Three Oaks Hospice

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the hospice interdisciplinary group completed an initial comprehensive assessment no later than five calendar days after the election of hospice care. Clinical Record 5: The election of the hospice benefit was 06/05/2024. The initial social work assessment was dated 09/21/2024, 16 days after the election of the hospice benefit. The clinical record did not include documentation of a reason for the late assessment. Clinical Record 13: The election of the hospice benefit was 09/19/2024. The initial social work assessment was dated 09/25/2024, 6 days after the election of the hospice benefit. The clinical record did not include documentation of a reason for the late assessment. During an interview on 11/13/2024, the Director of Clinical Services reviewed the records and stated, “There are no notes to indicate why the assessments were late.””

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. Agency policy #PC.85 “Medication List and Monitoring” (dated 09/01/2024) stated in part, “The Hospice Registered Nurse will be responsible for coordinating the efforts of monitoring the medication regimen by compiling assessment data through a collaborative effort of all hospice staff involved in the patient’s care, including the pharmacist. A medication/drug profile will be maintained on all patients. Medication monitoring will include appropriate data/information to develop an accurate patient medication history and a current, complete medication profile. The hospice will review, monitor, and maintain a current, accurate list of all prescription and over-the-counter medications, herbal remedies, and other alternative treatments that could affect drug therapy taken by the patient.” In 11 of 19 (58%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current medications. Clinical Record 5: The election of the hospice benefit was 06/05/2024. The plan of care dated 06/05/2024-09/03/2024 ordered: “Oxygen 2-5 liters via nasal cannula as needed for shortness of breath.” The drug profile dated 06/05/2024 did not document oxygen. Clinical Record 6: The election of the hospice benefit was 10/11/2024. The plan of care dated 10/11/2024-01/09/2024 ordered: “Oxygen 2-5 liters via nasal cannula as needed for shortness of breath.” The drug profile dated 10/11/2024 did not document oxygen. Clinical Record 8: The election of the hospice benefit was 04/16/2024. The plan of care dated 04/16/2024-07/14/2024 ordered: “Oxygen 2-5 liters via nasal cannula as needed for shortness of breath.” The drug profile dated 04/16/2024 did not document oxygen. Clinical Record 9: The election of the hospice benefit was 05/17/2024. The plan of care dated 05/17/2024-08/14/2024 ordered: “Oxygen 2-5 liters via nasal cannula as needed for shortness of breath.” The drug profile dated 05/17/2024 did not document oxygen. Clinical Record 10: The election of the hospice benefit was 10/03/2024. The plan of care dated 10/03/2024-01/01/2024 ordered: “Oxygen 2-5 liters via nasal cannula as needed for shortness of breath.” The drug profile dated 10/03/2024 did not document oxygen. Clinical Record 11: The election of the hospice benefit was 10/03/2024. The plan of care dated 10/03/2024-01/01/2025 ordered: “Oxygen 2-5 liters via nasal cannula as needed for shortness of breath.” The drug profile dated 10/03/2024 did not document oxygen. Clinical Record 12: The election of the hospice benefit was 06/01/2024. The plan of care dated 06/01/2024-08/30/2024 ordered: “Oxygen 2-5 liters via nasal cannula as needed for shortness of breath.” The drug profile dated 06/01/2024 did not document oxygen. Clinical Record 13: The election of the hospice benefit was 09/19/2024. The plan of care dated 09/19/2024-12/17/2024 ordered: “Oxygen 2-5 liters via nasal cannula as needed for shortness of breath.” The drug profile dated 09/19/2024 did not document oxygen. Clinical Record 15: The election of the hospice benefit was 01/05/2024. The plan of care dated 01/05/2024-03/31/2024 ordered: “Oxygen 2-5 liters via nasal cannula as needed for shortness of breath.” The drug profile dated 01/05/2024 did not document oxygen. Clinical Record 16: The election of the hospice benefit was 05/04/2024. The plan of care dated 05/04/2024-05/29/2024 ordered: “Oxygen 2-5 liters via nasal cannula as needed for shortness of breath.” The drug profile dated 05/04/2024 did not document oxygen. Clinical Record 17: The election of the hospice benefit was 01/05/2024. The plan of care dated 01/05/2024-03/01/2024 ordered: “Oxygen 2-5 liters via nasal cannula as needed for shortness of breath.” The drug profile dated 01/05/2024 did not document oxygen. On 11/14/2024, the Director of Clinical Services reviewed the records and confirmed that oxygen was not included in the medication profiles.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that all problems identified in the initial and updated comprehensive assessment had planned interventions in the patient’s written plan of care. Clinical Record 12: The election of the hospice benefit was 06/01/2024. The initial nursing assessment dated 06/01/2024 documented, “Patient has a history of seizures.” The plan of care dated 06/01/2024-08/30/2024 did not include documentation of planned interventions for seizure activity. Clinical Record 16: The election of the hospice benefit was 05/04/2024. A clinical record review revealed a physician’s order dated 05/08/2024: “Xarelto (anticoagulant) 20mg tablet by mouth daily.” The plan of care dated 05/04/2024-05/29/2024 did not include documentation of planned interventions for the patient’s risk for bleeding. Clinical Record 18: The election of the hospice benefit was 02/28/2024. A clinical record review revealed a physician’s order dated 02/28/2024: “Eliquis (anticoagulant) 5mg tablet by mouth twice daily.” The plan of care dated 02/28/2024-03/17/2024 did not include documentation of planned interventions for the patient’s risk for bleeding. In an interview on 11/14/2024, the Director of Clinical Services reviewed the records and stated, “There are no interventions for seizure precautions or bleeding risk.””

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 5 of 16 (31%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that hospice aide services were provided as included in the plan of care. Clinical Record 2: The election of the hospice benefit was 10/02/2024. The plan of care dated 10/02/2024 through 12/31/2024 ordered: “CNA 3x/week.” One HA visit was documented on 10/04/2024 for the week of 09/29/2024 through 10/05/2024. There was no evidence of documented missed visits. Clinical Record 6: The election of the hospice benefit was 10/11/2024. The plan of care dated 10/11/2024 through 01/09/2025 ordered: “CNA 3x/week.” A clinical record review revealed no HA visits for the week of 10/06/2024 through 10/12/2024. There was no evidence of documented missed visits. Clinical Record 11: The election of the hospice benefit was 10/03/2024. The plan of care dated 10/03/2024 through 01/01/2025 ordered: “CNA 3x/week.” One HA visit was documented on 10/05/2024 for the week of 09/29/2024 through 10/05/2024. There was no evidence of documented missed visits. Clinical Record 15: The election of the hospice benefit was 01/05/2024. The plan of care dated 01/05/2024 through 03/31/2024 ordered: “CNA 2x/week.” A clinical record review revealed no HA visits for the week of 12/31/2023 through 01/06/2024. There was no evidence of documented missed visits. Clinical Record 17: The election of the hospice benefit was 01/05/2024. The plan of care dated 01/05/2024 through 03/01/2024 ordered: “CNA 3x/week starting 01/07/2024.” A clinical record review revealed no HA visits for the weeks of 01/07/2024 through 01/13/2024 and 01/14/2024 through 01/20/2024. There was no evidence of documented missed visits. During an interview on 11/14/2024, the Director of Clinical Services reviewed the records, confirmed the findings, and stated, “There are no missed visit notes for these aide visits.””

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary; [and] the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients with a live discharge, the agency did not ensure that a copy of the hospice discharge summary was provided to the patient’s attending physician. Clinical Record 15: The election of the hospice benefit was 01/05/2024. A clinical record review revealed a hospice discharge visit note dated 03/31/2024 that documented, “Patient is being discharged due to extended prognosis. The attending physician was notified.” The clinical record did not include documentation that the hospice discharge summary was forwarded to the patient’s attending physician. During an interview and a joint record review on 11/14/2024, the Director of Clinical Services confirmed that the discharge summary was not sent to the attending physician.”