Gilchrist Hospice Care, Inc.

“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; Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. 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, document review and interview. In 1 of 37 (3%) clinical records reviewed revealed that the agency did not ensure that all medications were documented on the medication profile and reviewed for all potential interactions. Document 6: #13381446 Medication Therapy Management, stated in part, “An active Medication Report is generated following this review and is posted on their website. On each visit subsequent to initial assessment the Case Managing registered nurse (or designee) will enter any new medications or changes in existing medications into the Electronic medical record. Clinical Record 2: The initial comprehensive assessment was dated 07/30/2024 for the patient with a primary diagnosis of congestive heart failure and secondary of Senile Dementia. The updated nursing assessment documented on 08/08/2024 stated that the patient was using Preparation H for Hemorrhoids that worsened with some difficulty with constipation. A follow up assessment the next week documented that the Preparation H was continuing to help the patient. The medication was not updated to the medication profile as of review 11/05/2024, and consequently a full medication review for all potential interactions was not completed. During the interview on 11/05/2024 with the Associate Clinical Director of Support Services who jointly reviewed the clinical record stated that the medication had not been added to the profile which was their process and procedure.”

“It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. The documentation in the patient’s record is in accordance with the hospice’s policies and procedures. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 37 (5%) Clinical records for the home hospice program and the in-patient unit program were reviewed and revealed the agency did not ensure that all interventions were documented on the initial and updated plans and were individualized for the care of the patient. Document 6: #15175505 Plan of Care, stated in part,” The hospice plan of care will be based upon the assessment of the individual needs and include the identification of services provided, management of discomfort and symptom relief and the psychosocial and spiritual concern of the patient and the family. The hospice plan of care will state in detail the scope and frequency of services required to safely meet the patient’s and family’s care needs. Complete assessment of patient and family needs and wishes including: Types of services and the interventions required to meet the goals; the frequency of services and treatments. Clinical Record 30: The initial comprehensive assessment was dated 10/31/2024 for a patient with a primary diagnosis of pancreatic cancer who had a port in the right chest. The initial plan of care dated 10/31/2024 did not include intervention related to the port care, including dressing changes, port access, and port flushing. During the observed visit on 11/06/2024, the nurse provided medication for the patient, utilized the port for the medication delivery, verbalized the port’s care, and delivered the medication correctly. During interview on 11/06/2024 with the Clinical Manager of the inpatient unit who jointly reviewed the record and stated that the interventions for the port were not on the plan of care but the orders were documented for the care. Clinical Record 7: The initial comprehensive assessment was dated 01/09/2024 with the primary diagnosis of End Stage Renal Disease included documentation that the patient had a 16 FR/10 cc Foley catheter to large bag drainage. There were no interventions or goals on the plan of care for the foley catheter as of the patient’s death on 1/18/2024. During interview with the Associate Clinical Director of Support Services who jointly reviewed the record stated that the plan of care and updated plan of care did not document interventions for the Foley Catheter.”

“It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. It includes all services necessary for the palliation and management of the terminal illness, including the following: Drugs and treatments necessary to meet the needs of the patient. The documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 37 (3%) clinical records reviewed for the community team and the inpatient unit, the agency did not ensure that all medications and treatments were documented on the plan of care. Document 6: #15175505 Plan of Care stated in part, “The hospice plan of care will be based upon the assessment of the individual needs and include the identification of services provided, management of discomfort and symptom relief and the psychosocial and spiritual concern of the patient and the family. The hospice plan of care will state in detail the scope and frequency of services required to safely meet the patients’ and family’s care needs. Complete assessment of patient and family needs and wishes including: Medication and treatments.” Clinical Record 2: The initial comprehensive assessment was dated 07/30/2024 for a patient with a primary diagnosis of congestive heart failure and secondary of Senile Dementia. The updated nursing assessment documented on 08/08/2024 stated that the patient was using Preparation H for Hemorrhoids that worsened with some difficulty with constipation. A follow up assessment the next week documented that the Preparation H was continuing to help the patient. The Preparation H was not documented on the updated plan of care 08/15/2024 or any of the updated plans of care as of review 11/05/2024. During interview on 11/05/20024 with the Associate Clinical Director of Support Services, who jointly reviewed the record, stated that the medication was not updated to the plans of care”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. 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 1 of 23 (4%) clinical records reviewed in which hospice aides were accepted revealed the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient’s required care. Clinical Record 10: A review of the hospice aide plan of care dated 01/22/2024 included the task “Provide a partial bed bath, may shower if resident willing”. The patient’s primary diagnosis was Alzheimer’s. The bathing task continued with both bath options as the assignment as of review 11/07/2024. The aide visit frequency was two times a week. The aide documented a bed bath was provided; however, the task was not specific. During the interview on 11/08/2024, the Associate Clinical Director of Support Services stated that aide plan had now been corrected for bed bath as the only bathing option for the aide.”

“It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group. Included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records, for which the hospice aide was accepted for care, the agency did not ensure that the hospice aide followed the hospice aide’s care plan. Clinical Record 20: The aide plan of care dated 12/22/2023 included the assigned task of weight every visit. The aide visit frequency was 3 times a week. The plan continued through date of 10/31/2024 with the assigned task of weight every visit. There was no documented weight on the aide visit notes 12/26/2023, 01/03/2024, 02/02/2024, 04/15/2024, 07/03/2024, and 08/04/2024, however the task was marked as completed. During interview with the Associate Clinical Director of Support Services who jointly reviewed the record and stated on 11/08/2024 that the aide plan task was corrected not to require weight each visit for the facility patient.”