Apex Hospice and Palliative Care, Inc.

“This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 3 (67%) records reviewed, in which wounds were identified, revealed that the agency did not ensure the comprehensive assessment included assessment and documentation of wounds per agency policy. Policy and procedure “Wound Care No. C:2-100.1;” in relevant parts stated, “Through assessment at admission and during each visit, track and trend wound stages and care... Weekly the narrative will describe the wound and peri-wound length, width, and depth.” (Last reviewed and revised 9/2023) Clinical Record 2: The hospice election of benefit was dated 11/16/2021 with a diagnosis of primary lateral sclerosis. The comprehensive nursing assessment, dated 11/8/2023, documented a stage one pressure wound to the right great toe and stated, “continues to have protective foam dressing to right great toe due to pressure area.” The weekly nursing assessment narratives for visits made after 11/8/2023 did not include documented evidence of the wound and peri-wound length, width, and depth in accordance with the agency’s policy. Clinical Record 3 The hospice election of benefit was dated 7/1/2022 with a diagnosis of atherosclerosis heart disease. Recertification comprehensive assessment narrative (9/28/2023) documented two new “arterial wounds” to the right leg. There was no documented evidence describing the wounds peri-wound length, width, and depth in accordance with the agency’s policy. On 12/13/2023 during the joint clinical record review the Director of Clinical Services (DCS) confirmed that there was no additional documentation to show that the nurse had documented descriptions of the wounds and peri-wound length, width, and depth in the narratives per agency policy.”

“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. 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, document review and interview. In 1 of 19 (5%) records reviewed revealed that the agency did not ensure the drug profile included the patient’s current prescription medications and that medications were discontinued per the agency policy. Medication Profile/Reconciliation Policy (No. H:2-055.1) stated in relevant parts, “the medication profiles will be updated with each change to reflect current medication, allergies, and new and/or discontinued medications.” Clinical Record 11: The hospice election of benefit was dated 4/27/2023 with a diagnosis of cerebrovascular disease. The Certificate of Terminal Illness (CTI) for the current benefit period 10/24/2023-12/22/2023 stated that Eliquis was stopped due to high fall risk and bleeding out. The drug profile was reviewed on 12/13/2023 and revealed Eliquis 5mg one tablet twice a day, effective since 4/27/2023. An interdisciplinary team (IDT) meeting note, dated 6/13/2023, stated; “discussed stopping Eliquis in great lengths Pt (patient) at danger to bleed out.” The Administrator reported during the interview on 12/14/2023 that per a phone conversation with the RN, the Eliquis was discontinued on 6/13/2023 but “the end date for the medication was not entered into the medication profile.””

“It is required that each patient’s individualized written plan of care: 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, interview, and observation. In 6 of 19 (32%) records reviewed revealed that the agency did not ensure the plans of care contained specific interventions based on the problems identified in the comprehensive assessments. Home Visit 1/Clinical Record 1: The hospice election of benefit was dated 7/30/23 with a diagnosis of cerebrovascular disease. During the home visit observation with the registered nurse (RN) on 12/13/2023, RN (Personnel Record 6) asked the patient if she was continuing to use a “heating pad” to relieve neck pain. The current plan of care (POC) effective as of 11/11/2023 did not include a heating pad as an intervention. Clinical Record 7: The hospice election of benefit was dated 9/13/2023 with a diagnosis of heart disease. The initial RN comprehensive nursing assessment dated 9/13/2023 documented a fall risk assessment score of 10 (moderate risk). The RN documented two (2) falls prior to the hospice start of care, including, “patient had a fall off the couch.” The recertification assessment dated 11/28/2023 documented a fall risk assessment score of 12 (High Risk) and 1 or 2 falls over the previous 2 months. The Interdisciplinary Team (IDG) meeting dated 11/29/2023 note by the RN documented “HIGH FALL RISK.” The plan of care, effective 9/13/2023 to 12/720/23, did not contain any problems, goals, or interventions related to fall precautions or safety. An environmental safety problem that started on 12/7/2023 addressed fall precaution interventions. Clinical Record 11: The hospice election of benefit was dated 4/27/23 with a diagnosis of cerebrovascular disease. The recertification comprehensive assessment, dated 10/20/2023, documented a fall risk score of 15 which meant “high risk for falls.” The plan of care, effective 10/20/2023 to current, did not include problems, goals, or interventions related to fall precautions or safety. Clinical Record 12: The initial RN comprehensive assessment dated 4/12/2023 documented a diagnosis of Parkinsonism, difficulty swallowing, and a mechanical soft diet. The POC effective from 4/12/2023 to current, did not include problems, goals, or interventions related to swallowing issues or dietary modifications. Clinical Record 13: The hospice election of benefit was dated 3/13/2023 with a diagnosis of Alzheimer’s disease. The recertification nursing comprehensive assessment, 11/28/2023, documented dysphagia and a mechanical soft diet. The plan of care, effective from 11/28/2023 to current, did not include problems, goals, or interventions related to swallowing issues or dietary modifications. Clinical Record 17: The initial RN comprehensive nursing assessment dated 8/30/2023 documented a diagnosis of cerebrovascular disease and reported the patient had a percutaneous endoscopic gastrostomy (PEG) tube in place. The POC effective from 8/30/2023 until the date of death, 10/11/2023 did not include problems, goals, or interventions related to the PEG tube. An interview was conducted with the Director of Clinical Services (DCS) and the Administrator on 12/14/2023 in which the above POC were reviewed and the DCS reported the POC were missing the items described.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 19 (11%) records reviewed revealed that the agency did not ensure that nursing care and services were provided per the patient plan of care. Hospice Nursing Care/Documentation Policy No. H:2-004.1 stated in part, “The hospice nurse will: c. Document visits same day and in accordance with plan of care and patient response to visit...g. Prepare clinical and progress notes that reflect established goals and outcomes with each visit” and under section H:2-004.2 stated, “k. Provide and document an ongoing evaluation of the patient and family/caregiver response to care and hospice.” (Last reviewed and revised 4/2023) Clinical Record 9: The election of hospice benefit was dated 8/18/2023 with a diagnosis of dementia with Lewy bodies. The Plan of Care (POC) effective on 8/18/2023 included a nursing visit frequency order of two times per week. The Interdisciplinary Group (IDG) meeting notes for the weeks of 8/30/2023 and 9/13/2023 also documented a plan for nursing visits twice weekly. For the weeks 8/27/2023 through 11/18/2023, only one nursing visit was documented per week. On 12/12/2023 during the joint record review and interview with the Director of Clinical Services (DCS), confirmed that there were no orders to decrease the visits to once weekly until 11/21/2023 and no documentation to support why the visits were missed. Clinical Record 11: The election of hospice benefit was dated 4/27/2023 with a diagnosis of cerebrovascular disease. The recertification nursing comprehensive assessment dated, 7/14/2023, and the comprehensive assessment dated 10/20/2023, contained a narrative clinical summary note as verbatim as the previous note. This was identified during the joint record review with the DCS on 12/13/2023 who confirmed the narrative notes were identical and did not meet the documentation requirements outlined in the policy.”

“It is required that the bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) records reviewed, in which bereavement services were provided, revealed the agency did not ensure the bereavement services provided followed the frequency ordered in the plan of care (POC). Clinical Record 17: The election of hospice benefit was dated 8/30/2023 with a diagnosis of cerebrovascular disease. A review of the clinical record revealed the patient died on 10/11/2023 and the family accepted bereavement services at that time. The bereavement POC was initiated on the date of death 10/11/2023 and included the relevant service: “1 week card.” The bereavement record documentation stated the card was mailed on 11/9/2023 (29 days after the date of death). A joint record review and interviews were conducted with the DCS on 12/14/2023 stated, “We switched the mailing of the sympathy card to one month but didn’t switch that plan of care.””

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a registered nurse (RN) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) records reviewed, in which aide services were accepted, revealed that the agency did not ensure the RN provided the hospice aides with specific instructions related to the patient’s care needs. Clinical Record 11: The patient elected the hospice benefit on 4/27/2023 with a diagnosis of cerebrovascular disease. The initial RN comprehensive assessment narrative section stated the patient was on Eliquis with a risk for falls and “bleeding out.” The drug profile was reviewed on 12/13/2023 and revealed an active order for Eliquis 5mg one tablet BID effective since 4/27/2023. The hospice aide care plan, effective from 4/27/2023 to June 2023 when the medication was discontinued, did not alert the aide to the bleeding precaution needs of the patient. Clinical Record 17: The patient elected the hospice benefit on 8/30/2023 with a diagnosis of cerebrovascular disease. The initial RN comprehensive assessment, dated 8/30/2023, documented the patient had a Percutaneous Endoscopic Gastrostomy (PEG) tube in place. The aide plan of care, effective from 8/30/2023 to 10/11/2023 (date of death), contained the relevant tasks of; bed bath and dressing with each visit but did not alert the aide that the patient had the PEG tube or if the aide was to provide any site care. A joint record review, and interview, were completed with the director of clinical services (DCS) on 12/14/2023 who confirmed that the aide plans of care should have included the bleeding precautions and PEG tube information.”

“It is required that hospice aides are supervised by a registered nurse (RN) who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 15 (7%) records reviewed, in which aide supervision was required, the agency did not ensure the RN documented the aide supervisory visit at least every 14 days. Clinical Record 11: The patient elected the hospice benefit on 4/27/2023 with a diagnosis of cerebrovascular disease. The plan of care (POC) for the current benefit period 10/24/2023 to 12/22/2023 included orders for aide services twice weekly. The RN documented an aide supervisory visit on 11/15/2023 and the next aide supervisory visit was not documented until 12/6/2023 which was 21 days apart. On 12/13/2023 during the joint clinical record review with the Director of Clinical Services (DCS), the DCS confirmed that there was no additional documentation to show that the aide supervisory visit was made within the 14-day requirement.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) records reviewed, in which volunteer services were provided, revealed that the agency did not ensure volunteer services being provided were included in the plan of care (POC). Clinical Record 6: The patient elected the hospice benefit on 9/21/2023 with a diagnosis of chronic obstructive pulmonary disease (COPD). A physician order for a volunteer visit frequency of one time per month was written on 10/31/2023. The clinical record documented a completed volunteer visit on 11/10/2023, reporting the patient was visited in the dining room. The POC effective from 10/31/2023 to current, did not contain any goals or interventions to instruct the volunteer on services to be provided during the visits. A joint record review and an interview was conducted with the Volunteer Coordinator on 12/14/2023 who confirmed that a patient specific POC outlining the duties to be performed by the volunteer was not completed on or before the date of the visit.”