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; 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 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, interview and observation. In 1 of 14 (7%) clinical records reviewed, it was revealed that the agency did not ensure that the medication profile was updated with a full review of all medications that the patient was taking. Clinical Record 9/Home Visit 2: During the observed visit on 12/18/2024, the patient complained of nausea after his nebulizer treatment. The wife gave him a sublingual Zofran (anti-nausea) during the visit. The nurse (Personnel Record 11) and wife confirmed the use of Zofran, which was in the home. The hospice drug profile did not include Zofran. The nursing assessment visit documentation on 12/18/2024 documented that Zofran was taken and a review of side effects with patient and family, this education was observed during the visit. Medication review with the caregiver was observed during this visit but the nurse doing the review was utilizing a different software than the agency software (clarification of this was an I-prescribe app that documented patient medications.) There had not been a review for potential duplication of therapy or drug interactions documented, nor was there an updated medication profile. During an interview with the wife and nurse during the visit 12/18/2024 stated that the Zofran had been ordered and in the home for several weeks but that the patient had been resistant to trying it but did take it during the visit. Review of the record with the Regional Director of Quality who stated that the medication was not on the medication profile.”

“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, interview, and observation. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure the individualized plan of care included all drugs and treatments necessary to meet the needs of the patient. Clinical Record 9/Home Visit 2: During the observed visit on 12/18/2024, the patient complained of nausea after his nebulizer treatment. The wife gave him a sublingual Zofran (anti-nausea) during the visit. The nurse (Personnel Record 2) and wife confirmed the use of Zofran, which was in the home. The plan of care did not document the Zofran. The case manager, who was present during the visit, stated that the plan of care had not been updated with the Zofran.”

“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 3 of 8 (38%) clinical records reviewed in which a hospice aide was accepted, 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 1: The aide plan of care was documented on 10/24/2024 and updated on 10/31/2024. The assigned tasks included: (but were not exclusive) - Showering every visit, Apply Barrier cream, and transferring 1:1. The barrier cream did not include the application location. On 12/03/2024 during a nursing assessment visit the transfer was changed to a Hoyer Lift and each assessment thereafter described a Hoyer Lift transfer. It was documented that an aide was present for the education, but the aide’s plan of care was not updated to include the correct transfer task. The Hospice Aide visit frequency was 2 times a week. The patient was assisted with one pivot transfer on admission but declined during the time that the care was provided. Clinical Record 3: The aide plan was documented on 07/03/2024 and updated on 08/27/2024, 11/30/2024, and 12/06/2024 with the task of weighing weekly on all aide plans. On the following dates, it was documented that the weight was “not needed” and that the case manager was notified: 07/16/20204, 07/25/2024, 08/07/2024, 08/14/2024, 08/28/2024, 09/04/2024, 09/18/2024, 09/25/2024, 10/02/2024, 10/09/2024, 10/23/2024 and11/26/2024. The frequency for the aide was one time a week. There was a weight documented 10/16/2024, 11/19/2024, and 12/05/2024. From July 2024 to present, the aide plan continued with weekly frequency for weight with no update to the plan of care. Weights remained at 119.6 to 119 during this period of two benefit periods. The nurse was notified each time for unable or weight refusal. The plan should have been updated. Clinical Record 5: The aide plan dated 09/20/2024 (with no documented updates) included assigned tasks of shower and perineal care (not exclusive to these) each visit. On the initial nursing comprehensive assessment, 09/20/2024 a wound was identified on the right pre-tibial leg, with a kerlix dressing and low compression bandage. The aide plan provided no direction for what to do if the dressing was saturated or off. Documented on the updated nursing assessment on 10/24/2024 was a new wound on the left pretibial area which ordered kerlix dressing and low compression bandage. The wound on the right leg healed 11/25/2024 and the wound on the left healed 12/13/2024. The hospice aide did document on the 10/08/2024 visit note that the dressing on the right leg was falling off and that the nurse was notified. During interview with the Regional Director of Quality on 12/19/2024, who had reviewed the records, stated that the detail was not on the aide plan.”

“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. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) Clinical Records in which a hospice aide was accepted, the agency did not ensure documentation that the hospice aide notified the nurse of a change or refusal of care. Clinical Record 5: The aide plan dated 09/20/2024 included assigned tasks of shower and perineal care (not exclusive to these) each visit, with no documented updates, as of the 12/19/2024 review. The aide frequency was one time a week until 10/062024, when the frequency increased to 3 times a week. Aide visit documented on 11/09/2024 documented patient refused perineal care and shower. These tasks were ordered every visit. The clinical record lacked documented evidence of notification to the case manager (Registered Nurse) that the care was not provided. During an interview with the Regional Quality Director, who reviewed the record, and stated that the documentation did not include notification of the case manager.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of live discharges, it was revealed that the agency did not ensure that a discharge summary was sent to the attending physician at discharge from hospice services. Clinical Record 14: The patient elected to revoke hospice services on 03/05/2024 to pursue aggressive treatment. The discharge summary was documented but there was no documentation that the discharge summary was sent to the primary physician who would be providing care for the patient. During an interview with the Regional Quality Manager, on 12/19/2024, she stated that there was no documentation that the summary had been sent to the attending physician, but a recent process had been established for this self-identified problem.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed, in which a patient was provided care at a skilled nursing facility, the agency did not ensure that all care provided documented the specific responsibilities and who would perform. Clinical Record 8: The initial comprehensive nursing assessment dated 12/04/2024, documented that a Foley catheter was in place with a last changed date of 11/30/2024. The initial plan of care was documented on 12/04/2024 with intervention for a Foley catheter but no identification of facility involvement in or delineation of responsibilities for who will change and manage the catheter. The hospice plan of care included a ‘Facility Intervention: reviewed hospice plan of care with Facility Staff’ but the hospice plan of care was not specific for who would care for the catheter or if it was jointly cared for. On 12/19/2024 the Regional Quality Director was interviewed and stated that the direction for responsibility was not documented.”

“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, interview, and observation. In 1 of 5 (20%) clinical records reviewed and home visits observed, the agency did not ensure the medication profile was updated. Clinical Record 1/Home Visit 1: The patient elected hospice care on 10/26/2023 with a diagnosis of chronic obstructive pulmonary disease (COPD). During the home visit with the Registered Nurse (RN) [Personnel Record 3] on 11/05/2024, the family provided a box of the patient’s medications. The hospice medication profile printed on 11/4/2024 documented Ativan 0.5mg eff 10/26/23 every 6 hours as needed for anxiety and oxygen 2-3L effective 10/26/2023. The medication box did not include Ativan. The patient and caregiver reported Ativan was discontinued at “least four months ago or longer.” The patient used 4 liters (L) of oxygen during this visit. The patient and caregiver reported the patient had been using 4L “since at least March per the hospice instructions.” There was no documented evidence that the hospice medication profile was updated with the changes to Ativan and oxygen. The RN [Personnel Record 3] agreed the medication profile was not updated. During an interview on 11/05/2024, the Regional Director of Quality and Compliance agreed with the findings.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed of patients who received Hospice Aide services (HA), the agency did not ensure that HA services were provided as ordered by the Interdisciplinary Group. Clinical Record 4: The plan of care dated 03/05/2024 ordered HA services effective 03/20/2024 “1wk1, 2wk12.” During week one, 03/20/2024 through 03/23/2024, there was no evidence of a HA visit and no documented reason for the missed visit. Clinical Record 5: The plan of care order dated 07/03/2024 ordered HA services effective 07/15/2024 “2wk8, 1wk.” During week eight, 09/01/2024 through 09/07/2024, there was a documented HA visit dated 09/06/2024. A clinical record review revealed no evidence of a second HA visit and no documented reason for the missed visit. During a joint record review and interview on 11/04/2024, the Quality Assurance Nurse stated, “I agree the visits aren’t there, and I don’t know why they weren’t completed as ordered.” During an interview on 11/04/2024, the Clinical Manager did not have any additional information to provide. During an interview on 11/04/2024, the Regional Director of Quality and Compliance agreed with the findings.”

“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. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA reported changes to the Registered Nurse. Clinical Record 3: The HA documented a missed visit on 05/24/2024. A clinical record review revealed no documented evidence that the HA notified the RN of changes to the care plan. Clinical Record 5: The HA visit note dated 06/11/2024 documented, “red yeast underneath breast and underarms, complains of pain in leg.” A clinical record review revealed no documented evidence that the HA notified the RN of changes in the patient’s condition. During a joint record review and interview on 11/05/2024, the Quality Assurance Nurse stated, “They should be notifying the nurse and adding it to their note but there is no evidence it was done, more education is needed.” During an interview on 11/05/2024, the Clinical Manager did not have any additional information to provide. During an interview on 11/05/2024, the Regional Director of Quality and Compliance agreed with the findings.”

“It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. The hospice administrator: Is an employee of the organization; Informs the governing body about ongoing operations, including patient care delivery issues and QAPI activities; Has the education and experience as required by the governing body. If the administrator is not available, another individual is assigned the administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by document review and interview. The agency did not ensure that a qualified Administrator was appointed by the governing body and was responsible for the day-to-day hospice operations. A review of the governing body documents revealed no evidence that an Administrator was appointed between 07/18/2024 through 08/26/2024. During an interview on 11/05/2024, the Regional Director of Quality and Compliance (RDQC) stated that they did not have an appointed Administrator for this office between 07/18/2024 and 08/26/2024. The Regional Director of Quality and Compliance stated that they shared the Administrator responsibilities and duties with another leader with administrator experience between 07/18/2024 and 08/26/2024. The RDQC agreed there was no official appointment of an Administrator by the governing body during that period.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. Agency policy “Discharge Process and Documentation Policy” stated in part, “Prior to discharging a patient, the hospice shall obtain a written physician’s discharge order from the Hospice Physician. In 1 of 3 (33%) clinical records reviewed of patients discharged for no longer being terminally ill, the agency did not ensure that a physician’s discharge order was obtained before discharging the patient. Clinical Record 3: The discharge summary revealed the patient was discharged on 09/16/2024, no longer terminally ill. There was no documented evidence of a physician’s order to discharge the patient. During a joint record review and interview on 11/05/2024, the Quality Assurance Nurse stated, “There is no discharge order documented for this patient.” During an interview on 11/05/2024, the Clinical Manager did not have any additional information to provide. During an interview on 11/05/2024, the Regional Director of Quality and Compliance agreed with the findings.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary; The patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy, “Discharge Process and Documentation Policy,” stated in part, “Discharge summary will be sent to the attending physician.” In 3 of 3 (100%) clinical records reviewed of patients discharged for no longer being terminally ill, the agency did not ensure that the discharge summary was forwarded to the patient’s attending physician. Clinical Record 3: The discharge summary revealed the patient was discharged on 09/16/2024, no longer terminally ill. There was no documented evidence that the discharge summary was sent to the attending physician. Clinical Record 4: The discharge summary revealed the patient was discharged on 06/14/2024, no longer terminally ill. There was no documented evidence that the discharge summary was sent to the attending physician. Clinical Record 5: The discharge summary revealed the patient was discharged on 09/09/2024, no longer terminally ill. There was no documented evidence that the discharge summary was sent to the attending physician. During a joint record review and interview on 11/05/2024, the Quality Assurance Nurse stated, “They should be sending the discharge summary to the attending physician, but there is no evidence it was done.” During an interview on 11/05/2024, the Clinical Manager did not have any additional information to provide. During an interview on 11/05/2024, the Regional Director of Quality and Compliance agreed with the findings.”