Americans Hospice Care, Inc.

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) records reviewed it was revealed that the agency did not ensure that the initial comprehensive assessment included an initial bereavement assessment. Document 9: Agency policy, PC. B25 Bereavement Risk Assessment, read in part, “1. During the comprehensive assessment of the patient, an initial bereavement assessment is conducted to determine the cultural, social and spiritual factors that may impact the ability of family members or other involved individuals to cope with the patient’s death.” Clinical Record 10: The hospice election of benefit form was dated 09/11/2023. The registered nurse completed the initial comprehensive assessment inclusive of psychosocial and spiritual assessments on 09/11/2023. The social worker completed the initial bereavement risk assessment on 09/18/2023 which exceeded the comprehensive assessment timeline. During interview on 01/11/2024, the Director of Patient Care Services (DPCS) reviewed the associated record and stated the registered nurse had inadvertently omitted the initial bereavement risk assessment and it was not completed in the five-day window.”

“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. 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 6 of 19 (32%) records reviewed it was revealed that the agency did not ensure the drug profile contained the patient’s current prescription and over the counter (OTC) drugs. Document 3: Agency policy titled, PC.55 Medication - Profile, read in part, “2. The medication profile must include a. All current patient medications, d. Dose, e. Frequency, 3. The patient’s medication profile is reviewed by the IDG whenever there is a significant change and at a minimum, every fifteen days.” Clinical Record 1: The hospice election of benefit form was dated 02/08/2023. During review of the benefit period dated 11/05/2023, the medication profile read in part, “Amlodipine Besylate 10mg oral (no frequency), Hydrocodone Acetaminophen 5-325mg every 6 hours as needed (no dose or as needed qualifiers), Albuterol Sulfate HF 108 as needed (no dose or as needed qualifiers), and Flunisolide 0.25mg/cet (0.25%) daily as needed (no as needed qualifier).” The Interdisciplinary team meeting documentation dated 11/22/2023, 11/28/2023, 12/09/2023, 12/20/2023 and the 01/03/2024 and care plan updates, all included documentation of the completion of a medication profile review. Clinical Record 4: The hospice election of benefit form was dated 06/02/2023. During review of the benefit period dated 11/29/2023, the medication profile read, “Oxygen 2-4L as needed.” There were no “as needed” qualifiers documented at the time of the review on 01/09/2024. Interdisciplinary team meeting documentation and care plan updates dated 12/06/2023, 12/20/2023 and the 01/03/2024, included documentation of the completion of a medication profile review. Clinical Record 7: The hospice election of benefit form was dated 02/09/2023. The registered nurse visit note dated 01/04/2024 and the 12/06/2023 hospice plan of care included documentation that the patient utilized Oxygen at 1.5 liters via nasal cannula. The mediation profile for the benefit period dated 12/06/2023, did not include oxygen. The Interdisciplinary team meeting documentation and care plan updates dated 12/06/2023, 12/20/2023 and the 01/03/2024 included documentation of the completion of a medication profile review. Clinical Record 9: The hospice election of benefit form was dated 11/28/2023. The medication profile read in part, “Meclizine 25mg 1 tablet by mouth as needed.” There were no documented “as needed” qualifiers. The Interdisciplinary team meeting documentation and care plan updates dated 12/06/2023, 12/20/2023 and the 01/03/2024 included documentation of the completion of a medication profile review. Clinical Record 13: The hospice election of benefit form was dated 09/19/2023. The medication profile read in part, “Medi honey twice weekly and as needed to affected areas.” There were no documented “as needed” qualifiers. The 12/20/2023 and 01/03/2024 Interdisciplinary team meeting documentation and care plan updates included documentation that the medication profile was reviewed. Clinical Record 19: The hospice election of benefit form was dated 10/04/2021. During review of the benefit period dated 07/26/2023, the medication profile did not include oxygen. The 09/13/2023 Interdisciplinary team meeting documentation and care plan update included the use of Oxygen at 2 liters via nasal cannula. During interview on 01/11/2024, the Director of Patient Care Services (DPCS) reviewed the associated records and confirmed that the medication profiles were incomplete.”

“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 detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 19 (16%) records reviewed it was revealed that the agency did not ensure that the hospice written plan of care included a detailed statement of the scope and frequency for all service to be provided. Document 4: Agency policy, PC. P55 Plan of Care- Content, read in part, “2. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: c. A statement detailing the scope and frequency of services necessary to meet the patient and family needs; h. Drugs and treatments necessary to meet the needs of the patient.” Clinical Record 13: The hospice election of benefit form was dated 09/19/2023. The plan of care (POC), for the benefit period dated 12/28/2023, did not include a visit frequency for Physical Therapy (PT). There were documented PT visit notes dated 12/19/2023, 12/21/2023, 12/28/2023, 12/29/2023, 01/02/2024, 01/04/2024 and 01/09/2024. Clinical Record 14: The hospice election of benefit form was dated 09/06/2023. The POC for the benefit period dated 12/05/2023 did not include a visit frequency for Physical Therapy (PT). There were documented PT visit notes dated 12/05/2023, 12/08/2023, 12/12/2023, 12/15/2023, 12/21/2023, 12/26/2023, 12/29/2023 and 01/04/2024. Clinical Record 17: The hospice election of benefit form was dated 11/03/2023. The plan of care did not include a visit frequency for Physical Therapy (PT) or for Occupational Therapy (OT). There were documented PT visit notes dated 11/08/2023 and OT visits notes dated 11/06/2023 and 11/08/2023. During interview on 01/11/2024, the Director of Patient Care Services (DPCS) reviewed the associated records and confirmed that the therapy frequencies were not documented.”

“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 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 6 of 19 (32%) records reviewed it was revealed that the agency did not ensure that the written plan of care included all treatments necessary to meet the needs of the patient. Document 4: Agency policy, PC. P55 Plan of Care- Content, read in part, “2. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: c. A statement detailing the scope and frequency of services necessary to meet the patient and family needs; h. Drugs and treatments necessary to meet the needs of the patient.” Clinical Record 5: The wound care order written 01/04/2024 read, “Cleanse inner glut with Normal Saline, apply Allevyn foam dressing every 3-5 days and as needed (prn) until healed.” The order did not include any prn qualifiers. Clinical Record 9: The plan of care dated 11/28/2023 read in part, “Irrigate foley with Normal Saline (NS) prn - change foley q month and prn.” It did not include the amount of Normal Saline to use for irrigation and did not contain prn qualifiers. Clinical Record 13: The election of benefit form was dated 09/19/2023. During the review of the benefit period dated 12/18/2023, the plan of care dated 2/18/2023 read in part, “Change both pressure injuries with wound cleanser, apply saline moistened gauze to wound beds and cover with sterile 4x4 gauze and secure with Kerlix and tape 3xweek and prn.” The location of the wounds was not identified and there were no prn qualifiers for the wound care. Clinical Record 15: The plan of care dated 11/02/2023 read in part, “Irrigate foley with Normal Saline (NS) prn - change foley q month and prn.” The order did not specify the amount of NS to use for irrigation and did not contain prn qualifiers. Clinical Record 17: The plan of care dated 11/03/2023 read in part, “Irrigate foley with Normal Saline (NS) prn - change foley q month and prn.” The order did not specify the amount of NS to use for irrigation and did not contain prn qualifiers. Clinical Record 18: The plan of care dated 12/13/2023 read in part, “Irrigate foley with Normal Saline (NS) prn - change foley q month and prn.” The order did not specify the amount of NS to use for irrigation and did not contain prn qualifiers. During interview on 01/11/2024, the Director of Patient Care Services (DPCS) reviewed the associated records and agreed that the orders were missing components.”

“It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that care and services provided are in accordance with the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 19 (21%) records reviewed it was revealed that the agency did not ensure that services were provided in accordance with the plan of care. Document 5: Agency policy PC.C90 Coordination of Services read in part, “1. The hospice will maintain a system of communication and integration, in accordance with the hospice’s own policies and procedures, to: b. Ensure that the care and services provided are based on all assessments of the patient and family needs.” Clinical Record 4: The hospice election of benefit form was dated 06/02/2023. The plan of care for the benefit period dated 11/29/2023 included a chaplain visit frequency of 1 time per week. There was no documentation of the provision of chaplain services for the week of 12/24/2023 and no documented explanation of why services were not provided as ordered. Clinical Record 6: The hospice election of benefit form was dated 12/27/2023. The plan of care dated 12/27/2023 included orders for a Physical Therapy (PT) frequency of 2 times per week and an order for a Speech Therapy (ST) evaluation. There was no documentation of a PT second visit for the week of 12/08/2024. There was no evidence of a ST evaluation and there was no documented explanation of why services were not provided as ordered. Clinical Record 9: The hospice election of benefit form was dated 11/28/2023. The plan of care dated 11/28/2023 included a chaplain visit frequency of 1 time per month. There was no documentation of the provision of chaplain services and no documented explanation of why services were not provided as ordered. Clinical Record 16: The hospice election of benefit form was dated 12/11/2023. The plan of care dated 12/11/2023 included a chaplain visit frequency of 1 time per month. There was no documentation of the provision of chaplain services and no documented explanation of why services were not provided as ordered. During interview on 01/11/2024, the Director of Patient Care Services (DPCS) reviewed the records and stated that the documentation for the missed visits had since been entered.”

“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, document review and interview. In 2 of 18 (11%) records reviewed that included the provision of aide services, it was revealed that the agency did not ensure written patient care instructions for a hospice aide were prepared by a registered nurse (RN). Document 6: Agency policy, PC. H25 Hospice Aide Assignments and Duties, read in part, “5. The hospice RN responsible for the supervising the hospice aide and prepares written patient care instructions that are patient specific and not generic. 6. A hospice aide provides services that are: a. Ordered by the interdisciplinary group; b. Included in the plan of care.” Clinical Record 1: The hospice election of benefit form was dated 02/08/2023. During review of the benefit period dated 11/05/2023, the hospice aide plan of care created 11/05/2023 by the registered nurse included the task assignment of mouth care and assist with dressing. The assignment did not have any instruction related to the frequency of the provision of the tasks. Clinical Record 18: The hospice election of benefit form was dated 12/13/2023. The hospice aide plan of care created 12/13/2023 by the registered nurse included the task assignment to assist with elimination. The assignment did not have any instruction related to the frequency of the provision of the task. During interview on 01/11/2024, the Director of Patient Care Services (DPCS) reviewed the associated records and confirmed that the aide assignments were incomplete and had since been corrected.”

“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, document review and interview. In 6 of 18 (33%) records reviewed that included the provision of aide services, it was revealed that the agency did not ensure that services were provided by the hospice aide as per the hospice aide plan of care. Document 6: Agency policy PC. H25 Hospice Aide Assignments and Duties read in part, “6. A hospice aide provides services that are: a. Ordered by the interdisciplinary group, b. Included in the plan of care”. Clinical Record 1: The hospice election of benefit was dated 02/08/2023. During review of the 11/05/2023 hospice episode of care, the 11/05/2023 hospice aide plan of care created by the registered nurse did not include the task assignment of peri care or assist with ambulation. The aide visit documentation dated 11/06/2023 through 01/08/2023 included completion of completing these tasks. The Registered nurse visit note documentation dated 11/06/2023 through 01/03/2023, included the completion of aide supervision at each visit with no changes needed to the aide plan of care. Clinical Record 3: The hospice election of benefit form was dated 11/17/2023. The plan of care dated 11/17/2023 included an aide visit frequency of 2 times per week. There was no documentation that aide services were provided the week of 11/17/2023 and no documented explanation of why services were not provided. Clinical Record 5: The hospice election of benefit form was dated 12/02/2023. The plan of care dated 12/02/2023 included an aide visit frequency of 2 times per week. There was no documentation that aide services were provided for the week of 12/10/2023 and no documented explanation of why services were not provided. Clinical Record 9: The hospice election of benefit form was dated 11/28/2023. The plan of care dated 11/28/2023 included an aide visit frequency of 2 times per week. There was no documentation that aide services were provided the week of 12/25/2023 and no documented explanation of why services were not provided. Clinical Record 10: The hospice election of benefit form was dated 09/11/2023. During review of the 10/28/2023 and 12/27/2023 benefit periods, the 10/28/2023 and the 12/27/2023 hospice plans of care ordered the aide visit frequency of 2 times per week. The 10/28/2023 and 12/27/2023 aide plans of care created by the registered nurse included the task assignment of shower weekly. The aide visit documentation dated 10/30/2023 through 01/04/2023 included documentation of completion of a shower with each visit instead of weekly as assigned. The Registered Nurse visit note documentation dated 11/08/2023 through 01/03/2023, included completion of aide supervision at each visit with no changes needed to the aide plan of care documented. Clinical Record 13: The hospice election of benefit form was dated 09/19/2023. During review of the benefit period dated 12/18/2023, the aide plan of care aide dated 12/18/2023 included a visit frequency of 2 times per week. There was documented evidence of one aide visit dated 01/01/2024 for the week of 01/01/2024 and no documented explanation of why services were not provided at the frequency ordered. During interview on 01/11/2024, the Director of Patient Care Services (DPCS) reviewed the records and confirmed that tasks had not been completed as assigned and missed visit entries were not documented.”