Three Rivers Health Homecare & Hospice

“Based on record review and interview, the hospice failed to ensure the comprehensive assessment included a review of all the patients medications for actual or potential drug interactions per agency policy in 1 (P-6) of 2 sample live discharge records reviewed potentially resulting in improper drug therapy and poor patient outcomes. Findings include: Agency policy titled “;Medication Oversight” last revised 02/2021, was reviewed on 5/9/24. On page 1.-2., it stated “;C. The Case Manager will consolidate all pertinent orders for medications into the Plan of Care/Plan of Treatment at the time of admission” ... E. A Registered Nurse will assess all medications a patient may be taking to identify possible... drug reactions. Any problem will be documented in the medical record and reported to the physician.” P-6: This 96-year-old was admitted to the hospice on 1/22/24 with a terminal diagnosis of Alzheimer’s disease. The medical record was reviewed on 5/9/24. During record review it was noted that the registered nurse (RN) completed the initial assessment on 1/22/24 and under the “;Medication Profile Review” section, included documentation that there were new/changed medications identified. On further review, it was noted under “;Visit Plan-Contacts/Phone Calls”, that the only contact made regarding the initial visit was to the social worker. There was no drug review which included actual or potential drug interactions or physician notification of problems documented on the initial nursing assessment. Using the agencys electronic medical record (EMR) system, a drug interaction report was printed for surveyor review on 5/9/24 (for the medications at the time of admission). The report included 7 major interactions. The fist Intradisciplinary Team (IDT) meeting that included this patient occurred on 1/24/24 (2 days after admission) and it was noted that the documentation in the IDT report under the medication comments section stated that the medication profile for this patient was missing and that an update needed to occur. It was unclear when the medication profile for this patient was entered into the EMR. This patient revoked service on 1/26/24. During an interview on 5/9/24 at 11:45 with the Administrator (Staff A), Staff A was queried to why the IDT meeting 2 days after this patients admission stated that the drug profile was missing and how the RN would identify actual or potential drug interactions. Staff A stated that the patient was admitted later in the afternoon on 1/22/24 and the RN probably entered the profile on 1/23/24. Staff A stated that the agency pharmacy notifies the agency of drug interactions and that the pharmacy must not have had the profile in time for the IDT meeting on 1/24/24. Staff A was then queried to when the drug interactions would be reviewed and discussed with the physician if problems were identified, Staff A stated it would have been at the next IDT meeting (2 weeks from admission). A drug review for drug interactions was not completed at the time of admission for this patient.”

“Based on record review and interview, the hospice failed to ensure the initial Bereavement Risk Assessment was comprehensive and included family members or other individuals identified as involved during record review, to determine the social, spiritual, and cultural factors that may impact that individuals ability to cope with the patient’s impending death in 9 (P-2, 5, 8, 9, 10, 11, 12, 13, 14) of 14 sample records reviewed. This practice could potentially result in ineffective grieving and a lack of bereavement support for family or other individuals upon the patients death. Findings include: P-2: This 70-year-old was admitted to the hospice on 4/4/24 with a terminal diagnosis of Lewy body dementia (nervous system disorder affecting thinking, movement, and function). The medical record was reviewed on 5/7/24. During review, it was noted throughout the medical record that the patient has a spouse whom he was living with, a son, and a daughter. The registered nurse (RN) completed an initial visit on 4/4/24 and did not complete an initial Bereavement Risk Assessment but indicated it would be completed by the social worker. The Medical Social Worker (MSW) completed an initial visit including an initial Bereavement Risk Assessment on 4/8/24 with the patients spouse. The MSWs initial visit documentation noted that the daughter was part of the family support system and was involved in the care and support of the patient/spouse throughout the week. There was no evidence of a comprehensive bereavement risk assessment for the daughter who was noted to be involved and part of the support/care for patient/spouse. P-5: This 74-year-old was admitted to the hospice on 8/16/23 with a terminal diagnosis of cancer of the esophagus. The bereavement record was reviewed on 5/8/23. During review, it was noted throughout the medical record that the patient had a spouse, 2 children, and a brother and sister whom the patient raised. The RN completed an initial visit on 8/16/23 and did not complete an initial Bereavement Risk Assessment but indicated it would be completed by the social worker. The initial RN visit also included documentation that the patient had a supportive family. The MSW completed an initial visit including an initial Bereavement Risk Assessment on 8/17/23 with the patients spouse. The MSWs initial visit documentation noted the following: the patient had 2 children and a brother and sister who were raised by the patient, family support was provided during the visit, and the daughter received needed paperwork. There was no evidence of a comprehensive bereavement risk assessment for any other family member who was noted to be involved/supportive for the patient and spouse. During interview on 5/8/24 at 12:45 p.m. with the MSW (Staff C), Staff C was queried to how it was determined who received an initial Bereavement Risk Assessment. Staff C stated that initial assessments are done for the primary caregiver. These findings were reviewed and acknowledged during interview on 5/9/24 at 11:45 with the Administrator (Staff A). P-8: The Start of Care (SOC) was dated 12/19/23. The Plan of Care (POC) identified a terminal diagnosis of Pulmonary Fibrosis. During record review on 5/7/24, it was noted that the bereavement risk assessment was completed by the MSW on 12/20/23 for the patients Husband. On 12/19/23, Staff A documented a narrative note stating, “;...Spouse and patients daughter were present for admission visit...” The bereavement risk assessment failed to include the patients daughter. P-9: The Start of Care (SOC) was dated 5/23/23. The Plan of Care (POC) identified a terminal diagnosis of Left Kidney Cancer. During record review on 5/7/24, it was noted that the bereavement risk assessment was completed by the MSW on 1/11/24 for the patients wife. On 2/5/24, Staff D documented a narrative note stating, “;...She (patients wife) did call his brother and also his sister and left messages to call her and that if they want to see him before he dies to come now.” The bereavement risk assessment failed to include the patients brother and sister. P-10: The Start of Care (SOC) was dated 3/13/24. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 5/7/24, it was noted that the bereavement risk assessment was completed by the MSW on 3/14/24 for the patients wife. On 4/30/24, Staff C documented a narrative note stating, “;...She (patients wife) is having difficulty coping with all the stressors and multiple crises in the family with her brother, friend, patient and mother-in-law...” The bereavement risk assessment failed to include the patients mother. P-11: The Start of Care (SOC) was dated 4/19/24. The Plan of Care (POC) identified a terminal diagnosis of Parkinsons. During record review on 5/8/24, it was noted that the bereavement risk assessment was completed by the MSW on 4/19/24 for the patients Husband. On 4/20/24, Staff C documented a narrative note stating, “;...She (patient) has 2 children from a previous marriage...” The bereavement risk assessment failed to include the patients 2 children. P-12: The Start of Care (SOC) was dated 12/29/23. The Plan of Care (POC) identified a terminal diagnosis of Alzheimers. During record review on 5/8/24, it was noted that the bereavement risk assessment was completed by the MSW on 12/29/23 for the patients wife. On 1/7/24, Staff C documented a narrative note stating, “;...His (patient) daughter, her spouse and the son with help with respite care...” The bereavement risk assessment failed to include the patients daughter, son, and son-in-law. P-13: The Start of Care (SOC) was dated 4/15/24. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 5/8/24, it was noted that there was no bereavement risk assessment completed. P-14: The Start of Care (SOC) was dated 3/6/24. The Plan of Care (POC) identified a terminal diagnosis of Lung Cancer. During record review on 5/9/24, it was noted that the bereavement risk assessment was completed by the MSW on 3/7/24 for the patients daughter. On 3/10/24, Staff C documented a narrative note stating, “;...She (patient) shared a lot of out her life and her 7 children. She had a daughter who died when 30 plus years old to alcoholism. She grieved the loss of her daughter and husband.” The bereavement risk assessment failed to include the patients additional 5 children. These findings were reviewed with and acknowledged by the Staff A (Administrator) during an interview on 5/9/24 at 10:00 am.”

“Based on record review and interview, the hospice failed to ensure the Plan of Care (POC) included measurable outcomes anticipated from implementing and coordinating care in 7 (P-3, 7, 8, 10, 11, 12, 14) of 14 sample records reviewed resulting in the potential difficulty to determine if these patients are meeting their goals of care. Findings include: P-3: This 92-year-old was admitted to the hospice on 10/31/23 with a terminal diagnosis of weakness and paralysis of the left side of the body following a stroke. The medical record was reviewed on 5/8/24. During review of the POC for the certification period of 4/28/24 through 6/26/24, the following skilled nursing (SN) goals of care were entered: Will not develop new open areas; Patients cardiovascular status is stable, as disease progression allows; Absence of injury, as evidenced by safe environment maintained to accommodate neurological deficits. It was unclear how the SN would objectively measure these goals to determine progress toward the goals. P-7: This 95-year-old was admitted to the hospice on 9/26/23 with a terminal diagnosis of weakness and paralysis of the left side of the body following a stroke. The medical record was reviewed on 5/9/24. During review of the POC for the certification period of 9/26/23 to 12/24/23, the following SN goals of care were entered: Family/caregiver will verbalize understanding of signs and symptoms of impending death; Patient/caregiver will verbalize understanding of pain management regimen; and Family/caregiver will verbalize when to notify hospice of concerns, changes in patient condition, and at the time of death. It was unclear how the SN would objectively measure these goals to determine progress toward the goals. These findings were reviewed and acknowledged during interview on 5/9/24 at 11:45 with the Administrator (Staff A). P-8: The Start of Care (SOC) was dated 12/19/23. The Plan of Care (POC) identified a terminal diagnosis of Pulmonary Fibrosis. During record review on 5/7/24, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “Patient/caregiver can identify potential complications; actions to take, when to call Hospice.” Additionally, another goal stated, “;Patient/caregiver maintain necessary measures to reduce risk and avoid respiratory infection.” The goals in this plan of care were not specific to the patient’s hospice needs, nor were the goals objectively measurable to determine if the patient was progressing toward meeting each goal. P-10: The Start of Care (SOC) was dated 3/13/24. The Plan of Care (POC) identified a terminal diagnosis of Congestive Heart Failure. During record review on 5/7/24, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “Patient/caregiver administers medications appropriately with understanding of side effects and states implications and expected results.” Additionally, another goal stated, “;Patients symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow.” The goals in this plan of care were not specific to the patient’s hospice needs, nor were the goals objectively measurable to determine if the patient was progressing toward meeting each goal. P-11: The Start of Care (SOC) was dated 4/19/24. The Plan of Care (POC) identified a terminal diagnosis of Parkinsons. During record review on 5/8/24, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “Patient/family/caregiver receive psychosocial support in coping with the terminal illness and the dying process.” Additionally, another goal stated, “;Patient/caregiver will verbalize understanding of falls/injury prevention and hoe safety measures.” The goals in this plan of care were not specific to the patient’s hospice needs, nor were the goals objectively measurable to determine if the patient was progressing toward meeting each goal. P-12: The Start of Care (SOC) was dated 12/29/23. The Plan of Care (POC) identified a terminal diagnosis of Alzheimers. During record review on 5/8/24, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “Family/caregiver can identify safety concerns.” Additionally, another goal stated, “;Family/caregiver will verbalize understanding of falls prevention, hoe safety measures.” The goals in this plan of care were not specific to the patient’s hospice needs, nor were the goals objectively measurable to determine if the patient was progressing toward meeting each goal. P-14: The Start of Care (SOC) was dated 3/6/24. The Plan of Care (POC) identified a terminal diagnosis of Lung Cancer. During record review on 5/9/24, it was noted the goals were not measurable. Examples of goals on this patient’s POC included: “Patient will be able to eat/drink to his/her satisfaction.” Additionally, another goal stated, “;Patient/caregiver will know to contact hospice with changes in condition and verbalize knowledge of contact numbers.” The goals in this plan of care were not specific to the patient’s hospice needs, nor were the goals objectively measurable to determine if the patient was progressing toward meeting each goal. These findings were reviewed with and acknowledged by the Staff A (Administrator) during an interview on 5/9/24 at 10:10 am.”

“Based on record review and interview, it was determined the hospice failed to ensure the plan of care included accurate drugs necessary to meet the patient’s needs in 1 of 14 records reviewed (P-11), resulting in the potential for unmanaged symptoms. Findings include: ** Hospice policy “;Medication Oversight” # NU.751.400.21, revised date: 2/2021, stated, “L. Medication will be documented using the Medication Profile form in the clinical record...M. The Case Manager will, if applicable, document patient instruction in the clinical record and teach the patient care giver: 3. The dosage, route of administration, and duration of drug therapy, as appropriate...” P-11: The Start of Care (SOC) was dated 4/19/24. The Plan of Care (POC) identified a terminal diagnosis of Parkinsons. During record review on 5/8/24, it was noted that the medication profile contained Sinemet (carbidopa-levodopa) 25mg-100mg oral tablet; take 3 tabs orally 3 times a day. On 4/23/24, the medication was changed to “;take 3 tabs orally 4 times a day”. On 5/1/24, Staff E documented, “;...Had to change dose on Sinemet back to 3 times a day due to feeling poorly on it...” The medication profile was not updated, thus the agency failed to maintain an accurate medication profile. These findings were reviewed with and acknowledged by the Staff A (Administrator) during an interview on 5/9/24 at 10:30 am.”

“Based on record review and interview, the hospice failed to ensure visit frequency was provided as ordered in 1 (P-2) of 12 sample records reviewed for visit frequency, potentially resulting in the needs of the patient/family going unmet. Findings include: P-2: This 70-year-old was admitted to the hospice on 4/4/24 with a terminal diagnosis of Lewy body dementia (nervous system disorder affecting thinking, movement, and function). The medical record was reviewed on 5/7/24. During review, it was noted that the registered nurse received an order for hospice aide services on 4/22/24 with a frequency of one time per week. On the nursing visit note dated 4/22/24, the nurse documented that a hospice aide was added per the wifes request. The first hospice aide visit occurred on 5/1/24 (9 days later). There was no documentation that the patient/family asked for the visit to be postponed. There was no evidence that the hospice aide attempted a visit prior to 5/1/24. There was no documentation in the medical record of why this visit was delayed for 9 days before beginning services. This finding was reviewed and acknowledged during interview on 5/9/24 at 11:45 with the Administrator (Staff A). Staff A stated that the visit should have occurred within the first week that it was ordered and was not able to provide any other evidence of why the visit frequency was not provided as ordered.”

“Based on record review and interview, the hospice failed to ensure that safety measures identified by the registered nurse were included on the hospice aide care plan in 4 (P-2, 3, 12, 14) of 5 sample records reviewed with patients receiving hospice aide services, potentially resulting in unsafe practices and poor patient outcomes. Findings include: P-2: This 70-year-old was admitted to the hospice on 4/4/24 with a terminal diagnosis of Lewy body dementia (nervous system disorder affecting thinking, movement, and function). The medical record was reviewed on 5/7/24. During review, comparison was made between the safety measures identified in the plan of care (POC) dated for the certification period of 4/4/24 through 7/2/24, and the hospice aide care plan initiated by the registered nurse (RN) on 4/22/24. The following safety measures were identified in the POC but were not included on the hospice aide care plan: skin breakdown prevention; bleeding precautions; transfer precautions; and ambulation precautions. P-3: This 92-year-old was admitted to the hospice on 10/31/23 with a terminal diagnosis of weakness and paralysis of left side of the body following a stroke. The medical record was reviewed on 5/8/24. During review, comparison was made between the safety measures identified in the POC dated for the certification period of 2/28/24 through 4/27/24, and the hospice aide care plan initiated by the RN on 3/5/24. The following safety measures were identified in the POC but were not included on the hospice aide care plan: 24 hour supervision; oxygen precautions; head of bed elevated; seizure precautions; and bleeding precautions. These findings were reviewed and acknowledged during interview on 5/9/24 at 11:45 with the Administrator (Staff A). Staff A stated that the electronic medical record system does not transfer safety precautions from the POC over to the hospice aide care plan and that the nurse does have to re-type out the safety precautions on the hospice aide care plan. Staff A stated that she realizes that the safety precautions are not properly listed for the hospice aide and that the agency needs to fix the issue. P-12: The Start of Care (SOC) was dated 12/29/23. The Plan of Care (POC) identified a terminal diagnosis of Alzheimers. During record review on 5/8/24, it was noted that the “Aide Care Plan” dated 12/29/23 was completed by the Registered Nurse (RN). The following safety measures were identified in the POC but were not included on the hospice aide care plan: Aspiration precautions, infection control, skin breakdown prevention, aseptic technique, bleeding precautions and transfer precautions. The Aide Care Plan failed to include the necessary safety measure and precautions to alert the aide of the patient’s health concerns. P-14: The Start of Care (SOC) was dated 3/6/24. The Plan of Care (POC) identified a terminal diagnosis of Lung Cancer. During record review on 5/9/24, it was noted that the “Aide Care Plan” dated 4/29/24 was completed by the RN. The following safety measures were identified in the POC but were not included on the hospice aide care plan: Keep pathways clear, energy conservation, bleeding precautions, infection control, bathtub safety bars, aseptic techniques, 24 hour supervision. The Aide Care Plan failed to include the necessary safety measure and precautions to alert the aide of the patient’s health concerns. These findings were reviewed with and acknowledged by the Staff A (Administrator) during an interview on 5/9/24 at 10:00 am.”