Lamm Family Care Hospice

“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 and interview. In 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure each patient’s individualized written plan of care (POC) reflected patient and family goals and the planned interventions based on problems identified in the comprehensive assessments. Clinical Record 2/Home Visit 2: The initial nursing assessment completed on 02/12/2024 documented the patient had a significant cardiac history including New York Heart Association (NYHA) Class IV heart failure and the placement of a cardiac pacemaker due to arrhythmias. During Home Visit 2 with the Medical Social Worker (Staff 3), it was observed that the patient had a monitor used to evaluate and communicate issues associated with the pacemaker. The plan of care, effective 02/12/2024, did not include goals and interventions associated with the pacemaker. Clinical Record 18: The initial nursing assessment completed on 02/24/2023 documented that the patient had a non-accessed mediport (implanted central venous catheter) to the right chest wall. The plan of care, effective 02/24/2023, did not include goals and interventions associated with the mediport. On 04/19/2024 joint clinical record reviews and interviews were conducted with the Administrator/Director of Nursing who confirmed that the plans of care, for the clinical records identified, did not reflect patient and family goals and planned interventions associated with the identified pacemaker and mediport.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group, and written patient care instructions for a hospice aide are prepared by a 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 9 of 16 (56%) clinical records reviewed, in which hospice aide services were accepted, revealed that the agency did not ensure the Registered Nurse (RN) provided specific patient care instructions for the aide to follow. Clinical Record 1: The hospice aide’s visits completed on 03/28/2024 and 04/05/2024 were documented outside the electronic medical record (EMR) on a form titled, “Hospice Aide Visit Note,” and included documentation that the following tasks were performed by the aide: bed bath, comb hair, shampoo, skincare, nail care (soak and clean only), foot care (do not trim nails), dress patient, linen change, tidy patient area, perineal care, bed rails up, and vital signs (blood pressure, pulse, respirations, and temperature). The identified form did not contain documented evidence to support that a Registered Nurse had written specific patient care instructions for the aide to follow, forcing the aide to make decisions outside of the aide’s scope of practice. Clinical Record 5: The hospice aide’s visit completed on 01/04/2024 was documented outside the electronic medical record (EMR) on a form titled, “Hospice Aide Visit Note,” and included documentation that the following tasks were performed by the aide: bed bath, comb hair, range of motion, reposition, assistance with ambulation, foot care (do not trim nails), dress patient, tidy patient area, perineal care, bed rails up, and vital signs (blood pressure, pulse, respirations, and temperature). The identified form did not contain documented evidence to support that a Registered Nurse had written specific patient care instructions for the aide to follow, forcing the aide to make decisions outside of the aide’s scope of practice. Clinical Record 6: The hospice aide’s visit completed on 03/18/2024 was documented outside the electronic medical record (EMR) on a form titled, “Hospice Aide Visit Note,” and included documentation that the following tasks were performed by the aide: comb hair, range of motion, reposition, assistance with toileting, foot care (do not trim nails), dress patient, and vital signs (blood pressure, pulse, respirations, and temperature). The identified form did not contain documented evidence to support that a Registered Nurse had written specific patient care instructions for the aide to follow, forcing the aide to make decisions outside of the aide’s scope of practice. Clinical Record 11: The hospice aide’s visits completed on 03/04/2024, 03/08/2024, and 03/13/2024 were documented outside the electronic medical record (EMR) on a form titled, “Hospice Aide Visit Note,” and included documentation that the following tasks were performed by the aide: comb hair, foot care (do not trim nails), tidy patient area, perineal care, and vital signs (pulse and respirations). On 04/05/2024 the aide’s visit was also documented on the “Hospice Aide Visit Note,” and the aide documented personal care tasks were performed, including combing hair, shaving, foot care (do not trim nails), oral care, dentures, tidying patient area, perineal care, and vital signs (blood pressure, pulse, and respirations). The identified form did not contain documented evidence to support that a Registered Nurse had written specific patient care instructions for the aide to follow, forcing the aide to make decisions outside of the aide’s scope of practice. Clinical Record 12: The hospice aide’s visits completed on 02/22/2024 and 02/27/2024 were documented outside the electronic medical record (EMR) on a form titled, “Hospice Aide Visit Note.” The aide documented that the following tasks were performed on 02/22/2024: showering, combing hair, skincare, nail care (soak and clean only), dressing patient, linen change, tidying patient area, perineal care, and vital signs (blood pressure, pulse, respirations, and temperature), and on 02/27/2024 the documented tasks performed included shampoo and foot care (do not trim nails). The identified forms did not contain documented evidence to support that a Registered Nurse had written specific patient care instructions for the aide to follow, forcing the aide to make decisions outside of the aide’s scope of practice. Clinical Record 13: The hospice aide’s visit completed on 02/22/2024 was documented outside the electronic medical record (EMR) on a form titled, “Hospice Aide Visit Note,” and included documentation that the following tasks were performed by the aide: comb hair, shave, skin care, nail care (soak and clean only), dress patient, perineal care, bed rails up, and vital signs (blood pressure, pulse, respirations, and temperature). The identified form did not contain documented evidence to support that a Registered Nurse had written specific patient care instructions for the aide to follow, forcing the aide to make decisions outside of the aide’s scope of practice. Clinical Record 14: The hospice aide’s visits completed on 02/23/2024, 02/26/2024, and 04/05/2024 were documented outside the electronic medical record (EMR) on a form titled, “Hospice Aide Visit Note,” and included documentation that the following tasks were performed by the aide: shower, tub bath/shower, comb hair, shampoo, dress patient, oral care/dentures, assist with ambulation, assist to the bathroom, date of last bowel movement, tidy patient area, perineal care, and vital signs (blood pressure, pulse, respirations, and temperature). The identified form did not contain documented evidence to support that a Registered Nurse had written specific patient care instructions for the aide to follow, forcing the aide to make decisions outside of the aide’s scope of practice. The hospice aide care plan, effective 03/20/2023, included instructions for the aide to perform indwelling urinary catheter care and empty drainage bags. The nursing visit completed on 04/03/2023 documented that the indwelling urinary catheter was discontinued; however, the aide documented “treatment performed” regarding indwelling urinary catheter care and emptying drainage bags for visits completed on 04/01/2023, 04/03/2023, 04/05/2023, 04/08/2023, 04/12/2023, and 04/17/2023. The clinical record did not contain documented evidence to support that the aide care plan was updated by the Registered Nurse (RN) to reflect changes in the patient’s care needs. Clinical Record 18: On 4/10/2023 the hospice nurse obtained an order for and inserted an indwelling urinary catheter. Hospice aide services and an aide care plan were initiated on 04/13/2023 with instructions for the aide to perform patient care tasks that included: showering, assisting with commode, bedpan, and feeding. The care plan did not alert the aide that the patient had an indwelling urinary catheter or if the aide was to provide any catheter site care or drainage bag maintenance. Clinical Record 19: The nursing visit note completed on 05/26/2022 documented that an indwelling (Coude) urinary catheter was ordered and inserted due to urinary retention, and an order to discontinue the indwelling catheter was entered, effective 11/09/2022. The clinical record did not contain documented evidence to support that the hospice aide care plan, effective 04/22/2022, was updated to alert the aide that the patient had an indwelling urinary catheter or if the aide was to provide any catheter site care or drainage bag maintenance. During the interview with the aide on 04/17/2024 during the home visit at the SNF, the aide showed me how she accesses the aide visit. They have an EMR that the aide accesses through the phone. When they access it then they can see the care plan and document the tasks completed along with a narrative if needed. When they are unable to access the EMR through their phone, they have been using a paper form. The paper form simply had area for patient name, MR#, time in and out, then boxes with different tasks. The aide just checked off what she did at the visit. The form did not include any documentation from the RN instructing on what was to be done by the aide. On 04/18/2024 joint clinical record reviews and interviews were conducted with the Administrator/Director of Nursing who confirmed that the form titled, “Hospice Aide Visit Note,” did not contain written instructions from the Registered Nurse regarding the patient care to be provided, and a copy of the aide’s care plan in the EMR was not provided to the aide during the identified visits. Leadership also confirmed that the identified clinical records did not contain evidence that the aide care plans were updated to include indwelling catheter care.”

“It is required that a hospice aide provide services that are ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 3 of 16 (19%) clinical records reviewed, in which hospice aide services were accepted, revealed that the agency did not ensure the hospice aide provided services that were ordered by the Interdisciplinary Group (IDG). Clinical Record 1: The plan of care orders, effective 02/14/2024 through 04/13/2024, included a frequency of visits for the hospice aide of five (5) visits per week. For the week of 04/07/2024, the aide documented three (3) completed visits (04/08/2024, 04/11/2024, and 04/12/2024). The clinical record did not contain documented evidence to support that five (5) hospice aide visits were provided the week of 04/07/2024 as ordered or to support why two (2) visits were missed. Clinical Record 2: The plan of care orders, effective 02/12/2024, included a visit frequency for the hospice aide of two (2) visits per week. The clinical record did not contain documented evidence to support that two hospice aide visits were provided the week of 03/10/2024 as ordered or to support why the visits were missed. Clinical Record 4: The plan of care orders, effective 04/10/2024 through 04/13/2024, included a visit frequency for the hospice aide of two (2) visits per week. The hospice aide documented a completed visit on 04/12/2024. The clinical record did not contain documented evidence to support that a second hospice aide visit was provided as ordered from 04/10/2024 through 04/13/2024 or to support why the visit was missed. On 04/18/2024 joint clinical record reviews and interviews were conducted with the Administrator/Director of Nursing who confirmed that the records identified did not contain documented evidence to support that hospice aides had provided visits as ordered.”

“It is required that a hospice aide provide services that are included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 16 (6%) clinical records reviewed, in which hospice aide services were accepted, revealed that the agency did not ensure the hospice aide provided services that were included in the plan of care. Clinical Record 2: The plan of care orders, effective 02/12/2024, included a visit frequency for the hospice aide of two (2) visits per week and tasks to be performed by the aide at each visit. The aide completed visits on 02/13/2024, 02/22/2024, 02/27/2024, 04/02/2024, 02/04/2024, and 04/16/2024 and documented in the clinical notes that the aide had transferred the patient using a Hoyer lift. The aide’s care plan did not include instructions for the aide to transfer the patient from one surface to another or to use the Hoyer lift, and the clinical record did not contain documented evidence to support that the aide received verbal instructions from the hospice Registered Nurse to transfer the patient. On 04/18/2024 joint clinical record reviews and interviews were conducted with the Administrator/Director of Nursing who confirmed that the aide’s care plan did not include instructions for the aide to transfer the patient with or without a Hoyer lift and that there wasn’t documented evidence that the RN had given verbal instruction to transfer the patient.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 6 of 16 (38%) clinical records reviewed, in which hospice aide services were accepted, revealed that the agency did not ensure the hospice aides reported to the Registered Nurse (RN) changes in the patient’s care needs warranting changes to the plan of care. Clinical Record 4: The hospice aide care plan, effective 01/11/2024, included instructions for the aide to shampoo the patient’s hair and perform denture care each visit. The aide completed visits on 03/14/2024, 03/18/2024, 03/20/2024, and 03/22/2024 and documented “n/a (not appropriate for this visit)” regarding the ordered shampoo and denture care. The clinical record did not contain documented evidence to support that the aide reported to the Registered Nurse (RN) that the tasks were not completed or that changes in the patient’s needs warranted a change in the plan of care. Clinical Record 11: The hospice aide care plan, effective 02/21/2024, included instructions for the aide to perform shampoo, and denture care, and assist the patient with dressing each visit. The aide completed visits on 03/01/2024, 03/06/2024, 03/11/2024, 03/18/2024, 03/20/2024, 03/22/2024, 03/35/2024, and 03/27/2024 and documented “n/a (not appropriate for this visit)” regarding the ordered shampoo, denture care, and assist the patient with dressing. The clinical record did not contain documented evidence to support that the aide reported to the Registered Nurse (RN) that the tasks were not completed or that changes in the patient’s needs warranted a change in the plan of care. Clinical Record 12: The hospice aide care plan, effective 10/31/2023, included instructions for the aide to perform indwelling urinary catheter care each visit. The aide completed visits on 03/07/2024, 03/14/2024, 03/19/2024, 03/21/2024, 04/02/2024, 04/03/2024, and 04/11/2024 and documented “n/a (not appropriate for this visit)” regarding the care of the indwelling urinary catheter. The clinical record did not contain documented evidence to support that the aide reported to the Registered Nurse (RN) that the tasks were not completed or that changes in the patient’s needs warranted a change in the plan of care. Clinical Record 14: The hospice aide care plan, effective 03/20/2023, included instructions for the aide to perform indwelling urinary catheter care and empty drainage bags. The nursing visit completed on 04/03/2023 documented that the indwelling urinary catheter was discontinued; however, the aide documented “treatment performed” regarding indwelling urinary catheter care and emptying drainage bags for visits completed on 04/01/2023, 04/03/2023, 04/05/2023, 04/08/2023, 04/12/2023, and 04/17/2023. The clinical record did not contain documented evidence to support that the aide reported to the Registered Nurse (RN) that changes in the patient’s care needs warranted a change in the plan of care. Clinical Record 16: The hospice aide care plan, effective 01/09/2023, included instructions for the aide to provide the patient with a shower and shampoo hair at each visit. The aide completed two (2) visits per week from 05/02/2023 through 05/20/2023 and documented that the patient had declined both the shower and shampoo each visit. The clinical record did not contain documented evidence to support that the aide reported to the Registered Nurse (RN) that the tasks were not completed or that changes in the patient’s needs warranted a change in the plan of care. Clinical Record 18: The hospice aide care plan, effective 04/13/2023, included instructions for the aide to provide the patient a shower and to assist the patient with the commode, bedpan, and feeding each visit. The aide completed visits on 04/14/2023, 04/18/2023, 04/19/2023, 04/20/2023, and 04/21/2023 and documented, “patient too sick,” as the reason the tasks were not performed as instructed. The clinical record did not contain documented evidence to support that the aide reported to the Registered Nurse (RN) that the tasks were not completed or that changes in the patient’s condition and needs warranted a change in the plan of care. On 04/18/2024 joint clinical record reviews and interviews were conducted with the Administrator/Director of Nursing who confirmed that the clinical records identified did not contain evidence that the hospice aide had reported changes in patient care needs affecting the aide’s ability to perform tasks as instructed or that warranted a change in the plan of care.”

“It is required that volunteers be used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 6 of 6 (100%) clinical records reviewed, in which volunteer services were accepted, revealed that the agency did not ensure volunteer services provided to patients/families were clearly defined and noted in the plan of care. Clinical Record 4: A “Volunteer Assessment Form” was completed by the Medical Social Worker and signed by the Volunteer Coordinator on 01/11/2024 and documented that the patient/family had accepted volunteer services. The clinical record did not contain documented evidence to support that volunteer services were provided to the patient/family, subsequent refusal of volunteer services, or why volunteer services have not been provided. Clinical Record 5: Direct patient care volunteer visits were completed on 04/17/2023, 08/14/2023, and 09/14/2023, and the volunteer documented that contact was made with the patient and prayer was provided. A care plan intervention stating, “PRN (as needed) patient/caregiver request,” was started on 04/17/2023. The clinical record did not contain documented evidence of a plan of care that defined the specific role and services the volunteer was to provide. Clinical Record 8: Direct patient care volunteer visits were completed on 08/14/2023 and 09/19/2023, and the volunteer documented that contact was made with the patient and prayer was provided. A care plan intervention stating, “PRN (as needed) patient/caregiver request,” was started on 08/14/2023. The clinical record did not contain documented evidence of a plan of care that defined the specific role and services the volunteer was to provide. Clinical Record 13: Direct patient care volunteer visits were completed on 04/17/2023 and 09/18/2023 by two (2) volunteers concurrently, and the volunteers documented that contact was made with the patient and prayer was provided. A care plan intervention stating, “PRN (as needed) patient/caregiver request,” was started on 04/17/2023. The clinical record did not contain documented evidence of a plan of care that defined the specific role and services the volunteer was to provide, including the need for concurrent visits. Clinical Record 16: Direct patient care volunteer visits were completed on 01/17/2023, by a single volunteer, and 04/17/2023 by two (2) volunteers concurrently, and the volunteers documented that contact was made with the patient and prayer was provided. A care plan intervention stating, “PRN (as needed) patient/caregiver request,” was started on 01/17/2023. The clinical record did not contain documented evidence of a plan of care that defined the specific role and services the volunteer was to provide, including the need for concurrent visits. Clinical Record 19: Direct patient care volunteer visits were completed on 04/18/2023 and 09/19/2023 by two (2) volunteers concurrently and on 01/16/2024 by a single volunteer. The volunteers documented that contact was made with the patient and prayer was provided. A care plan intervention stating, “PRN (as needed) patient/caregiver request,” was started on 04/18/2023. The clinical record did not contain documented evidence of a plan of care that defined the specific role and services the volunteer was to provide, including the need for concurrent visits. On 04/18/2024 joint clinical record reviews and interviews were conducted with the Administrator/Director of Nursing who confirmed that plans of care, defining the specific roles and services to be provided by the volunteer, were not evident in the identified clinical records.”

“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 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, interview, and observation. In 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure the clinical record contained updated plans of care associated with new problems or changes identified in updated comprehensive assessments. Clinical Record 3/Home Visit 3: During Home Visit 3 with the Chaplain (Staff 4) on 04/17/2024, it was discussed in conversation with the patient that on two (2) occasions his truck had been stolen from his home, and most recently there had been two shootings within his neighborhood. The clinical record did not contain documented evidence to support that the plan of care had been updated to include goals and interventions associated with the patient’s safety needs and risks related to living within an increasingly volatile area. Clinical Record 10: The skilled nursing visit completed on 04/15/2024 documented that the patient’s door lock had been strategically placed outside of the patient’s reach to prevent the patient’s elopement and subsequent wandering. The clinical record did not contain documented evidence to support that the plan of care had been updated to include goals and interventions associated with the patient’s risk of elopement and wandering. On 04/18/2024 joint clinical record reviews and interviews were conducted with the Administrator/Director of Nursing who confirmed that the plans of care, for the clinical records identified, were not updated to reflect new problems or changes associated with patients’ safety identified in the updated comprehensive assessments.”

“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 physician orders. This standard was not met as evidenced by clinical record review, interview, and observation. In 4 of 19 (21%) clinical records reviewed revealed that the agency did not ensure the clinical records included physician orders for all care and services provided. Clinical Record 2/Home Visit 2: During Home Visit 2 with the Medical Social Worker (Staff 3) on 04/17/2024, the facility nurse was observed administering the patient’s medications crushed in pudding. The patient confirmed that she received all of her medications crushed in pudding. The clinical record did not contain a physician’s order for medications to be crushed and given mixed in pudding. Clinical Record 3: The initial nursing assessment completed on 08/21/2023 documented that the patient had an ileostomy to the right upper quadrant. The plan of care, effective 08/21/2023 and current for the benefit period 02/17/2024 through 04/16/2024, included an order for the skilled nurse or caregiver to perform ostomy care. The clinical record did not contain a complete physician’s order specifying the type and frequency of ostomy care. Clinical Record 4: The plan of care orders, effective 01/11/2024, included a visit frequency for the hospice aide of three (3) visits per week. The hospice aide documented four visits were completed the week of 03/04/2024 (03/04/2024, 03/06/2024, 03/07/2024, and 03/08/2024). The clinical record did not contain a physician’s order for the frequency of aide visits to be increased to four (4) visits during the week of 03/04/2024. Clinical Record 15: The initial nursing assessment completed on 03/11/2024 documented that the patient’s blood sugar was being tested before each meal, before bed, and as needed by the caregiver, and the medication profile included fast-acting insulin to be dosed using a sliding scale based on blood sugar results and was scheduled as needed. The clinical record did not contain a physician’s order for blood glucose monitoring to be performed before meals and bedtime. The nursing clinical note on 03/25/2024 documented that the hospice Medical Director had instructed the nurse on safety measures to be initiated to maintain the patient’s current hospice services which included the patient being transferred to a facility or the family obtaining a private sitter. The nurse documented that the family elected to transfer the patient to another hospice on 03/25/2024. The clinical record did not contain a signed physician’s order for the transfer to another hospice. On 04/18/2024 joint clinical record reviews and interviews were conducted with the Administrator/Director of Nursing who confirmed that the clinical records identified did not contain physician orders for all care and services provided, including orders for crushing and mixing medications in pudding, specific ostomy care, aide visits, and the transfer of patient care.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 9 (44%) clinical records reviewed, in which the patient resided in a skilled nursing facility (SNF), revealed that the agency did not ensure the plan of care specified which provider would be responsible for performing functions agreed upon and included in the plan of care. Clinical Record 2: The patient’s caregiver elected hospice services, provided in the skilled nursing facility (SNF), on 02/12/2024. The plan of care, effective 02/12/2024, included orders for blood sugars to be checked before meals and at bedtime, midline site care every week on Wednesday, turn and reposition the patient every two (2) hours as appropriate, and intravenous medication to be administered every eight (8) hours. The clinical record did not contain documented evidence to support that the specific provider responsible for performing blood sugar checks, midline site care, turn and repositioning, and administration of intravenous medications was identified. Clinical Record 4: The patient’s representative elected hospice services, provided in SNF, on 01/11/2024. The plan of care, effective 01/11/2024 to current, included orders to turn the patient every two (2) hours and to float the patient’s heels when in bed. The clinical record did not contain documented evidence to support that the specific provider responsible for turning and floating the patient’s heels was identified. Clinical Record 5: The initial nursing assessment completed on 04/11/2023 documented that the patient had a medical history of seizures. The plan of care orders, effective 10/17/2023 to the current date, included an order to draw blood labs associated with medications, Keppra and Phenobarbital, every month. The clinical record did not contain documented evidence to support that the specific provider responsible for drawing blood labs was identified. Clinical Record 7: The initial nursing assessment on 05/06/2023 documented a drug profile that included Humulin R insulin to be administered using a sliding scale dose based on blood sugar results. The plan of care, effective on 05/06/2023, included an order to check blood sugar every week. The plan of care order was updated on 05/20/2023 and included an order to draw blood labs associated with the medication Keppra and again on 06/24/2023 detailing the use of a Geri chair locking tray. The clinical record did not contain documented evidence to support that the specific provider responsible for performing blood sugar checks, drawing blood labs, and performing timed tasks associated with preventing patient seclusion and restraint during the use of a locking tray was identified. On 04/18/2024 joint clinical record reviews and interviews were conducted with the Administrator/Director of Nursing who confirmed that the plans of care, for the clinical records identified, did not specify the provider responsible for performing blood sugar checks, blood labs associated with medications, intravenous (IV) site care, IV medication administration, and frequent pressure relieving measures as agreed on by the SNF and hospice.”