Faith Hospice at Trillium Woods

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy and drug side effects actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in hospice populations are anticipated, and as appropriate, preventive measures 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 5 (20%) clinical records reviewed of patients receiving care in the in-patient facility, it was revealed that the agency did not ensure that all medications were updated on the Medication Administration Record and then reviewed. Document 4: Agency Policy Medication Administration and Monitoring At the Hospice Care Center Policy, stated in part, “A patient Medication Administration Record (MAR) is initiated on admission and updated as changes in medication order occur.” Clinical Record 16: The hospice patient was admitted to the inpatient unit on 02/18/2024. The initial nursing assessment documented on 02/18/2024 included the insertion of a subcutaneous device. The interventions documented included that the subcutaneous device would be changed 2 (two) times a week for medication administration. The Medication Administration Record (MAR) did not document the flush of normal saline that was required before and after subcutaneous medication delivery. During the interview with the executive director and in-patient director, the saline would be added to the MAR as intravenous and /or subcutaneous medications were only used in the in-patient unit and not for community hospice patients.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 5 (20%) clinical records reviewed of patients in the inpatient unit, it was revealed that the agency did not ensure that the plan of care documented all medications that were required for the care of the patient the inpatient unit. Document 4: Agency Policy titled Plan of Care Policy stated in part, “The plan of care includes: An identification of services necessary for palliation and management of the terminal illness and related conditions including management of discomfort, pain, and symptom relief with treatments, drugs, and interventions to assist with the end-of-life care.” Clinical Record 16: The initial plan of care dated 02/18/2024 and all updates to the plans of care, did not document all medications used to treat the hospice patient. The Initial comprehensive assessment was documented on 02/18/2024. A subcutaneous device was inserted for the infusion of subcutaneous medications at the inpatient unit. The medications ordered through the devices were Dilaudid (pain medication), Ketorolac (treats severe pain) and Glycopyrrolate (for drying section). The medications were ordered as needed and had been provided to the patient. The device required a saline flush of 3 cc normal saline after the medication was administered. The saline was not documented on the initial plan or any of the updated plans of care. During an interview with the Clinical Director and the Inpatient Director, they stated that subcutaneous medication delivery was only used at the inpatient facility not in the community and that the saline was not on 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 4 of 29 (14%) clinical records reviewed in which a hospice aide was accepted, it was revealed that the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for all care that the patient required. Clinical Record 1: The Hospice Aide was accepted with an aide plan documented on 02/09/2024 that included the task to provide a bath. The initial comprehensive nursing assessment documented on 02/09/2024 identified a pleurex drain with a dressing and a left chest wound that was necrotic and required a dressing. The aide plan provided no written directions for care if the dressing was saturated or came off. Clinical Record 4: The Hospice Aide was accepted with an aide plan documented on 06/13/2024. The initial comprehensive nursing assessment documented on 06/13/2024 identified a pleurex drain placed to the left chest and required a dressing. The aide plan provided no written directions for care if the dressing was saturated or came off. Clinical Record 17: The Hospice Aide was accepted with a plan documented on 04/11/2024 that included the task to perform a bed bath every visit. The initial comprehensive assessment documented on 04/11/2024 included the presence of chest tubes. The aide plan provided no written directions for care around the chest tubes or what to do if the split gauze dressings were saturated or came off. Clinical Record 18: The Hospice Aide was accepted with a plan documented on 03/21/2024 with an assigned bathing task of a shower every visit. The initial comprehensive assessment was documented on 03/21/2024 and identified biliary catheters with a dressing in the LUQ (left upper quadrant). The aide plan provided no written directions for care around the chest tubes or what to do if the split gauze dressings were saturated or came off. During an interview with the Executive Director and Clinical Director they stated they would review aide plans for the detail of direction related to wounds. They noted that the communication problem and skin integrity problem on the plan of care did document the detail, and that the aide could view this but was not part of the aide plan.”

“It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 29 (7%) clinical records reviewed that the hospice aide was accepted for care, it was revealed that the agency did not ensure that the hospice aide followed all duties assigned to the hospice aide’s plan of care. Clinical Record 24: The aide plan of care completed on 01/16/2024 and all updated plans until 08/20/2024 assigned the task of weight monthly at the beginning of the month. The first aide visit of 08/2024 was 08/02/2024 and documented that the patient was dressed and declined care for the day. The aide visits documented on 08/05/2024 and 08/08/2024 documented that the weight was N/A (not applicable) There was no weight documented at the beginning of the month of 08/2024. Clinical Record 5: The aide plan of care completed on 02/23/2024 and all updated plans until 08/21/2024 assigned the task of weight monthly at the beginning of the month. The first aide visit of 06/2024 was 06/05/2024 documented that the weight was N/A (not applicable.) There was no weight documented for the month of 06/2024. The weight documented 07/2024 documented minimal weight loss. During an interview with the Director of Informatics and Quality, it was stated that the weights were not documented.”

“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. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 15 (13%) personnel records reviewed of direct care staff, it was revealed that the agency did not ensure that skills and competencies were assessed as required by the agency’s policy. Document 4: The agency’s Competency Training of Clinical Staff Policy (effective 08/2015 and revised in 08/2024) stated in part, “The competency evaluation process for direct care staff includes mechanisms for assessing skills, updating skills, and testing and observing skills performance every 12 months and/or annually.” Personnel Record 2: The chaplain was hired on 03/04/2016. The personnel record did not contain documentation of a completed competency evaluation for the year 2023. The chaplain actively provided patient care for the past 3 years. Personnel Record 3: The chaplain was hired on 09/26/2018. The personnel record did not contain documentation of a competency evaluation for the years 2022 or 2023. The chaplain actively provided patient care for the past 3 years. In an interview with the agency’s Quality Assurance Nurse on 08/22/2024, she reviewed the personnel records in question and confirmed that additional competency assessments were not present.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. In 1 of 6 (17%) contracts that include provisions for direct patient care and/or access to patient records, it was revealed that the agency did not ensure that the contract included a provision to obtain criminal background checks on staff that would be providing direct patient care and/or have access to patient records. Contract 7: The contract with a skilled nursing facility (SNF) did not include a clause requiring the SNF to obtain criminal background checks for staff providing direct patient care and/or having access to patient records. In an interview with the agency’s Executive Director (Personnel Record 8), on 08/22/2024, she reviewed the facility contract and agreed that there was no provision for criminal background checks documented in the contract.”