Heart of Hospice

“Based on record reviews and interviews, the agency failed to coordinate and communicate changes in the hospice aide (HA) services and schedule to ensure services were received per the plan of care for 3 (Patient #1, Patient #2, and Patient #3) of 3 (Patient #1, Patient #2, and Patient #3) sampled patients reviewed for care and services per the plan of care. Findings: Review of the agencys Interdisciplinary Group (IDG) Membership and Responsibilities policy and procedure with a revision date of 11/01/2021 revealed the IDG responsibilities included but were not limited to, in part: -maintaining responsibility for directing, coordinating, and supervising the care and services provided; -ensuring the care and services were provided in accordance with the plan of care; -ensuring ongoing sharing of information between all disciplines providing care; and, -reviewing and facilitating resolution of conflict of care. Patient #1 Review of Patient #1s Physician Order dated 05/18/2024 revealed Patient #1 was to receive HA services five times per week. Review of Patient #1s record of documented services for the week of 05/19/2024 through 05/25/2024 revealed Patient #1 had received HA services on 05/20/2024, 05/21/2024, 05/22/2024, and 05/24/2024. Review of Patient #1s record of documented services revealed Patient #1 did not receive HA services from 05/25/2024 until Patient #1s discharge on 06/19/2024. Review of Patient #1s Nurse Visit Note Report dated 06/04/2024 revealed Patient #1 did not have a HA assigned at the time due to staffing issues. Review of Patient #1s Nurse Visit Note Report dated 06/11/2024 revealed Patient #1s hospice aide being evaluated was documented as TBD (to be determined). Review of Patient #1s Nurse Visit Note Report dated 05/30/2024 revealed Patient #1 did not have a HA assigned due to staffing issues. Review of Patient #1s Complaint Report dated 06/19/2024 revealed, in part, Patient #1s daughter had filed a grievance because Patient #1 did not have an aide visit in two weeks. In an interview on 08/06/2024 at 1:26 p.m., S2Patient Care Manager (PCM) stated the agency had issues staffing Patient #1. S2PCM further stated the agency did not ensure HA services were performed per Patient #1s plan of care. Patient #2 Review of Patient #2s Hospice Certification and Plan of Care for the certification period of 04/14/2024 through 07/12/2024 revealed Patient #2 was to receive HA services two times per week. Review of Patient #2s HA Visit Notes revealed the following: -the week of 06/02/2024 through 06/08/2024 Patient #2 received services on Thursday 06/06/2024 and Friday 06/07/2024; -the week of 06/09/2024 through 06/15/2024 Patient #2 received services on Monday 06/10/2024 and Thursday 06/13/2024; -the week of 06/16/2024 through 06/22/2024 Patient #2 received services on Monday 06/17/2024 and Thursday 06/20/2024; -the week of 06/23/2024 through 06/29/2024 Patient #2 received services on Wednesday 06/26/2024 and Friday 06/28/2024; and, -the week of 06/30/2024 through 07/06/2024 Patient #2 received services on Monday 07/01/2024 and Friday 07/05/2024. Review of Patient #2s Nurse Visit Note dated 06/06/2024 revealed S3HA did not meet the requirement of notifying Patient #1 and/or Patient #1s family in a timely fashion of schedule/time changes. Review of Patient #2s Visit Note Report dated 06/25/2024 revealed S3HA did not meet requirements related to the HA notifying the patient/family timely of any schedule/time changes. Review of the Patient #2s Complaint Report dated 06/26/2024 revealed Patient #2s son had filed a grievance that S3HA had missed visits and also had not notified them as to when she would or would not be able to conduct a visit as scheduled. Review of Patient #2s Visit Note Report dated 07/29/2024 revealed S3HA did not meet the requirements related to evidence of good rapport between Patient #2 and S3HA. Review of Patient #2s record revealed no documented evidence of the agency had informed Patient #2s son of the changes in Patient #2s HA visit schedule. In an interview on 08/06/2024 at 10:10 a.m., Patient #2s son indicated S3HA had missed multiple scheduled visits without notifying Patient #2 or Patient #2s son. Patient #2s son further indicated S3HA would make unannounced visits on unscheduled days. Patient #2s son indicated Patient #2s scheduled HA days were supposed to be Mondays and Fridays, but S3HA would miss Fridays mostly. Patient #2s son further indicated S3HA was making the visits in June and July 2024 but had been very sporadic. In an interview on 08/06/2024 at 2:26 p.m., S2PCM indicated the agency had no documented evidence of the agency following up on the communication issues with Patient #2s son and S3HA to ensure Patient #2s son was aware of the schedule of HA services. S2PCM indicated S4Registered Nurse had not communicated the issues identified on the HA supervisory visits to the administrative staff. Patient #3 Review of Patient #3s Hospice Certification and Plan of Care for the certification period of 06/28/2024 through 08/26/2024 revealed, in part, Patient #3 was to receive HA services twice a week for one week then three times a week thereafter. Review of Patient #3s HA Visits Notes for the week of 07/07/2024 through 07/13/2024 (the third week of the certification period) revealed, in part, HA visits were completed on 07/08/2024 and 07/12/2024. Further review revealed no documented evidence and the agency presented no documented evidence a third HA visit was conducted the week of 07/07/2024 through 07/13/2024. Review of Patient#3s Nurse Triage Note dated 07/10/2024 at 2:23 p.m. revealed Patient #3s wife called the agency to ask if the HA would make the visit on 07/10/2024. In an interview on 08/05/2024 at 1:00 p.m., S2PCM indicated on 07/10/2024 S5HA was on leave for jury duty. S2PCM indicated the agency had no documented evidence of the agency had notified Patient #3s spouse of S5HA not being available for a visit on 07/10/2024. S2PCM further indicated the agency did not have documented evidence of Patient #3s missed HA visit.”

“Based on record reviews and interviews, the agency failed to coordinate care timely with a patients outpatient wound care specialist for 1 (Patient #1) of 1 (Patient #1) sampled patients reviewed for outpatient consult services. Findings: Review of Patient #1s Clinical Note dated 12/20/2023 revealed a call was placed to an outpatient wound care specialist to set up an initial appointment for Patient #1, but was unsuccessful in scheduling an appointment. Review of Patient #1s record revealed no documented evidence, and the agency presented no documented evidence the agency had attempted to coordinate with the outpatient wound care specialist to schedule an appointment for Patient #1 from 12/21/2023 through 03/17/2024. Review of Patient #1s Clinical Note dated 03/18/2024 and 03/20/2024 revealed a call was placed to an outpatient wound care specialist to get an update on Patient #1s wound care appointment. Further review revealed no documented evidence the agency had received a return phone call regarding Patient #1s outpatient wound care specialist appointment. Review of Patient #1s record revealed no documented evidence, and the agency presented no documented evidence the agency had attempted to coordinate with the outpatient wound care specialist to schedule an appointment for Patient #1 from 03/21/2024 through 05/21/2024. Review of Patient #1s Complaint Report dated 05/22/2024 revealed, in part, Patient #1s caregiver filed a complaint that it took so long to obtain an appointment with the outpatient wound care clinic. Review of Patient #1s Client Coordination Note Report dated 05/22/2024 revealed a call was placed to an outpatient wound care specialist to get an update on wound care appointment that was requested in December 2023. Further review revealed an appointment was scheduled for 05/29/2024. In an interview on 08/06/2024 at 1:26 p.m., S2Patient Care Manager (PCM) indicated the agency did not have any documentation of coordination of care with the outpatient wound care specialist in order to schedule Patient #1s initial appointment during the above mentioned time frames. S2PCM further indicated the agency should not have waited three months between each contact with Patient #1s consulted outpatient wound care specialist.”

“Based on record reviews and interviews the agency failed to ensure verbal orders were appropriately documented for 1 (Patient #1) of 3 (Patient #1, Patient #2, and Patient #3) sampled patients reviewed for care and services delivered per physicians orders. Findings: Review of Patient #1s Physician Order dated 05/18/2024 revealed Patient #1 was to receive hospice aide (HA) services five times a week. Review of Patient #1s Complaint Report dated 06/19/2024 revealed Patient #1s asked the nurse why Patient #1 had not had an aide visit in two weeks. Review of Patient #1s Nurse Visit Note Report dated 06/04/2024 revealed Patient #1 did not have a HA assigned at this time due to staffing issues. Review of Patient #1s Nurse Visit Note Report dated 06/11/2024 revealed Patient #1s hospice aide was to be determined. Review of Patient #1s record completed on 07/22/2024 and 08/05/2024 revealed no documented evidence of Patient #1s hospice aide services having been discontinued per physicians order. Further review revealed no documented evidence of hospice aide services discontinued at any interdisciplinary group meetings. Review on 08/06/2024 of Patient #1s Physician Order # 34705227 dated 05/30/2024 revealed hospice aide services were discontinued due to inability to provide service at caregiver requested times. Review of Patient #1s Order Details for Physician Order # 34705227 revealed Patient #1s order was entered on 08/06/2024 and was not signed by a physician. In an interview on 08/06/2024 at 12:18 p.m., S6Patient Care Manager (PCM) indicated she entered Physician Order #34705227 today (08/06/2023) as a verbal order to discontinue hospice aide services effective 05/30/2024. S6PCM indicated she had no documented evidence a verbal order was received on 05/30/2024 to discontinue hospice aide services. S6PCM further indicated she did not have an explanation why the registered nurse was completing HA supervisory visits if the order for HA services had been discontinued. S6PCM indicated the reason for the order to discontinue HA services was due to staffing issues, but the agency did not have any documented evidence this information was communicated to the physician on 05/30/2024. S6PCM then refused to answer any further questions. In an interview on 08/06/2024 at 12:22 p.m., S2PCM indicated the agency had no documented evidence of a verbal order to discontinue Patient #1s HA services had been received on 05/30/2024. S2PCM further indicated S6PCM should not have entered the verbal order on 08/06/2024 and backdated it for 05/30/2024.”

“Based on record review and interview the agency failed to: 1. Ensure the skilled nurse provided care per the frequency in the plan of care (Patient #1 and Patient #12); and 2. Ensure the hospice aide provided care per the frequency in the plan of care (Patient #17 and Patient #19). This deficient practice was identified for 4 (Patient #1, Patient #12, Patient #17, and Patient #19) of 20 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, Patient #19, and Patient #20) sampled patients reviewed for care and services per the plan of care. Findings: Patient #1 Review of Patient #1s Hospice Certification and Plan of Care for certification period of 01/19/2024 to 04/17/2024 revealed Patient #1 was to receive skilled nursing services once a week. Review of Patient #1s record revealed no documented evidence and the agency presented no documented evidence Patient #1 had received a skilled nurse visit the week or 02/04/2024 to 02/10/2024. Review of Patient #1s Physician Order dated 03/26/2024 revealed to increase skilled nurse visits to daily for three days due to signs of symptoms of a decline. Review of Patient #1s record revealed no documented evidence and the agency presented no documented evidence the skilled nurse visits were made on 03/27/2024 and 03/28/2024. In an interview on 04/12/2024 at 3:57 p.m., S1Director of Patient Care (DPC) indicated the agency had no documented evidence a skilled nurse had made a visit or documented a missed visit the week of 02/04/2024 to 02/10/2024, and/or visits made on 03/27/2024 and 03/28/2024. Patient #12 Review of Patient #12s Hospice Certification and Plan of Care for certification period of 02/11/2024 to 04/10/2024 revealed Patient #12 was to receive skilled nursing services twice a week for eight weeks. Review of Patient #12s record revealed no documented evidence and the agency presented no documented evidence skilled nurse visits were made the week of 02/18/2024 to 02/24/2024. Further review revealed the week 03/31/2024 to 04/06/2024) Patient #12 only received skilled nursing services on 04/04/2024. In an interview on 04/12/2024 at 4:01p.m., S1DPC indicated the agency had no documented evidence skilled nursing visits were completed per the plan of care. Patient #17 Review of Patient #17s Hospice Certification and Plan of Care for certification period of 06/28/2023 to 07/16/2023 revealed, in part, hospice aide to provide services twice a week effective 07/02/2023. Review of Patient #17s record revealed no documented evidence and the agency presented no documented evidence hospice aide visits were conducted the week of 07/02/2023 to 07/08/2023. In an interview on 04/12/2024 at 5:36 p.m., S1DPC indicated the agency had no documented evidence the hospice aide visits were conducted the week of 07/02/2023 to 07/08/2023 per the plan of care. Patient #19 Review of Patient #19s Hospice Certification and Plan of Care for certification period of 04/05/2023 to 05/27/2023 revealed Patient #19 was to receive hospice aide services once a week for one week then twice a week for the rest of the certification period. Review of Patient #19s record revealed the week of 04/09/2023 to 04/15/2023 only one hospice aide visit was made of 04/14/2023; and the week of 04/23/2023 to 04/29/2023 only one missed visit was documented on 04/28/2023 and no visits were made. In an interview on 04/12/2024 at 5:43 p.m., S1DPC indicated the agency had no documented evidence Patient #19s hospice aide visits were conducted per the plan of care for the weeks mentioned above.”

“Based on observation, record review, and interview, the agency failed to ensure the registered nurse followed infection control standards during wound care for 1 (Patient #20) of 2 (Patient #3 and Patient #20) sampled patients observed for wound care. Findings: Review of Patient #20s Hospice Certification and Plan of Care for the certification period of 03/20/2024 to 06/17/2024 revealed, in part, cleanse wounds to numerous sites daily with wound cleanser using aseptic technique, paint with betadine daily, and cover moist wounds with dressing. Further review revealed for finger amputations, apply xeroform (dressing used to promote wound healing) over suture lines and cover with gauze. Observation on 04/12/2024 at 9:28 a.m. revealed S2Registered Nurse (RN) washed his hands and applied two gloves to his right hand and one to his left hand. S2RN then used uncontained bandage scissors he retrieved from the top drawer of Patient #20s bedside table, to cut off the bandages to Patient #20s left and right hand. S2RN then, without removing his gloves, reached under his isolation gown into his shirt pocket and removed his cell phone. S2RN then, without removing his gloves or performing hand hygiene, removed Patient #20s left thumb bandage. With the same pair of gloves, S2RN then repositioned his eyeglasses and proceeded to clean the wounds to Patient #20s right and then left hand without changing gloves in between wounds. S2RN then placed the soiled bandage scissor directly on Patient #20s bed linen. S2RN then, without removing his gloves, grabbed his chair and pulled the chair closer to the bed. S2RN then dressed Patient #20s left and right hand amputation sites. S2RN did not remove his gloves or perform hand hygiene until the wounds to both Patient #20s left and right hands had been dressed and the soiled dressings had been disposed of. In an interview on 04/12/2024 at 11:20 a.m., S2RN confirmed the above findings and indicated the above observations were breaches in infection control guidelines. In an interview on 04/12/2024 at 11:31 a.m., S1Director of Patient Care (DPC) indicated the above mentioned observations during Patient #20s home visit were breaches in infection control practices.”

“Based on record review and interview, the agency failed to ensure the nurse measured the patients wounds weekly to monitor wound status for 3 (Patient #14, Patient #15, and Patient #17) of 5 (Patient #3, Patient #14, Patient #15, Patient #17, and Patient #20) sampled patients with wounds reviewed for weekly wound assessments. Findings: Review of the Wound Ostomy and Continence Nurses Society’s Guidelines revealed assessment and documentation of wound status, which includes comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment includes: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; evidence of infection in surrounding tissues. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Patient #14 Review of Patient #14s Hospice Certification and Plan of Care for certification period of 02/26/2024 to 04/25/2024 revealed, in part, cleanse wounds to multiple decubiti, apply dressing, and change daily. Further review revealed Patient #14 was to receive skill nursing services three times a week for the first week then twice a week thereafter. Review of Patient #14s Wound Record Report revealed Patient #14 had the following wounds: unstageable (wound with tissue that obscures the base of the wound) pressure ulcer to the right shoulder; unstageable pressure ulcer to the left greater trochanter (area near the thigh bone); unstageable pressure ulcer to the right greater trochanter; unstageable pressure ulcer to the left shoulder; unstageable pressure ulcer to the left second toe; unstageable pressure ulcer to the left lower buttock; unstageable pressure ulcer to the right lower buttock; unstageable pressure ulcer to the left upper buttock; unstageable pressure ulcer to the right upper buttock; stage III (wound that is into the fat tissue) pressure ulcer to the right ear; unstageable pressure ulcer to the right flank (wound on the backside area); stage III pressure ulcer to the left ear; and unstageable pressure ulcer to the left ankle. There was no documented evidence and the agency did not present any documented evidence that wound care measurements were completed for the time period of 02/26/2024 to 04/10/2024 other than on 02/27/2024. In an interview on 04/12/2024 at 5:08 p.m., S1Diretor of Patient Care (DPC) indicated the agency did not have documented evidence Patient #14s wounds had been measured weekly. Patient #15 Review of Patient #15s Hospice certification and Plan of Care for certification period of 02/08/2024 to 03/04/2024 revealed Patient #15 was to receive skilled nursing services twice a week. Further review revealed Patient #15s facility staff was to perform wound care to multiple decubitus ulcers according to a coordinated plan of care. Review of Patient #15s Wound Record Report for certification period of 02/08/2024 to 03/04/2024 revealed Patient #15 had the following wounds, in part: unstageable pressure ulcer to the left proximal pretibial area (lower leg); unstageable pressure ulcer to the right distal pretibial area; stage III pressure ulcer to the sacrum (area of above the buttock); unstageable pressure ulcer to the left posterior heel; unstageable pressure ulcer to the right posterior heel; and unstageable pressure ulcer to the posterior right upper back. Further review revealed no documented evidence and the agency presented no documented evidence of wound care measurement had been obtained by the hospice nurse. In an interview on 04/12/2024 at 5:20pm, S1DPC indicated the agency did not have any wound care measurements documented and did not have documentation of coordinating with Patient #15s nursing facility to assess the wound. Patient #17 Review of Patient #17s Hospice Certification and Plan of Care for certification period of 06/28/2023 to 07/16/2023 revealed Patient #17 was to receive skilled nursing services twice a week for Patient #17s stage II (wound where the first layer of skin is open) sacral pressure ulcer. Review of Patient #17s Wound Record Report revealed no documented evidence and the agency presented no documented evidence of Patient #17s pressure ulcer to the sacrum had been measured weekly. In an interview on 04/12/2024 at 5:36 p.m., S1DPC indicated the agency had no documented evidence to present that Patient #17s sacral wound had been measured weekly.”

“Based on record review and interview the agency failed to ensure the registered nurse made an on-site visit every 14 days to supervise the hospice aide for 5 (Patient #1, Patient #3, Patient #12, Patient #14, and Patient #19) of 14 (Patient #1, Patient #2, Patient #3, Patient #7, Patient #8, Patient #10, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #19, and Patient #20) sampled patients with hospice aide services reviewed for supervisory visit. Findings: Patient #1 Review of Patient #1s Hospice Certification and Plan of Care for certification period of 01/19/2024 to 04/17/2024 revealed Patient #1 was to receive hospice aide services three times a week effective the week of 01/21/2024. Review of Patient #1s record revealed Patient #1 started receiving hospice aide services per the plan of care the week of 01/21/2024; however, the record revealed no documented evidence and the provider presented no documented evidence the registered nurse had completed any hospice aide supervisory visits during the certification period. In an interview on 04/12/2024 at 3:57 p.m., S1Director of Patient Care (DPC) indicated the agency did not have documentation of supervisory visits for hospice aides for the certification period of 01/19/2024 to 04/17/2024. Patient #3 Review of Patient #3s Hospice Certification and Plan of Care for certification period of 03/05/2024 to 05/03/2024 revealed Patient #3 was to receive hospice aide services once a week for one week, then twice a week for eight weeks. Review of Patient #3s record revealed Patient #3 received hospice aide services on 03/19/2024, 03/22/2024, 03/26/2024, 03/29/2024, 04/02/2024, and 04/05/2024. Further review revealed Patient #3 did not have a hospice aide supervisory visit conducted from 03/19/2024 through 04/04/2024. In an interview on 04/12/2024 at 4:10 p.m., S1DPC indicated hospice aide supervisory visits were not completed as required every 14 days. Patient #12 Review of Patient #12s Hospice Certification and Plan of Care for certification period of 02/11/2024 to 04/10/2024 revealed Patient #12 was to receive hospice aide services three times a week for eight weeks then once a week for one week. Review of Patient #12s record revealed Patient #12 received hospice aide services per the plan of care. Further review revealed Patient #12 did not receive a hospice aide supervisory visit for the time period of 02/12/2024 through 03/07/2024 and for the time period of 03/19/2024 through 04/10/2024. In an interview on 04/12/2024 at 4:10 p.m., S1DPC indicated hospice aide supervisory visits were completed as required. Patient #14 Review of Patient #14s Hospice Certification and Plan of Care for certification period of 02/16/2024 to 04/25/2024 revealed Patient #14 was to receive hospice aide services once a week for one week, then twice a week. Review of Patient #14s record revealed Patient #14 did not receive a hospice aide supervisory visit for the time period of 03/18/2024 through 04/04/2024. In an interview on 04/12/2024 at 5:08 p.m., S1DPC indicated Patient #14 did not receive hospice aide supervisory visits every 14 days as required. Patient #19 Review of Patient #19s Hospice Certification and Plan of Care for certification period of 04/05/2023 to 05/27/2023 revealed Patient #19 was to receive hospice aide services one a week for one week, then twice a week thereafter. Review of Patient #19s record revealed Patient #19 started receiving hospice aide services on 04/07/202; however, Patient #19 never received a hospice aide supervisory visit by a registered nurse. In an interview on 04/12/2024 at 5:43 p.m., S1DPC indicated Patient #19 did not receive hospice aide supervisory visits as required.”