Oakland Hospice

“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, interview and observation. In 1 of 13 (8%) clinical record reviewed in which the patient received Hospice Aide services it was revealed that the agency did not ensure that the RN provided instruction regarding the patient’s wound to the Aide. Clinical Record 2: The patient elected the hospice benefit on 12/24/2022. The patient had a documented wound to the right shoulder with an onset date of 8/1/2023. The Plan of Care 8/21/2023 - 10/19/2023 included wound care orders to clean the right shoulder wound with soap and water, pat dry, then cover with dry dressing/border gauze every Tuesday and Thursday, and PRN if soiled. There was a physician order documented on 10/20/2023 with the same wound treatment but the frequency of the wound care was changed to three times weekly. There were two Hospice Aide Care Plans. One was dated 7/18/23 and the other was documented on 11/15/2023 and both included the intervention to shower the patient every visit. However, there was no direction in the care plan for how the Aide should handle the wound/dressing during the shower or what to do if it became wet or soiled. Personnel Record 1: In an interview with the Executive Director (Staff 1) on 12/14/2023, it was confirmed that the Aide Care Plan did not contain instructions for the patient’s wound care. She also agreed that since the patient was receiving a shower by the Hospice Aide, there should be instructions on what to do with the patient’s wound and dressing during the shower and if it became wet or soiled.”

“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, document review and interview. In 4 of 13 (31%) clinical records reviewed in which Hospice Aide services were accepted, it was revealed that the agency did not ensure that the Hospice Aide documented collaboration with the RN when the Hospice Aide Care Plan was not followed as written. Document 1: The agency policy Hospice Aide Documentation 11.3.1 (dated 6/2019 and reviewed 1/27/203) stated in part, “The Hospice Aide will document services rendered to the patient on the appropriate Hospice Aide Charting form as directed in the aide care plan/assignment sheet. The Hospice Aide will be responsible for reporting any changes in the patient’s condition and/or other pertinent observations to the supervising RN. The Manager of Patient Services or designated RN is responsible for reviewing the Hospice Aide’s charting. Clinical Record 8: The patient elected the hospice benefit on 8/24/2023. The Plans of Care dated 8/24/2023 - 11/21/2023 and 11/22/2023 - 2/19/2024 included orders for aide visits twice weekly. The Hospice Aide Care Plan dated 8/24/2023 included the intervention to shampoo the patient’s hair every visit. During the aide visits on 11/14/2023 and 11/25/2023, the aide documented that the patient refused to have their hair shampooed. The Aide did not document that the hospice RN or the facility staff was notified that the intervention was not completed. There was no Coordination of Care note documenting that the RN was notified and no documentation during the Interdisciplinary Group Meetings on 11/15/2023 or 11/29/2023 that the aide was unable to follow the care plan as documented. Clinical Record 10: The patient elected the hospice benefit on 9/27/2023. The Plan of Care dated 9/27/2023 - 12/25/2023 included orders for aide visits twice weekly. The Hospice Aide Care Plan dated 9/27/2023 included the intervention to shampoo the patient’s hair every visit. During the Hospice Aide visits on 10/4/2023, 10/31/2023, 11/9/2023, 11/17/2023, and 11/28/2023, the aide documented that the patient refused to have their hair shampooed. The aide did not document that the hospice RN or the facility staff was notified that the intervention was not completed. There was no Coordination of Care note documenting that the RN was notified and no documentation during the Interdisciplinary Group Meetings on 10/4/2023, 10/18/2023, 11/1/2023, 11/15/2023, or 11/29/2023 that the aide was unable to follow the Care Plan as documented. Clinical Record 12: The patient elected the hospice benefit on 10/28/2023. The Plan of Care dated 10/28/2023 - 1/25/2023 included orders for aide visits twice weekly. The Hospice Aide Care Plan dated 10/28/2023 included the intervention to shampoo the patient’s hair every visit. During the Hospice Aide visit on 11/3/2023, the Aide documented that the patient refused to have their hair shampooed. The Aide did not document that the hospice RN or the facility staff was notified that the intervention was not completed. There was no Coordination of Care note documenting that the RN was notified and no documentation during the Interdisciplinary Group Meeting on 11/1/2023 that the aide was unable to follow the Care Plan as documented. Clinical Record 13: The patient elected the hospice benefit on 1/4/2023. The Plan of Care dated 7/3/2023 - 8/31/2023 included orders for aide visits twice weekly. The Hospice Aide Care Plan dated 7/3/2023 included the intervention to shower the patient every visit. During the Hospice Aide visit on 8/7/2023, the Aide documented that the patient did not receive a shower and that the patient received a bed bath instead. The Aide did not document that the hospice RN provided that instruction to provide a bed bath instead of the regular shower intervention or that the RN was notified of the change. There was no Coordination of Care note documenting that the RN was notified and no documentation during the Interdisciplinary Group Meeting on 8/8/2023 or 8/23/2023 that the aide was unable to follow the Care Plan as documented. Personnel Record 1: On 12/14/2023, during the joint record review and interview with the Executive Director (Staff 1) and the Director of Clinical Services (Staff 2), it was confirmed that there were no notes entered by the Aide or the RN regarding communication about the change in the Hospice Aide Care Plan interventions being completed as directed.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed in which Hospice Aide services were accepted revealed that the agency did not ensure that the RN documented Hospice Aide supervision at least every 14 days. Clinical Record 7: The patient elected the hospice benefit on 9/28/2023. The Plan of Care for 9/28/2023 - 11/26/2023 included orders for twice-weekly Hospice Aide visits. The RN completed Hospice Aide Supervision during visits on 10/1/2023, 11/8/2023, 11/10/2023, 11/15/2023, and 12/1/2023. There was a 38-day gap in Aide supervision from 10/1/2023 to 11/8/2023 and a 16-day gap from 11/15/2023 to 12/1/2023. Personnel Record 1: During a joint record review and interview on 12/14/2023 with the Executive Director, it was confirmed that the hospice RN did not complete Hospice AIde Supervision every 14 days.”

“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 1 of 8 (12%) personnel records reviewed of agency staff providing care, it was revealed that the agency did not ensure that the staff member’s competency was documented during the orientation period per agency policy. Document 1: The agency policy titled, Staff Competency Program (4.28.2) (revised 5/2023), stated in part, “Patient care staff will be competency assessed ... for each new employee during orientation.” Personnel Record 8: The file for the Chaplain with the date of hire of 7/10/2023 included a form “Initial and Ongoing Competency for Chaplain/Spiritual Counselor” that was documented on 12/13/2023. The employee had not signed the form. The employee saw patients prior to a documented completed clinical competency. Personnel Record 1: An interview with the Executive Director (Staff 1) on 12/14/2023 confirmed that this was the only competency form for the Chaplain and that it was completed outside of the hospice’s policy.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which there was a live discharge from the hospice agency and the patient was admitted to a Medicare-certified facility it was revealed that the agency did not ensure that the receiving facility received a copy of the patient’s discharge summary. Document 1: The agency policy Discharge Criteria 9.28.2 (revised 2/2022 and reviewed 1/27/2023), stated in part, “A complete list of reconciled medications will be provided to each patient on discharge...Staff will be knowledgeable about discharge procedures including instructions and follow-up responsibilities.” Clinical Record 11: The patient elected the hospice benefit on 5/24/2023 and was discharged and admitted to the hospital on 7/16/2023. There was no documentation in a discharge note, discharge summary, a coordination of care note, scanned documents, or in the post-discharge Interdisciplinary Team Meeting on 7/26/2023 that the discharge summary or any clinical record documentation was sent to the hospital. Clinical Record 12: The patient elected the hospice on 10/28/2023 and was discharged and admitted to the hospital on 11/11/2023. There was no documentation in a discharge note, a discharge summary, coordination of care note, scanned documents, or in the post-discharge Interdisciplinary Team Meeting on 11/15/2023 that the discharge summary or any clinical record documentation was sent to the hospital. Personnel Record 1: During a joint record review and interview with the Executive Director on 12/14/2023, she confirmed after reviewing the clinical records and her emails that there was no documentation that any clinical record information for either patient was sent to the hospital when the patient was discharged from care.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which there was a live discharge from the Hospice, it was revealed that the agency did not ensure that the discharge summary included the required clinical information. Document 1: The agency policy Discharge Summary 9.29.1 (dated 2/2022 and reviewed 1/27/2023), stated in part that, “The Hospice Discharge Summary will include a summary of the patient’s stay including treatments, symptoms, and pain management, the patient’s current Plan of Care, the patient’s latest physician orders ... the date and reason for discharge, any instructions or referral information given to the patient or family, the patient’s identifying information, the patient’s physician, the hospice diagnosis, significant health history, discharge orders, instructions, medication profile and allergies, a brief description of services provided and ongoing needs that cannot be met, status of the patient at the time of discharge, presence of Advance Directives, End-of-Life decisions.” Clinical Record 11: The patient elected the hospice benefit on 5/24/2023 and was discharged and admitted to the hospital on 7/16/2023. The discharge summary did not include the required elements of the summary of the patient’s hospice stay, the patient’s current Plan of Care, or the current physician orders. There was no documentation of a visit made at discharge. The RN documented on 7/16/2023 a note that stated that the reason for discharge was the patient was going to be taken to the hospital. Clinical Record 12: The patient elected the hospice benefit on 10/28/2023 and was discharged and admitted to the hospital on 11/11/2023. The discharge summary did not include the required elements of the summary of the patient’s hospice stay, the patient’s current Plan of Care, or the most current physician orders. A Coordination of Care note dated 11/11/2023 documented by the RN stated, “Pt sitting in room with brother and husband. RN introduced self. Husband stated that wife needed to go to hospital due to skin tears on bilateral elbows. Husband to take pt to hospital. Family made aware that pt will be discharged from hospice care.” Personnel Record 1: A joint record review with the Executive Director (Staff 1) on 12/14/2023, confirmed that there was no other documentation in the clinical record that contained the required elements for a discharge summary, nor was there any documentation that the plan of care, medication list, or physician orders were sent to the hospital when the patient was discharged.”