Luxe Hospice and Palliative Care LLC

“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. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 6 (33%) clinical records reviewed and home visits observed, it was revealed that the agency did not ensure that the drug profile included the patient’s current medications. Agency Policy 2.40 Medication Administration (Effective date: 2023) read in part, “3. The patient’s medication profile is reviewed by the IDG/HOSPICE CARE TEAM whenever there is a significant change and, at a minimum, every fifteen days. 5. The patient’s medication profile review includes, but is not limited to: a. Determining accuracy and completeness of the profile; b. Monitoring medication effectiveness, actual or potential mediation-related effects and untoward interactions; c. Ensuring appropriateness of the medication, the dose, route of administration, and dosage schedule; d. Ensuring that the prescribed medications are safe and appropriate and the most cost-effective solution for the patient’s symptom (s); e. Determining if there are medications that have been or may be discontinued; f. Identifying duplicate drug therapy and drug therapy associated with laboratory monitoring; g. Reviewing lab values to ensure appropriate medication dosing; and h. Assisting with the determination of which medications are and are not related the patient’s terminal diagnosis.” Clinical Record 1/Home Visit 1: The patient elected hospice care on 10/07/2024 with a diagnosis of senile degeneration of the brain. The patient resided in a memory care unit. During the home visit with the Hospice Aide (HA) [Personnel Record 1] on 12/04/2024, the patient’s hospice medication profile and facility medication administration record were reviewed with the Director of Nursing [Personnel Record 2]. The facility medication profile record included Polyethylene Glycol Powder 3350NF, mix one capful twice daily beginning 08/05/2024. The clinical record lacked evidence that Polyethylene Glycol Powder 3350NF was included on the hospice medication profile. Clinical Record 2/Home Visit 2: The patient elected hospice care on 09/27/2024 with a diagnosis of severe protein-calorie malnutrition. The patient resided in a memory care unit. During the home visit with the Registered Nurse (RN) [Personnel Record 2] on 12/04/2024, the patient’s hospice medication profile and facility medication administration record were reviewed. The facility medication profile record included the following medications with an effective date of 09/27/2024: Sertraline 50mg one-half tab daily, Bisacodyl Supp 10mg daily as needed, Docusate Sodium 100 mg daily as needed, Genteal Tear Sol one drop each eye daily as needed, Geri-Lanta 200-200-20mg/5ml give 30ml every four hours as needed, Loperamide 2mg after each loose stool as needed, and Milk of Magnesia 400mg/5ml give 30 ml as needed daily. The clinical record lacked evidence that the hospice drug profile included those current medications (Sertraline, Bisacodyl, Docusate Sodium, Genteal Tear, Geri-Lanta, Loperamide, and Milk of Magnesia) that the facility was administering or that were available for the patient. During an interview, clinical record review, and the joint home visit observation on 12/04/2024, the Director of Clinical Services confirmed that the hospice medication profile did not accurately reflect the medications the facility was administering or that were available to the patient.”

“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, document review and interview. In 3 of 6 (50%) clinical records reviewed, it was revealed that the agency did not ensure the individualized plan of care reflected patient and family goals and identified planned interventions based on problems identified in comprehensive spiritual counselor assessment. Agency Policy 2.41 Plan of Care (Effective date: 2023) read in part, “The hospice written interdisciplinary plan of care is developed and individualized for each patient and family, reflects patient/family goals based upon problems identified in the initial/updated comprehensive assessments, and includes all services necessary for palliation and management of the terminal illness and related conditions, including the following: (i.) interventions to manage pain and symptoms and (p.) patient goals/outcomes. Clinical Record 1: The patient elected hospice care on 10/07/2024 with a diagnosis of senile degeneration of the brain. A comprehensive spiritual counselor assessment was completed on 11/14/2024. The documentation read in part “Interventions Performed: explore issues of conflict and listening/emotional support.” The clinical record lacked evidence that the individualized written plan of care included patient/family goals based on the interventions provided and problems identified in the comprehensive assessment. Clinical Record 2: The patient elected hospice care on 09/27/2024 with a diagnosis of unspecified severe protein-calorie malnutrition. A comprehensive spiritual counselor assessment was completed on 11/08/2024. The documentation read in part “Interventions Performed: anointing/blessing and listening/emotional support.” The clinical record lacked evidence that the individualized written plan of care included patient/family goals based on the interventions provided and problems identified in the comprehensive assessment. Clinical Record 4: The patient elected hospice care on 09/13/2024 with a diagnosis of unspecified severe protein-calorie malnutrition. A comprehensive spiritual counselor assessment was completed on 09/18/2024. The documentation read in part “Interventions Performed: anointing/blessing, listening/emotional support, explore issues of conflict, and prayer/meditation.” The clinical record lacked evidence that the individualized written plan of care included patient/family goals based on the interventions provided and problems identified in the comprehensive assessment. During a joint record review and interview on 12/04/2024, the Director of Nursing confirmed that the individualized written plan of care did not include patient/family goals and interventions based on problems identified in the initial/comprehensive spiritual assessment.”

“It is required that each patient’s individualized written plan of care include all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 6 (17%) clinical records reviewed, it was revealed that the agency did not ensure that the individualized written plan of care included a detailed statement of the scope and frequency of services necessary to meet specific spiritual patient and family needs. Agency Policy 2.41 Plan of Care (Effective date: 2023) read in part, “The hospice written interdisciplinary plan of care is developed and individualized for each patient and family, reflects patient/family goals based upon problems identified in the initial/updated comprehensive assessments, and includes all services necessary for palliation and management of the terminal illness and related conditions, including the following: l. Detail of the scope and frequency of services needed to meet the patient/family needs.” Clinical Record 2: The patient elected hospice care on 09/27/2024 with a hospice diagnosis of unspecified severe protein-calorie malnutrition. A spiritual counselor (SC) comprehensive assessment was completed on 11/08/2024. The documentation read in part “SC Evaluation Completed, Need for SC Services Indicated: Requires Spiritual Counselor assessment and evaluation of spiritual and existential concerns that affect care of the patient and/or caregiver (s), including provision of interventions to assist patient/caregiver with desired outcomes. Spiritual Counselor indicated for counseling and spiritual support.” The clinical record lacked evidence that the individualized written plan of care included a detailed scope and frequency of spiritual counselor services needed to meet the patient/family needs. During a joint record review and interview on 12/04/2024, the Director of Nursing (personnel record 2) confirmed that the individualized plan of care did not include the scope and frequency for the spiritual counselor.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required; have written policies and procedures describing the method(s) of assessing competency, and maintain a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. In 2 of 11 (18%) personnel records reviewed, it was revealed that the agency did not ensure that all individuals providing care completed a competency evaluation prior to providing unsupervised care. Agency Policy 3.8 Competency Assessment (Effective date: 2023) read in part, “3. As a component of the orientation process, new staff and volunteers complete a competency evaluation prior to providing unsupervised care. 4. Competency evaluations are specific to the skills needed for each job category and the services provided. Specific competencies are delineated in job descriptions and performance evaluations. 5. Competency assessments occur during the orientation period, annually, and as needed, when patient outcomes are directly related to an individual’s performance.” Personnel Record 2: Director of Nursing/Registered Nurse. Date of hire: 06/10/2024. The personnel record lacked evidence that a competency evaluation for the role of the registered nurse was completed prior to providing unsupervised care. Personnel Record 3: Social Worker/Volunteer Coordinator/Bereavement Coordinator. Date of hire: 09/12/2024. The personnel record lacked evidence that a competency evaluation for the role of the bereavement coordinator was completed prior to providing unsupervised care. During a joint personnel record review and interview on 12/04/2024, the Administrator confirmed that personnel records 2 and 3 did not include competency evaluations per agency policy.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 6 (33%) clinical records reviewed, it was revealed that the agency did not ensure that the clinical record contained physician orders for changes in visit frequency not included in the patient’s plan of care. Agency Policy 2.36 Physician Orders (Effective date: 2023) read in part, “3. Some of the reasons orders are obtained from physicians include but are not limited to: b. Change in visit frequency if not within the range specified in the patient’s plan of care.” Clinical Record 1: The patient elected hospice care on 10/07/2024 with a diagnosis of senile degeneration of the brain. Spirit Care services were not requested on admission. A spiritual care assessment visit was completed on 11/14/2024. The clinical record lacked evidence that the record included a physician order for the spiritual care visit provided on 11/14/2024. Clinical Record 2: The patient elected hospice care on 09/27/2024 with a hospice diagnosis of unspecified severe protein-calorie malnutrition. The initial plan of care effective 09/27/2024 included a spiritual counselor frequency order of one time per week for one week beginning 09/27/2024. The registered nurse completed the initial comprehensive assessment and noted ‘no spiritual concerns.’ A spiritual care assessment visit was provided on 11/08/2024. The clinical record lacked evidence that the record included physician orders for the missed visit occurring the week of 09/27/2024 and there were no visit frequency orders initiated to cover the spiritual care assessment visit provided on 11/08/2024. During a joint record review and interview on 12/04/2024, the Director of Nursing (personnel record 2) confirmed clinical records 1 and 2 did not include physician orders for changes in visit frequency not included in the plan of care.”