative therapies are ordered for 0/month and 2 prn visits. PRN visits cannot stand alone. Patient #10: The social worker is ordered to see patient 0/month with 2 prn. PRN visits cannot stand alone. Patient #14: The SC is ordered to see patient 0/month and one prn. PRN visits cannot stand alone.”

“Upon patient record review, 3 of 19 (Patients #2, 3, 4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: Patient has a wound labeled as “pressure ulcer to sacrum” The order reads “Pressure ulcer sacrum, 0.5x1.0cm. Absorbent dressing 2 times weekly and prn soiled. This order does not specify cleaning of wound, what absorbent dressing is being used (this wound was with alginate), what the cover dressing is, or who would change the dressing at each ordered treatment (ie. Nurse, caregiver) Patient #3: Patient has wound. Order reads, “wound, change prn and every day shift. There is no evidence of location/type of wound, what is the wound being cleansed with, type of primary and/or secondary dressing, Who will change dressing on what days, or reason for prn dressing changes. Patient #4: Patient is on service with breast cancer and has a fungating wound on left breast. Wound order reads, “wound to left chest, 1.7x2cm. Absorbent dressing 2 times weekly by wound care RN. This order does not specify cleansing method of wound, type of absorbent dressing to be used, if there is a cover dressing, or if there would be PRN changes for soilage and who would perform those dressings.”

“Upon client record review, 7 of 19 (Patients #1, 8, 10, 11, 12, 13, 14) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patient #1: The IDG report from 06/26/25 has no evidence of an RN signature. The IDG report from 06/12/25 has no evidence of a SC signature. Patient #3: The IDG report from 06/12/25 has no evidence of an RN or SC signature. Patient #8: The IDG report from 06/12/25 has no evidence of a signature from the SC. The IDG report from 06/26/25 has no evidence of an RN signature. Patient #10: The IDG report from 06/12/25 has no evidence of a signature from the SC. The IDG report from 06/26/25 has no evidence of an RN signature. Patient #11: The IDG report from 06/12/25 has no evidence of an RN or SC signature. Patient #12: The IDG report from 06/12/25 has no evidence of a signature from the SC. The IDG report from 06/26/25 has no evidence of an RN signature. Patient #13: The IDG report from 06/12/25 has no evidence of a signature from the SC. The IDG report from 06/26/25 has no evidence of an RN signature. Patient #14: The IDG report from 06/12/25 has no evidence of a signature from the SC. The IDG report from 06/26/25 has no evidence of an RN signature.”

“Upon client record review, 3 of 19 (Patient #1, 2, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Alternative therapies are ordered at 6 per month with 6 prn. There are 8 routine visits in June and no evidence of an added order for change in routine frequency. Patient #2: The wound RN is seeing the patient for wound care, however, the visits are all entered as prn rather than scheduled 2 times weekly. Patient #4: The wound RN is seeing the patient twice weekly in addition to the routine RN visits. All wound care visits are entered as prn visits despite the fact that they are scheduled.”

“Upon patient record review, 5 of 19 (Patient #3, 8, 9, 10, 11) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #3: The Aide assignment states, “Foot care by trimming OR applying lotion” and “Nail care trimming AND/OR cleaning fingernails”. The aide assignment cannot leave choice to aide of which tasks to do. Patient #8: The aide assignment states, “Foot care by trimming OR applying lotion” and “Nail care trimming AND/OR cleaning fingernails”. The aide assignment cannot leave choice to aide of which tasks to do. Patient #9: The aide assignment states, “offer to trim nails and toenails” and “offer skincare” The use of patient choice (in this case, “offer”) is not acceptable. The assignment does not specify what skincare will be performed. Patient #10: The aide assignment states “oral care” There is no specification of what oral care is to be performed, for instance, denture care, brushing teeth, mouthwash. Patient #11: The aide assignment states, “Foot care by trimming OR applying lotion” and “Nail care trimming AND/OR cleaning fingernails”. The aide assignment cannot leave choice to aide of which tasks to do. The assignment also states “offer showers”. The use of patient choice (in this case, “offer”) is not acceptable.”

“Upon patient record review 4 of 19 (Patients #3, 8, 9, 11) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3: The Aide assignment included trimming toenails which is not a specific part of Aide competency orientation. Patient #8: The Aide assignment included trimming toenails which is not a specific part of Aide competency orientation. Patient #9: The Aide assignment included trimming toenails which is not a specific part of Aide competency orientation. Patient #11: The Aide assignment included trimming toenails which is not a specific part of Aide competency orientation.”

“Based on medical record review, policy review, and staff interview, it was determined the hospice failed to ensure the IDG updated and revised care plans in response to patient changes in status for 4 of 6 patients (Patients #1, 2, 3 and 5) whose records were reviewed. This had the potential to lead to unmet needs of patients and family. Findings include: An agency policy titled, “Interdisciplinary Group Meeting,” Revised April 2018 stated the following: - The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program.- Problem solving for optimal care of the patient and family/caregiver will occur, and changes will be documented on the interdisciplinary group meeting form.- Patient being discharged from hospice will be reviewed to ensure appropriateness of ongoing care.- Grievances and issues of ethical concern will be discussed.- Patient requesting transfer to another hospice or revocation of the hospice benefit will be reviewed to determine any assistance he/she may need to complete these processes.This policy was not followed. Examples include: 1. Patient #2 was an 80 year old female admitted to the hospice on 10/30/24 with the primary diagnosis of chronic obstructive pulmonary disease. Patient #2 died on 4/19/25 while on hospice services. Patient #3’s medical record, including IDG meetings, was reviewed. Patient #2’s medical record documented an IDG meeting on 5/02/25. The IDG documentation did not include Patient #2 had died. Patient #2’s medical record documented updates to the care plan including but not limited to, “Skilled nursing: Assess for dyspnea or shortness of breath … Assess patient’s pain and comfort level related to skin breakdown … Assess sleep patterns … Validate the patient’s feelings and experiences.” Additionally, family engagement was documented as “The IDG team has discussed patient family/representative’s engagement in the plan of care and has determined that the family/representative understands and agrees with the care plan and has demonstrated a willingness to engage with the plan.” At time of the IDG meeting Patient #2 had been dead for 13 days. The IDG meeting did not reflect the patient or family’s status. 2. Patient #3 was an 86 year old female admitted to the hospice on 4/03/25 with the primary diagnosis of acute respiratory failure with hypoxia. Patient #4 died on 4/04/25. Patient #3’s medical record, including IDG meetings, was reviewed. Patient #3’s medical record documented an IDG meeting on 4/18/25. Patient #3’s medical record documented updates to the care plan including but not limited to, “Skilled nursing: Assess for dyspnea or shortness of breath … Assess patient’s pain and comfort level related to skin breakdown … Assess sleep patterns … Validate the patient’s feelings and experiences.” Additionally, family engagement was documented as, “The IDG team has discussed patient family/representative’s engagement in the plan of care and has determined that the family/representative is aware of and in agreement with the proposed plan of care and has shown enthusiasm for being involved with the plan.” At time of the IDG meeting Patient #4 died earlier that day but it was not discussed in IDG. The IDG meeting did not reflect the patient or family’s status. 3. Patient #5 was a 90 year old female admitted to the hospice on 10/08/24 with the primary diagnosis of malignant neoplasm of head of pancreas. Patient #5 died on 10/27/2024 while on hospice services. Patient #5’s medical record, including IDG meetings, was reviewed. Patient #5’s medical record documented a IDG meeting on 11/01/24. Patient #5’s medical record documented updates to the care plan including but not limited to, “Skilled nursing: Assess patient’s pain level and manage pain appropriately … Assess patient’s pain and comfort level related to skin breakdown … Assess sleep patterns … Validate the patient’s feelings and experiences.”Additionally, family engagement was documented as “The IDG team has discussed patient family/representative’s engagement in the plan of care and has determined that the family/representative understands and is in alignment with the proposed plan of care and has conveyed a willingness to engage with the plan.” At time of the IDG meeting Patient #5 had been dead for 4 days.The IDG meeting did not reflect the patient or family’s current status, and the care plan was not revised or updated based on Patient #5’s death status. 4. Patient #1 was an 85 year old female admitted to the hospice on 3/06/25 with the primary diagnosis of cerebrovascular disease. Patient #1 discharged from the hospice on 5/02/25. Patient #1’s medical record, including IDG meetings, was reviewed. Patient #1’s record included multiple care coordination notes from a Care Conference with the IDG and Patient #1’s daughter. The notes included but were not limited to the following:- Social work note dated 4/29/25 stated, “Phone call with patient daughter to discuss her frustration regarding a recent care conference that took place on 4/28/2025. There were various reports of how the hospice team did not advocate for the patient with some of the daughters complaints of falls happening to her mother.”- Social work note dated 4/29/25 stated, “Hospice Admin asked if she was wanting to switch hospice companies due to the feelings and perception she has that our hospice team did not advocate for her the way she felt they should have. She said that she was thinking about it and would make a decision later.”- Nursing note dated 4/29/25 stated, “[Daughter] explained that her mother resides at [Assisted Living Facility] and has experienced frequent falls, often remaining on the floor for extended periods. Additionally, Patient #1’s record included she fell on 4/25/25, 4/29/25, and 5/01/25. Patient #1’s record included an IDG meeting on 5/15/25, 13 days after she discharged from the hospice. The discussion related to falls stated, “[Patient #1] will experience reduction of risk of injury related to falls with the use of fall prevention measures as measured by reduction in fall events by 07/30/25.” It did not include her progress towards the goal of reduction in falls, or include that she fell on 4/25/25, 4/29/25, and 5/01/25. Additionally, under “Family engagement,” the note stated, “The IDG team has discussed patient family/representative’s engagement in the plan of care and has determined that the family/representative understands and acknowledges the care plan and is in agreement with it, and is interested in being included in the plan.” It did not include that Patient #1’s daughter was dissatisfied with the care or that there was a care conference with multiple staff members. Additionally, the note did not include that Patient #1 had discharged to another agency on 5/02/25. The Clinical Director was interviewed on 6/17/25 beginning at 11:10 AM and Patient #1’s record was reviewed with her. She confirmed the IDG from 5/15/25 did not reflect Patient #1’s current status. Add interview”

“Based on medical record review, agency document review, and staff interview, it was determined the agency failed to ensure the plan of care included correct interventions to effectively manage pain and symptoms by not using drugs for their indicated reason for 1 of 5 patients (Patient #1) whose records were reviewed. Failure to effectively manage pain and symptoms by not using drugs for their indicated reason had the potential to cause adverse drug reactions and uncontrolled symptoms related to the terminal diagnosis. Findings include: Patient #1 was an 85 year old female admitted to the agency on 3/06/25 with a terminal diagnosis of cerebrovascular disease. An additional diagnosis included Alzheimer’s disease. She received SN, MSW, and aide services. Her record for the certification period 3/06/25 to her discharge on 5/02/25 was reviewed. Patient #1’s record included the following medication orders: Haloperidol Lactate Concentrate 2 MG/ML Directions: Take 0.25 ml Concentrate Oral every 4 hours (q4h) as needed for Agitation, nauseaLORazepam Intensol Concentrate 2 MG/ML Directions: Take 0.25 ml Concentrate Oral every 4 hours (q4h) as needed for anxietyMorphine Sulfate (Concentrate) Solution 100 MG/5ML Directions: Take 0.25 ml Solution by mouth every 4 hours (q4h) as needed for Pain, shortness of breath Patient #1’s record included a care coordination note dated 3/13/25 authorizing the use of PRN medication. It stated, “Pt is agitated, turning on the shower and kicking at doors which is upsetting other residents,” and authorized the use of lorazepam and haloperidol. It was unclear why lorazepam was authorized when the note did not say Patient #1 had anxiety. Patient #1’s record included a care coordination note dated 4/21/25 authorizing the use of PRN medication. It stated, “Request for PRN agitated combative and in pain,” and authorized the use of haloperidol, morphine sulfate, and lorazepam. It was unclear why lorazepam was authorized when the note did not say Patient #1 had anxiety. Patient #1’s record included a care coordination note dated 4/28/25 authorizing the use of PRN medication. It stated, “increased pain, anxiety,” and authorized the use of haloperidol and lorazepam. It was unclear why haloperidol was authorized when the note did not include Patient #1 was agitated or nauseated. It was unclear why morphine sulfate was not authorized despite the note stating Patient #1 had increased pain. The Clinical Director was interviewed on 6/17/25 beginning at 11:10 AM and Patient #1’s record was reviewed in her presence. She confirmed Patient #1’s medications were not used for the indicated reasons. The agency failed to use drugs for the indicated reason as stated on the POC.”