Crossbridge Hospice

“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 [and]; 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; [and] 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, interview, and observation. Agency policy “Medication Administration” (revised 7/16) ) stated in part, “The agency will maintain the current medication list and administration record...The ongoing monitoring occurs to evaluate the continued use of medication in its current regimen.” In 4 of 4 (100%) home visits observed, the hospice agency did not ensure the comprehensive assessment included a drug profile that contained the patient’s current medication regimen. Home Visit 1/Clinical Record 1: The patient elected hospice care on 5/18/2023 and resided in a skilled nursing facility (SNF). A medication reconciliation was performed during the home visit on 11/7/2023, comparing the agency’s medication profile dated 11/7/2023 to the patient’s SNF medication list. The agency’s medication profile documented, “Lorazepam 0.5 mg tablet, take one (1) tablet every four (4) hours as needed (PRN) for anxiety. The SNF medication list did not contain Lorazepam medication. The agency’s medication profile documented, “Tramadol 50 mg tablet, take one (1) tablet every six (6) hours for analgesia.” The SNF medication list documented,” Tramadol 50 mg tablet, take one half (1/2) tablet every six (6) hours for analgesia.” The SNF medication list documented, “Acetaminophen oral tablet three-325 mg, take two (2) tablets by mouth every six (6) hours as needed (PRN) for pain.” The agency’s medication profile did not document Acetaminophen. There was no evidence that Acetaminophen was reviewed as part of the patient’s medication regimen. Home Visit 2/Clinical Record 2: The patient elected hospice care on 9/27/202. A medication reconciliation was performed during the home visit on 11/7/2023, comparing the agency’s medication profile dated 11/7/2023 to the patient’s current medication regimen. The agency’s medication profile dated 11/7/2023 documented, “Losartan 100 mg, take one (1) tablet daily.” The patient and the caregiver reported the patient did not take the medication Losartan. The caregiver stated, “He stopped that a while ago, but he used to take the Losartan.” The caregiver confirmed the patient took one (1) multivitamin daily. The hospice agency medication profile did not document the multivitamin. There was no evidence the multivitamin was reviewed as part of the patient’s medication regimen. Home Visit 3/Clinical Record 4: The patient elected hospice care on 10/6/2023. A medication reconciliation was performed during the home visit on 11/7/2023, comparing the agency’s medication profile dated 11/7/2023 to the patient’s current medication regimen. The caregiver stated and confirmed the patient took Metoprolol 100 mg tablet, take one (1) tablet per day, and Metoprolol 25 mg tablet, take one (1) per day. The caregiver confirmed the patient took 125 mg of Metoprolol per day. The agency’s medication profile dated 11/7/2023 documented, “Metoprolol 25 mg, take one (1) tablet per day.” The agency’s medication profile did not include documentation of Metoprolol 100 mg. Home Visit 4/Clinical Record 3: The patient elected hospice care on 6/8/2023 and resided in a group home. A medication reconciliation was performed during the home visit on 11/7/2023, comparing the agency’s medication profile dated 11/7/2023 to the patient’s current medication regimen. The caregiver stated the patient takes Midodrine 2.5 mg, take one (1) tablet two (2) times daily, and a multivitamin five 500 mg, take one (1) tablet daily. The agency’s medication profile did not include documentation of the Midodrine and the Multivitamin. During a joint record review and interview on 11/7/2023, the Hospice Quality Assurance Nurse present for the visits confirmed that the agency’s medication profiles did not contain the current medications.”

“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. 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, interview, and observation. Agency policy “Interdisciplinary Group Plan of Care” (revised 7/16) stated in part, “Any significant change in the patient’s condition must result in a change in the plan of care.” In 2 of 19 (10%) clinical records reviewed, the agency did not ensure the plan of care contained goals and interventions based on the problems identified in the updated comprehensive assessment. Clinical Record 3: The patient elected hospice care on 6/8/2023 with the diagnosis of Protein Calorie Malnutrition. At admission, the patient had a percutaneous endoscopic gastrostomy (PEG) tube. The comprehensive assessment completed by the Registered Nurse (RN) on 8/11/2023 documented, “the hospice RN removed the PEG tube per hospice physician ok.” The plan of care dated 11/6/2023 documented goals and interventions for the PEG tube, “need for skilled teaching related to tube feeding (gastrostomy tube) with multiple interventions. SN (skilled nursing) instructed regarding placement of the tube. SN instructed regarding the preparation of tube feedings. SN instructed regarding the care of the gastrostomy site.” The plan of care was not updated to remove goals and interventions pertaining to the PEG tube. During a joint record review and interview on 11/6/2023, the Hospice Quality Manager confirmed the plan of care was inaccurate, as the PEG tube was no longer in place as of 8/11/2023. Clinical Record 7: The patient elected hospice care on 8/31/2023 with the diagnosis of Amyotrophic Lateral Sclerosis. The Certificate of Terminal Illness (CTI) documented in part, “vital capacity dropping from 90% to 29% supplemental oxygen needs increased while patient is on bi-pap during day.” The comprehensive assessment completed by the skilled nurse on 8/31/2023 identified the patient’s use of the bilevel positive airway pressure (Bi-PAP). The plan of care dated 8/31/2023 through 11/7/2023 did not document goals and interventions for the Bi-PAP machine. During a joint record review and interview on 11/8/2023, the Hospice Quality Assurance Nurse confirmed that the patient’s plan of care did not reference the Bi-PAP machine.”

“It is required that each patient’s individualized written plan of care includes all drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy “Interdisciplinary Group Plan of Care” (revised 7/16) stated in part, “The Plan of care will contain the following but is not limited to (J) drugs and treatments necessary to meet the needs of the patient.” In 4 of 14 (29%) home visits observed and clinical records reviewed, the hospice did not ensure the written plan of care contained all drugs necessary to meet the needs of the patient. Home Visit 1/Clinical Record 1: The patient elected hospice care on 5/18/2023 and resided in a skilled nursing facility (SNF). A medication reconciliation was performed during the home visit on 11/7/2023, comparing the agency’s medication profile dated 11/7/2023 to the patient’s SNF medication list. The SNF medication list documented, “Acetaminophen oral tablet three-325 mg, take two (2) tablets by mouth every six (6) hours as needed (PRN) for pain.” The agency’s medication profile did not document Acetaminophen. The hospice plan of care dated 5/18/2023 through 11/7/2023 did not include documentation of Acetaminophen. Home Visit 2/Clinical Record 2: The patient elected hospice care on 9/27/202. A medication reconciliation was performed during the home visit on 11/7/2023, comparing the agency’s medication profile dated 11/7/2023 to the patient’s current medication regimen. The caregiver reported the patient took one (1) multivitamin daily. The agency’s medication profile did not document the multivitamin. The hospice plan of care dated 9/27/2023 through 11/7/2023 did not include documentation of the multivitamin. Home Visit 3/Clinical Record 4: The patient elected hospice care on 10/6/2023. A medication reconciliation was performed during the home visit on 11/7/2023, comparing the agency’s medication profile dated 11/7/2023 to the patient’s current medication regimen. The caregiver stated and confirmed the patient takes Metoprolol 100 mg, take one (1) tablet per day, and Metoprolol 25 mg, take one (1) per day. The caregiver confirmed the patient takes 125 mg of Metoprolol per day. The agency’s medication profile dated 11/7/2023 documented the medication Metoprolol 25 mg, take one (1) tablet per day. The agency’s medication profile did not document Metoprolol one-hundred (100) milligrams (mg). The hospice plan of care dated 10/6/2023 did not include documentation of Metoprolol 100 mg. Home Visit 4/Clinical Record 3: The patient elected hospice care on 6/8/2023 and resided in a group home. A medication reconciliation was performed during the home visit on 11/7/2023, comparing the agency’s medication profile dated 11/7/2023 to the patient’s current medication regimen. The caregiver stated the patient takes Midodrine 2.5 mg, take one (1) tablet two (2) times daily, and a multivitamin five 500 mg, take one (1) tablet daily. The agency’s medication profile did not include documentation of the Midodrine and the Multivitamin. The hospice agency plan of care dated 6/8/2023 through 11/7/2023 did not include documentation of the Midodrine and the Multivitamin. During a joint record review and interview on 11/7/2023, the Hospice Quality Assurance Nurse confirmed that the plans of care did not contain all of the medications needed by the 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: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Interdisciplinary Group Plan of Care” (revised 7/16) sub-section eight (8) stated in part, “The Plan of care will contain the following but is not limited to (K) Medical Supplies and appliances necessary to meet the needs of the patient.” In 1 of 19 (5%) clinical records reviewed, the hospice agency did not ensure the written plan of care contained all medical appliances necessary to meet the needs of the patient. Clinical Record 7: The patient elected hospice care on 8/31/2023 with the diagnosis of Amyotrophic Lateral Sclerosis. The Certificate of Terminal Illness (CTI) documented in part, “vital capacity dropping from 90% to 29% supplemental oxygen needs increased while patient is on bi-pap during day.” The plan of care dated 8/31/2023 through 11/7/2023 did not document the bilevel positive airway pressure (Bi-PAP) with the patient’s medical appliances and supplies. During a joint record review and interview on 11/8/2023, the Hospice Quality Assurance Nurse confirmed that the patient’s plan of care did not reference the Bi-PAP machine.”

“It is required that spiritual counseling to meet the spiritual needs of the patient is provided in a manner consistent with the patient’s and family’s beliefs and desires. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Interdisciplinary Group Plan of Care” (revised 7/16) sub-section policy stated in part, “A comprehensive patient Interdisciplinary Plan of Care will be established and maintained for each individual admitted to the hospice program, and the care provided to the individual must be in accordance with the plan.” In 1 of 14 (7%) clinical records reviewed of patients accepting spiritual counseling, the hospice agency did not ensure spiritual counseling was provided to meet the patient’s needs. Clinical Record 4: The patient elected hospice care on 10/6/2023. The plan of care dated 10/6/2023 through 1/3/2024, for the patient who accepted spiritual counseling ordered Chaplain services effective 10/11/2023 four (4) times monthly. The patient received two (2) Chaplain visits in October. The Chaplain visits completed were 10/9/2023 and 10/23/2023. A clinical record review revealed no documented missed visits or documented communication with the physician to change the Chaplain’s visit frequency. During a joint record review and an interview on 11/6/2023, the Hospice Quality Assurance Nurse confirmed that the Chaplain services were not provided as ordered per the care plan. In addition, the interview confirmed the clinical record did not contain evidence or documentation for the missed Chaplain visits.”

“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 1 of 16 (6%) clinical records reviewed of patients that received hospice aide services, the hospice agency did not ensure the hospice aide provided services ordered by the Interdisciplinary Group (IDG). Clinical Record 10: The patient elected hospice care on 2/1/2022. The plan of care dated 7/26/2023 through 9/23/2023 ordered hospice aide services three (3) times weekly. The week of 9/3/2023 through 9/9/2023 the patient did not receive hospice aide services. A review of the clinical record revealed a missed visit note entered by the hospice aide on 9/5/2023 which documented, “caregiver provided care. Office Manager (office manager name) notified of missed visit.” There was no evidence of documented missed visits for the two (2) other missed visits and no evidence of an ordered change in the frequency of hospice aide services. During a joint record review and an interview on 11/8/2023, the Hospice Quality Assurance Nurse confirmed the missed visit documentation notes should have been completed for each missed visit.”

“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. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical records reviewed of patients that received hospice aide services, the agency did not ensure the hospice aide reported changes in the patient’s needs to the Registered Nurse. Clinical Record 1: The patient elected hospice care on 5/18/2023. The plan of care dated 5/18/2023 ordered hospice aide services two (2) times a week. The week of 5/28/2023 through 6/3/2023, the patient did not receive hospice aide services. The hospice aide documented a missed visit on 6/1/2023, which stated in part, “Holiday office manager (office manager name) notified.” The week of 6/18/2023 through 6/24/2023, the hospice aide documented a missed visit, stating in part, “Office manager (office manager name) notified.” There was no evidence the Registered Nurse was notified of the missed visits and changes to the plan of care. Clinical Record 10: The patient elected hospice care on 2/1/2022. The plan of care dated 7/26/2023 through 9/23/2023 ordered hospice aide services three (3) times weekly. The week of 9/3/2023 through 9/9/2023, the patient did not receive hospice aide services. A clinical record review revealed a missed visit note entered by the hospice aide on 9/5/2023, which documented, “caregiver provided care. Office Manager (office manager name) notified of missed visit.” There was no evidence the Registered Nurse was notified of the missed visits and changes to the plan of care. During a joint record review and an interview on 11/8/2023, the Hospice Quality Assurance Nurse confirmed that the hospice aide notified the Office Manager about the missed visits, who is not a nurse and did not notify the Registered Nurse about the missed visits.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Interdisciplinary Group Plan of Care” (revised 7/16) sub-section eight (8) stated in part, “The Plan of Care will contain the following, but not be limited to (B) Physician Orders.” In 1 of 19 (5%) clinical records reviewed, the hospice agency did not ensure the clinical record contained physician orders for care and services provided. Clinical Record 3: The patient elected hospice care on 6/8/2023 with the diagnosis of Protein Calorie Malnutrition. At admission, the patient had a percutaneous endoscopic gastrostomy (PEG) tube. The comprehensive assessment completed by the Registered Nurse (RN) on 8/11/2023 documented, “the hospice RN removed the PEG tube per hospice physician ok. The patient tolerated well.” A clinical record review revealed no physician’s order to remove the PEG tube. During a joint record review and interview on 11/6/2023, the Hospice Quality Assurance Nurse confirmed the clinical record did not contain a signed physician order to remove the PEG tube on 8/11/2023. The Hospice Quality Assurance Nurse stated, “If the nurse removed the PEG tube, there should be an order for that.” No further documentation was provided as of the exit conference on 11/09/2023.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: hospice election form and any advance directives. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 2 (50%) clinical records reviewed of patients residing in a skilled nursing facility (SNF), the hospice agency did not ensure the designated IDG member provided the SNF with the patient’s hospice benefit election form. Home Visit 1/Clinical Record 1: The patient elected hospice care on 5/18/2023, residing in a SNF. During the home visit on 11/7/2023, a joint review of the patient’s SNF medical record and the Hospice Binder with the Hospice Quality Assurance Nurse [Personnel Record 1] revealed no copy of the patient’s Hospice Notice of Election Benefit form. The Hospice Quality Assurance Nurse spoke with the Skilled Nursing Facility medical records department, who confirmed the SNF did not have a copy of the patient’s Hospice Benefit Election form. During an interview on 11/7/2023, the Hospice Quality Assurance Nurse confirmed the Skilled Nursing Facility did not have a copy of the Hospice Benefit Election form.”