United Hospice, Inc.

“Based on home visits, clinical record reviews and staff interviews, it was determined that in 2 of 3 (Pts. # 1 and 2) routine home visits conducted, wherein the Pt. resides in an Assisted Living Facility (ALF), the Hospice failed to ensure services were coordinated with facility staff. Findings include: 1. Pt. #1 was admitted to hospice services on 10/23/23 with diagnosis of Senile Degeneration of Brain, Not Elsewhere Classified. A home visit was conducted on 07/16/24 with Employee #12. During the home visit, an interview was conducted with the employee. It was stated, she does not provide any documentation regarding personal care services provided to the Pt. by the hospice. A verbal report is provided to facility staff. An interview was conducted with facility staff. It was stated, the hospice does not provide a written POC, care coordination documentation, or written physician orders to the facility. A medication list is provided to facility staff. As of 07/16/24, the hospice failed to provide the facility with documentation indicating the goals, services, treatments, and nutritional requirements of the hospice Pt. to ensure effective care coordination between the ALF and the hospice. 2. Pt. #2 was admitted to hospice services on 10/20/23 with diagnosis of Alzheimer’s Disease, Unspecified. A home visit was conducted on 07/16/24 with Employee #18. During the home visit, an interview was conducted with the Employee. It was stated, she does not provide any documentation regarding professional services provided to the Pt. by the hospice. The facility staff is not provided with the hospice POC and/or written care coordination. A written medication list and a verbal report regarding the care/service provided to the Pt. is shared with the facility staff. An interview was conducted with facility staff that stated the hospice does not provide a written POC, care coordination documentation, or written physician orders to the facility. A medication list is provided to facility staff. As of 07/16/24, the hospice failed to provide the facility with documentation indicating the goals, services, treatments, and nutritional requirements of the hospice Pt. to ensure effective care coordination between the ALF and the hospice. 3. During an interview with the Administrator and Director of Clinical Services on 7/17/24 at 1:40 PM, the Director of Clinical Services stated the ALF should have a hospice folder with the POC and other Pt. related documents contained in the folder. .”

“Based on the review of the Governing Board minutes and Staff interview, it was determined the Hospice failed to ensure the details of the quality assessment and performance improvement program were approved by the governing body. This has the potential to affect all patients served by the Hospice. Findings include: 1. The Governing Board minutes and Hospice quality assessment and performance improvement program were reviewed on 07/16/24. The minutes lacked documentation that the Governing Body met to approve the data collection frequency and details of the quality assessment and performance improvement program. 2. The findings were confirmed during the interview on 07/16/24 at 10:30 AM, with the QA Director and Administrator.”

“Based on the review of the Governing Board minutes and Staff interview, it was determined the Hospice failed to ensure the annual evaluation of the QAPI program. Findings include: 1. The Governing Board minutes and Hospice quality assessment and performance improvement program were reviewed on 07/16/24, and lacked the annual evaluation. During the interview with the Director of Clinical Services, it was stated the last Governing Body meeting was in 2024. 2. The findings were confirmed during the interview on 07/16/24 at 10:30 AM, with the Director of Clinical Services and the Administrator.”

“Based on a review of clinical records and staff interview, it was determined that in 2 of 17 (Pts. #1 and 9) clinical records reviewed of Pts. receiving hospice Aide services, the hospice failed to ensure the Aide was supervised by the RN every 14 days. Findings include: 1. Pt. #1 was admitted to hospice services on 10/23/23 with a diagnosis of Senile Degeneration of Brain, Not Elsewhere Classified. The clinical record was reviewed on 07/16/24. The clinical record contained the Hospice Aide supervisory visit completed by the RN and dated 06/10/24. The Hospice Aide provided services 2 times a week from 06/11/24 to 06/29/24. The next Hospice Aide supervisory visit was conducted by the RN on 07/01/24. The record lacked documentation the RN supervised the Hospice Aide every 14 days. 2. Pt. #9 was admitted to hospice on 02/17/23 with a diagnosis of Cerebrovascular Disease, Unspecified. The clinical record was reviewed on 07/17/24. The clinical record contained the Hospice Aide supervisory visit completed by the RN and dated 06/16/24. The Hospice Aide provided services 3 times a week form 06/17/24 to 07/4/24. The next Hospice Aide supervisory visit was conducted on by the RN on 07/07/24. The record lacked documentation the RN supervised the Hospice Aide every 14 days. 3. During an interview with the Administrator and Director of Clinical Services on 7/17/24 at 1:40 PM, the Director of Clinical Services confirmed the hospice failed to ensure the Aide was supervised every 14 days.”

“Upon patient record review, 5 of 19 (Patient #4,7,9,12,18) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 4: The medical record contains an election of benefits that is signed by the POA though no election of attending physician was completed. Patient 7: The medical record contains an election of benefits that is signed by the POA though no election of attending physician was completed. Patient 9: The medical record contains an election of benefits that is signed by the POA though no election of attending physician was completed. Patient 12: The medical record contains an election of benefits that is signed by the POA though no election of attending physician was completed. Patient 18: The medical record contains an election of benefits that is signed by the POA though no election of attending physician was completed.”

“Upon patient record review, 4 of 19 (Patient #9, 12, 18, 19) did not have evidence of the appropriate documentation for release of confidential information. Patient 9: The PHI consent has a section of items to check that pt consents to giving access to PHI and none of them are marked. Patient 12: The PHI consent has a section of items to check that pt consents to giving access to PHI and none of them are marked. Patient 18: The PHI consent has a section of items to check that pt consents to giving access to PHI and none of them are marked. Patient 19: The PHI consent has a section of items to check that pt consents to giving access to PHI and none of them are marked.”

“Upon patient record review 5 of 19 (Patient #10,11,15,16,19) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient 10: There is evidence the patient/family refused social work and chaplain upon admission. The comprehensive assessment by the RN did not include a spiritual or psychosocial assessment and the MSW and SC providers did not see the patient. Patient 11: The family refused chaplain and there is no evidence the RN performed a spiritual assessment in the comprehensive assessment. Patient 15: The family refused the chaplain and there is no evidence the RN performed an spiritual care assessment on the comprehensive assessment. Patient 16: The family declined social work and there is no evidence the RN performed a psychosocial assessment in the comprehensive assessment. Patient 19: The family declined chaplain, there is no evidence the RN performed a spiritual comprehensive assessment.”

“Upon patient record review, 4 of 19 (Patient #1,2,9,11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 1: The medication profile contains an order for Aspirin 81mg daily, the facility has the Aspirin 325mg daily. Corrected on site. Patient 2: The nurse documented on 4/5/24 “O2 used intermittently”, this was not included on the medication profile. Corrected on site. Patient 9: The medication profile contains an order for Miralax with no diluent. Corrected on site. Patient 11: SN documents on 3/2 and 3/24 “O2 2 liters via nasal cannula” and on 3/21 SN documented “O2 3 liters via nasal cannula”. There is no evidence of an order for Oxygen on the medication profile. Corrected on site.”

“Upon patient record review, 4 of 19 (Patient #1,2, 9,11) 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 1: The POC contains an order for Aspirin 81mg daily, the facility has the Aspirin 325mg daily. Corrected on site. Patient 2: The nurse documented on 4/5/24 “O2 used intermittently”, this was not included on the POC. Patient 9: The POC contains an order for Miralax with no diluent. Corrected on site. Patient 11: SN documents on 3/2 and 3/24 “O2 2 liters via nasal cannula” and on 3/21 SN documented “O2 3 liters via nasal cannula”. There is no evidence of an order for Oxygen on the POC. Corrected on site.”

“Upon patient record review, 3 of 19 (Patient #17,18,19) did not have evidence the hospice offers bereavement counseling that includes: Patient 17: The medical record does not contain a bereavement POC and the record indicated last mailing was to the family on 11/9/23 patient expired 4/30/23. Patient 18: The Bereavement assessment completed by the MSW/BC indicated family is at high risk for bereavement. There was no bereavement assessment completed with in 4-6 weeks of death as per bereavement agency policy, no phone call made after death as per bereavement policy. The medical record does not contain a bereavement POC and the record indicated last mailing was to the family on 10/16/23 patient expired 4/16/23. Patient 19: The medical record does not contain a bereavement POC and the record indicated last mailing was to the family on 10/30/23 patient expired 4/30/23.”

“Upon patient record review, 12 of 19 (Patient #2,4,5,6,7,8,11,12,13,14,15,16) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 2: The aide POC 6/21/21 contains orders for the following tasks to be done PRN: turn, reposition, change linens, make bed and ambulation. There is no documentation to support pt can decide whether or not these tasks should be completed and the aide is not able to make this choice. . Corrected on site. Patient 4: The aide POC 4/6/24 contains the following tasks ordered PRN: Transfers, change linen, make bed, housekeeping, nail care and shave. There is no documentation to support pt can decide whether or not these tasks should be completed and the aide is not able to make this choice. . Corrected on site. Patient 5: The aide POC 3/27/24 contains the following tasks ordered PRN: Transfers, change linen, make bed, housekeeping, nail care and shave. There is no documentation to support pt can decide whether or not these tasks should be completed and the aide is not able to make this choice. . Corrected on site. Patient 6: The aide POC 1/21/24 contains the following tasks ordered PRN: Transfers, change linen, make bed, housekeeping, nail care and shave. There is no documentation to support pt can decide whether or not these tasks should be completed and the aide is not able to make this choice. . Corrected on site. Patient 7: The aide POC 11/3/23 contains the following tasks ordered PRN: foot care, oral care, dentures, shave. It also orders both tasks of shower and bed bath every visit. There is no documentation to support pt can decide whether or not these tasks should be completed. Corrected on site. Patient 8: The aide POC 2/16/24 contains the following tasks ordered PRN: bed bath, comb hair, back rub, shower. There is no documentation to support pt can decide whether or not these tasks should be completed and the aide is not able to make this choice. . Corrected on site. Patient 11: The aide POC 10/5/23 contains the following tasks ordered PRN: change linen, house keeping, make bed, ambulate, transfer, ROM. There is no documentation to support pt can decide whether or not these tasks should be completed and the aide is not able to make this choice. . Corrected on site. Patient 12: The aide POC 2/24/24 contains an order for aides 2-4 times per week. The aide POC orders to complete the following tasks all every visit: complete shower, complete bed bath, partial shower. There is no evidence the pt is documented as being able to make those decisions and the aide is not able to make this choice. Corrected on site. Patient 13: The aide POC 3/14/24 contains the following tasks ordered PRN: Foot care, denture care, partial bath, shower, ambulation, ROM. There is no evidence the pt is documented as being able to make those decisions. Corrected on site. Patient 14: The aide POC 2/7/24 has both complete and partial showers ordered every visit. There is no evidence the pt is documented as being able to make those decisions and the aide is not able to make this choice and the aide is not able to make this choice. . Corrected on site. Patient 15: The aide POC 1/1/24 has “x” beside every task the aide is to perform with no frequency. Shower, partial shower, bed bath all ordered. There is no evidence the pt is documented as being able to make those decisions and the aide is not able to make this choice. Patient 16: The aide POC 7/2/23 has all of the tasks ordered “yes” with no frequencies.”

“Upon patient record review 5 of 19 (Patient #3,11,12,13,14) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 3: The POC contains on order for Aide 4 times per week. The week of 3/24/24-3/30/24 the aide saw the pt on 3/26,3/28,3/29. There was no fourth visit made that week and no missed visit documentation. The aide documented on 3/22/24 the showered and shaved the pt and this is not ordered on the aide POC. On 3/21/24 and 3/28/24 the aide documented they shaved the patient and this is not ordered on the aide POC. Patient 11: The aide POC contains orders for aide 2 times per week. The aide saw the pt the week of 9/31-10/7 once on 10/5. There is no missed visit documentation or evidence it was reported to the RN. Patient 12: The aide documented completing the following tasks 4/10/24: shower, bed bath and partial shower. The aide did not complete foot care that was ordered every visit. There was no documentation the Aide contacted the RN. The aide was ordered to see pt 2-4 times per week though the week of 2/18-2/24/24 the aide saw the pt on time on 2/24/24. Patient 13: The aide documented on 4/1,4/5,4/8 completed all of the following during their visit: partial shower, complete shower. Patient 14: The aide documented on 2/8 and 3/29 completing both a partial shower and complete shower.”

“Upon patient client record review, 6 of 19 (Patient #4,7,8,9,12,18) did not have evidence that each patient record contains: Patient 4: The medical record contains an election of benefits that is signed by the POA though no election of attending physician was completed. The level of care with cost of services were omitted from the documentation the form was signed by POA with out the costs of service. Patient 7: The medical record contains an election of benefits that is signed by the POA though no election of attending physician was completed. Patient 8: The level of care with cost of services were omitted from the documentation the form was signed by POA with out the costs of service. Patient 9: The medical record contains an election of benefits that is signed by the POA though no election of attending physician was completed. Patient 12: The medical record contains an election of benefits that is signed by the POA though no election of attending physician was completed. Patient 18: The medical record contains an election of benefits that is signed by the POA though no election of attending physician was completed. The date of election was blank.”

“Upon patient client record review, 4 of 9 (Patient #1,8,9, #16) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The RN documented in the comprehensive assessment 11/2/23 the patient is “alert, forgetful, non responsive”. Patient #5: The nurse documented 3/27,3/30,4/4,4/6 “Cleanse with NS, pat dry, apply calcium alginate and cover with Optifoam”. This is just restating the order no evidence nurse followed POC. 4/6 nurse documented “wound care done, pt tolerated well” no evidence the nurse followed POC. Patient 8: The RN documented 3/29 “Pain subsided b4 Sn left”. b4 and Sn are not approved abbreviations. Patient 9: The RN documented in the comprehensive assessment 2/22/24 the patient is “alert, forgetful, non responsive”. Patient 16: The SN documented 12/6/23 “Cleanse wound with NS iodine applied.” and on 11/29/23 “wound care performed per order”. There is no evidence the SN followed the POC orders.”

“Upon client record review, 14 of 19 (Patient #2,3,4,5,6,7,8,10,12,13,14,15,17,19) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 2: The POC contains an order for SN 2x per week. Patient seen one time per week on 2/9, 2/16, 2/23 no second visits completed those weeks and no missed visit documentation or documented refusals.. The patient was seen one time per week on 3/1, 3/8, 3/16, 3/22, 3/29. No missed visit docs/refusals. Patient 3: The POC contains an order for SN visits 1 time per week. The medical record contains evidence the SN made 2 visits in the weeks of 3/31/24-4/6/24. Patient 4: The POC 3/12/24 and 4/6/24 contains an order to “Irrigate urinary drainage device as ordered”. There is no frequency, dose, fluid. Corrected on site. Patient 5: The POC order SN visits 1 time per week. The week of 3/24-3/30 visits completed 3/27 & 3/30. Patient 6: The POC 1/23/24 contains an order for SN 1 time per week. The SN saw the pt twice weekly from 1/22/23 through 4/4/24 with no order to increase visits and no evidence of any of the visits being PRN. Patient 7: The record contains an order for ST eval. There is no evidence this was completed or refused. The ST did call one time and documented not being able to get ahold of the pt though did not try again. POC 2/6/24 contains SN 1 time per week, the SN has documented visits twice weekly from 2/5/24-4/5/24. There is no evidence of an order to increase visits to twice weekly. The POC contains an order for PT and OT evals. The PT performed 3 visits 11/7,11/18,11/25 and the OT performed 3 visits 11/6,11/13,11/24. There is no evidence of an order for the visits beyond the evals. Patient 8: The SC is ordered 1 time per week, The SC saw the pt on 2/20 and 3/20 once per month. MSW is ordered “once per qtr” and was visited by MSW 2/19,3/19,4/22,5/20. The nurse documented 3/25 “Pt requested for Valsartan and hospice doctor gave order for 160mg daily”. This was not added to the POC. The POC contains order for PT eval, there is evidence the PT made further visits with no orders for further visits. There is an order 2/16 “per family request SN decrease to 1 time per week.” The SN continued to see pt twice weekly 2/19/24-4/15/24 with no orders to see pt twice weekly. Patient 10: The POC 2/19/24 order is for SN 3 times a week. Pt was seen by SN 4 times per week 3/31/24-4/6/24 and 3/17/24-3/23/24. The medical record contains evidence of the pt refusing MSW and SC, The POC continues to have orders for the MSW and SC 1x per month without evidence of visits. Patient 12: POC order SN 1 time a week. The SN saw pt twice weekly from 2/26/24 through 4/3/24 with no orders to increase the visits. Patient 13: The POC 12/15/23 has no frequency orders for any disciplines and was not updated until 1/2/24. POC 12/15/23 order SN 2x a week. SN saw one time the week of 3/10-3/16 on 3/14. In addition, the nurse documented on 4/4/24 “pt high risk for falls” and on 4/2/24 “max assist for transfers”. There is no fall risk care plan implemented on the POC. Corrected on site. Patient 14: The POC 2/17 order for SN 1x a week. Pt seen by SN 2x a week from 2/7/24 through 4/4/24 with no orders to increase visits to twice weekly. Patient 15: POC 12/13/23 SN visits 1x week. The week of 12/10/23-12/16/23 the pt was seen by the SN 3 times. The week of 12/17/24-12/23/24 pt was seen by the SN twice. The week of 1/2/24 through 2/20/24 the SN saw patient twice weekly. No orders for increased visits, visits were not PRN. Patient 17: POC SN 1x week, pt seen 4/28 and 4/29. No order to increase visits and visit was not PRN. Patient 19: POC SN 1xweek, seen 4/23&4/29,4/24&4/27. 4/27 wound care performed by SN to sacrum no order.”