Illuminate 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 3 of 14 (21%) clinical records reviewed, it was revealed that the agency did not ensure that an initial comprehensive assessment was completed within 5 days after election of care to ensure the psychosocial and spiritual needs of the patient were assessed. Clinical Record 2: The election of hospice care was dated 10/17/23. The initial hospice plan of care (POC) effective 10/17/23, included orders for medical social worker (MSW) visits 1 time a month. The MSW assessment was dated 10/26/23 (9 days). The clinical record did not include documentation that explained why the comprehensive assessment was not completed within 5 days after the election of care. Clinical Record 6: The election of hospice care was dated 3/14/23. The initial hospice POC effective 3/14/23, included orders for chaplain visits 1 time a month. The chaplain assessment was dated 3/21/23 (7 days). The clinical record did not include documentation that explained why the comprehensive assessment was not completed within 5 days after the election of care. Clinical Record 10: The election of hospice care was dated 10/14/23. The initial hospice POC effective 10/14/23, included orders for MSW visits 1 time a month. The MSW assessment was dated 11/8/23 (25 days). The clinical record did not include documentation that explained why the comprehensive assessment was not completed within 5 days after the election of care. During an interview on 1/4/24, the administrator confirmed the findings.”

“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 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. In 2 of 14 (14%) clinical records reviewed, it was revealed that the agency did not ensure the drug profile included the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. Clinical Record 3 / Home Visit 3: During the home visit on 1/4/23, a review of the assisted living facility (ALF) medication record included medications the following: Alprazolam 0.25mg twice daily; Haloperidol concentrate 2mg/ml 0.5mg every 4 hours, as needed; Lorazepam intensol 2mg/ml 0.5mg every 4 hours, as needed; Morphine Sulfate 100mg/ml 5mg every 2 hours, as needed; and Scopolamine 2.5mg/ml topical gel every 6 hours, as needed. These medications were not listed on the hospice medication profile or the updated plan of care dated 1/2/24. Clinical Record 4 / Home Visit 1: During the home visit on 1/4/23, a review of the ALF medication record included the following: Quetiapine 50mg twice daily; and Quetiapine 50mg daily, as needed. The ALF record contained evidence that the medication orders were changed on 12/20/23. The hospice record included the following: Quetiapine 75mg every morning; and Quetiapine 100mg every evening, The change in orders that were effective 12/20/23 were not listed on the hospice medication profile or the updated plan of care dated 1/2/24. During an interview on 1/4/24, the Administrator confirmed the findings and stated in part, “The nurses should be updating the medication profile at every visit.””

“It is required that each patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, it was revealed that the agency did not ensure that the patient’s individualized written plan of care included the treatment necessary to meet the needs of the patient. Clinical Record 1: The nursing assessment documentation from the visit conducted on 12/22/23 included, “Cleansed wound with wound cleanser, pat dry with 4x4 gauze, applied Medi-Honey, then covered with bordered silicone foam dressing.” The clinical record did not contain evidence that Medi-Honey was included on the plan of care (POC) dated 12/26/23. Clinical Record 2: The nursing assessment documentation from the visit conducted on 12/9/23 included, “Wound cleansed with wound spray, pat dry, applied zinc oxide 20% ointment then covered with Duoderm.” The clinical record did not contain evidence that zinc oxide was included on the POC dated 12/26/23. During a joint record review and interview on 1/4/24, the Administrator confirmed the findings.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling that are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services should 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, document review, and interview. In 1 of 2 (50%) clinical records reviewed, for bereavement services, it was revealed that the agency did not ensure bereavement services were provided per the plan of care. Agency policy PC.B30, Bereavement Services (revised 5/27/23). stated in part, “Bereavement Services provided include but are not limited to: letters and supportive information provided at one, three, six, nine and thirteen months after the patient’s death; support groups; memorial services; bereavement visits and/or calls.” Clinical Record 13: Date of discharge was 2/13/23. The bereavement plan of care ordered letters to be sent at three, six, and nine months. However, there was no evidence that the letters were sent as ordered in the plan of care. During an interview on 1/4/24, the Administrator confirmed the finding.”

“It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group. This standard was not met as evidenced by observation, document review, and interview. In 1 of 12 (8%) clinical records reviewed, that received hospice aide services, it was revealed that the agency did not ensure the hospice aide provided services ordered by the Interdisciplinary Group. Agency policy PC.H20, Hospice Aide Assignments and Duties (revised 5/27/23), stated in part, “A hospice aide provides services that are ordered by the interdisciplinary group.” Home Visit 3 / Clinical Record 3 / Staff 6: During a home visit on 1/4/24 with the hospice aide, it was revealed that the aide helps with the patient’s right lower extremity wound care when the nurses are busy. The aide plan of care dated 11/17/23,, did not include cleaning the wound or reapplying a dressing. During an interview, the Aide stated, “I was a nurse in the (country) and have worked in the operating room, I will change the dressings and clean the wound with wound wash, and reapply a dressing if it comes off or if it gets dirty.” During an interview on 1/4/24, the Clinical Supervisor/Registered Nurse stated, “She (the aide) will help with wound care if needed.” During an interview on 1/4/24, the Administrator confirmed the finding and stated that, the aide provided services that were not ordered by the Interdisciplinary Group.”

“It is required that a hospice aide provides services that are consistent with the hospice aide training. This standard was not met as evidenced by observation, personnel record review, and interview. In 1 of 12 (8%) records reviewed, it was revealed that the agency did not ensure that the hospice aide provided services consistent with the hospice aide training. Agency policy PC.H20, Hospice Aide Assignments and Duties (revised 5/27/23), stated in part, “A hospice aide provides services that are: consistent with the hospice aide’s training.” Home Visit 3 / Staff 6: During a home visit on 1/4/24 with the hospice aide, it was revealed that the aide helps with the patient’s right lower extremity wound care, when the nurses are busy. During an interview the Aide stated, “I was a nurse in the (country) and have worked in the operating room. I will change the dressings, clean the wound with wound wash, and reapply the dressing if it comes off or if it gets dirty.” The aide plan of care dated 11/17/23, did not include cleaning the wound or reapplying dressing. During an interview on 1/4/24, the Clinical Supervisor/Registered Nurse stated,, “She (the aide) will help with wound care if needed.” Personnel Record 6: Aide with 4/13/22 date of hire. The personnel record for the hospice aide did not contain evidence of training or assessment of competency for wound care. During an interview on 1/4/24, the Administrator confirmed the finding and stated there was no documentation of competency for wound care.”

“It is required that hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 12 (8%) clinical records reviewed, it was revealed that the agency did not ensure hospice aide documentation complied with hospice policies and procedures. Agency policy PC.D25, Documentation Requirements (revised 5/27/23), stated in part, “Documentation is completed by all hospice staff and volunteers whenever: patient/caregiver visits occur.” Clinical Record 2: The updated plan of care dated 12/12/23, included hospice aide visits 2 times a week. The clinical record did not contain documentation of the aide visits completed on 12/21/23, 12/23/23, 12/28/23, and 12/30/23. During an interview on 1/3/24, the Administrator confirmed the finding and stated, “The visits were done. We are behind in documentation.””

“It is required that hospice aides are supervised by a registered nurse 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 and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical records reviewed, that received hospice aide services, it was revealed that the agency did not ensure a registered nurse made 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 and to ensure that the services ordered met the patient’s needs. Clinical Record 3: The Initial plan of care (POC) dated 11/17/23, included orders for hospice aide visits 2x/week. Hospice aide visits began on 11/20/23. The clinical record did not contain evidence that hospice aide supervisory visits were completed for visits provided in December 2023. Clinical Record 8: The revised plan of care dated 11/10/2023, included orders for hospice aide visits 3x/week. A hospice aide supervisory visit was completed on 11/25/23. The clinical record did not contain evidence that hospice aide supervisory visits were completed for visits provided in December 2023. During a joint record review and interview on 1/4/24, the administrator confirmed the findings.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient and contains correct clinical information that is available to the patient’s attending physician and hospice staff and includes the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 10 (50%) clinical records reviewed, it was revealed that the agency did not ensure the clinical record contained clinical notes including the care and services provided. Agency policy PC.D25, Documentation Requirements (revised 5/27/23), stated in part, “Documentation is completed by all hospice staff and volunteers whenever: patient/caregiver visits occur.” Clinical Record 2: The updated plan of care effective 12/12/23, included orders for nursing visits 1 time a week. There was no evidence that the nursing visits conducted on 12/22/23 and 12/29/23 were documented. Clinical Record 5: The updated plan of care effective 12/19/23, included orders for nursing visits 1 time a week. There was no evidence that the nursing visits conducted on 12/22/23 and 12/29/23 were documented. Clinical Record 6: The updated plan of care effective 12/19/23, included orders for nursing visits 1 time a week. There was no evidence that the nursing visits conducted on 12/19/23 and 12/26/23 were documented. Clinical Record 7: The updated plan of care effective 12/19/23, included orders for nursing visits 1 time a week. There was no evidence that the nursing visits conducted on 12/22/23 and 12/29/23 were documented. Clinical Record 8: The updated plan of care effective 12/12/23, included orders for nursing visits 2 times a week and chaplain visits 1 time a week. There was no evidence that the nursing visits conducted on 12/19/23, 12/22/23, 12/26/23, and 12/29; and chaplain visits provided on 12/12/23, 12/19/23, and 12/2623, were documented. During an interview on 1/3/24, the Administrator confirmed the finding and stated, “The visits were done. We are behind in documentation.””

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge includes a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, for a live discharge, it was revealed that the agency did not ensure that a discharge summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation was provided upon discharge to assist in the post-discharge continuity of care. Clinical Record 11: The election of hospice was dated 2/23/23. The patient was discharged to another hospice on 5/10/23. There was no evidence that a discharge summary was provided to the receiving facility or the attending physician. Clinical Record 12: The election of hospice was dated 1/13/23. The patient was discharged on 12/1/23, due to an out-of-state residential move. There was no evidence that a discharge summary was provided to the receiving facility or the attending physician. During a joint record review and interview on 1/4/24, the Administrator confirmed the findings.”