Amber Hospice Care, LLC

“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 effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, 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 and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that all of the patient’s current medications were included in the drug profile. Document 1: Agency Policy 11.10.1 titled Medication Profile, dated 6/2019, read in part, “The initial assessment performed by the RN includes a review of all medications that the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicative drug therapy and noncompliance with drug therapy. The RN checks all medications a patient may be taking and documents on the medication profile. The nurse will add all new/changed medication(s) to the medication profile”. Clinical Record 3: The physician’s order dated 06/18/2024 read in part “Oxygen at 2-4 liters via nasal cannula for dyspnea”. The drug profile dated 06/18/2024 did not include oxygen. In an interview on 08/14/2024, the Director of Nursing reviewed the record and stated, “There is not oxygen listed on this patient’s drug profile”.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals; 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 procedure. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that all problems identified in the initial and updated comprehensive assessments had planned interventions in the patient’s plan of care. Clinical Record 2: The record revealed an initial nursing assessment dated 10/05/2023 that read in part, “Patient is a Type 2 diabetic.” The plan of care dated 10/05/2023-01/02/2024 lacked interventions related to diabetes. In an interview on 08/13/2024, the Director of Nursing reviewed the record and stated, “There are no interventions on the plan of care for diabetes”.”

“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 13 (23%) clinical records reviewed of patients that received aide services, it was revealed that the agency did not ensure that all patient care instructions were included in the aide care plan. Clinical Record 5: The record revealed a physician’s order dated 05/28/2024 that included wound care with wound dressings to wounds on the left scapula, right lower back and left foot. The aide care plan dated 05/28/2024 lacked instructions related to the wound dressings. Clinical Record 9: The record revealed an initial nursing assessment dated 06/15/2024 that read in part “Patient has skin tears to the right shin and left upper arm with wound dressings that are intact”. The aide care plan dated 06/15/2024 lacked instructions related to the wound dressings. Clinical Record 15: The record revealed an initial nursing assessment dated 05/07/2024 that read in part “Patient has a foley catheter that is draining dark yellow urine”. The aide care plan dated 05/07/2024 lacked instructions for catheter care. In an interview on 08/14/2024, the Director of Nursing reviewed the records and stated, “There are no instructions about the wound dressings or catheter care in the aide care plans”.”

“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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 7 of 14 (50%) clinical records reviewed of patients that received aide services it was revealed that the agency did not ensure that aide supervisory visits were completed no less frequently than every 14 days. Clinical Record 1: The patient elected the hospice benefit on 09/07/2023. The physician’s order dated 09/07/2023 read in part, “Aide services 2 times per week.” The first aide supervisory visit was dated 09/19/2023 and the next supervisory visit was dated 10/05/2023, a total of 16 days and 2 days outstanding. Another supervisory visit was documented by the RN on 11/13/2023 and the next supervisory visit was dated 12/04/2023, a total of 21 days and 7 days outstanding. The RN completed a supervisory visit on 01/01/2024 and the next supervisory visit dated 01/19/2024, a total of 18 days and 4 days outstanding. The RN completed a supervisory visit on 01/29/2024 and the next supervisory visit dated 02/16/2024, a total of 18 days and 4 days outstanding. The next supervisory visit was dated 03/11/2024, a total of 24 days and 10 days outstanding. The RN completed a supervisory visit on 05/09/2024 and the next supervisory visit dated 05/31/2024, a total of 22 days and 8 days outstanding. The RN completed a supervisory visit on 07/02/2024 and the next supervisory dated 07/30/2024, a total of 28 days and 14 days outstanding. Clinical Record 2: The patient elected the hospice benefit on 10/05/2023. The physician’s order dated 10/05/2023 read in part, “Aide services 2 times per week.” The RN completed a supervisory visit on 12/11/2023 and the next supervisory visit was dated 01/01/2024, a total of 21 days and 7 days outstanding. The next supervisory visit was completed on 01/19/2024, a total of 18 days and 4 days outstanding. The RN completed a supervisory visit on 01/29/2024 and the next supervisory visit dated 02/16/2024, a total of 18 days and 4 days outstanding. The RN completed a supervisory visit on 07/02/2024 and the next supervisory visit dated 07/30/2024, a total of 28 days and 14 days outstanding. Clinical Record 4: The patient elected the hospice benefit on 11/09/2023. The physician’s order dated 11/09/2023 read in part, “Aide services 2 times per week.” The RN completed a supervisory visit on 01/16/2024 and the next supervisory visit was dated 02/06/2024, a total of 21 days and 7 days outstanding. The RN completed a supervisory visit on 03/19/2024 and the next supervisory visit was dated 04/12/2024, a total of 24 days and 10 days outstanding. The next supervisory visit was completed on 05/09/2024, a total of 27 days and 13 days outstanding. The RN completed a supervisory visit on 06/06/2024 and the next supervisory visit dated 07/05/2024, a total of 29 days and 15 days outstanding. Clinical Record 7: The patient elected the hospice benefit on 06/12/2024. The physician’s order dated 06/12/2024 that read in part, “Aide services 2 times per week.” The RN completed a supervisory visit on 07/08/2024 and the next supervisory visit was dated 07/24/2024, a total of 16 days and 2 days outstanding. Clinical Record 9: The patient elected the hospice benefit on 06/15/2024. The physician’s order dated 06/15/2024 read in part, “Aide services 2 times per week.” The RN completed a supervisory visit on 06/25/2024 and the next supervisory visit was dated 07/12/2024, a total of 17 days and 3 days outstanding. Clinical Record 10: The patient elected the hospice benefit on 01/17/2024. The physician’s order dated 01/17/2024 read in part, “Aide services 2 times per week.” The RN completed a supervisory visit on 01/31/2024 and the next supervisory visit was dated 02/23/2024, a total of 23 days and 9 days outstanding. The RN completed a supervisory visit on 03/15/2024 and the next supervisory visit was dated 04/19/2024, a total of 35 days and 21 days outstanding. Clinical Record 12: The patient elected the hospice benefit on 09/08/2023. The physician’s order dated 09/08/2023 read in part, “Aide services 3 times per week.” The RN completed a supervisory visit on 12/26/2023 and the next supervisory visit was dated 01/12/2024, a total of 17 days and 3 days outstanding. On 08/14/2024, the Director of Nursing reviewed the records and confirmed the evidence and stated, “We recently identified that we were having an issue with supervisory visits falling off the EMR’s (electronic medical record) schedule”.”

“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. In 3 of 14 (21%) clinical records reviewed it was revealed that the agency did not ensure that all physician’s orders were included in the patient’s clinical record. Clinical Record 4: The record revealed a physician’s order dated 07/06/2024 that read in part, “Wound care to bilateral leg wounds 3 times a week”. The physician’s order lacked documentation of what specific wound care to perform. Clinical Record 12: The record revealed a physician’s order dated 09/08/2023 that read in part, “Foley catheter to gravity drainage as needed for urinary retention. Change catheter monthly”. The physician’s order lacked the size of the foley catheter to use. Clinical Record 15: The record revealed an initial nursing assessment dated 05/07/2024 that read in part “Patient has a foley catheter that is draining dark yellow urine. Foley irrigated with normal saline.”. The record lacked physician’s orders for the foley catheter and irrigation of the foley catheter. In an interview on 08/14/2024, the Director of Nursing reviewed the records and stated, “There are no orders in these patient’s chart for the type of wound care that was to be performed or the size of the foley catheter”.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: The most recent hospice plan of care, hospice election form and any advance directives, physician certification and recertification of the terminal illness, names and contact information for hospice staff involved in the patient’s care, instructions on how to access the hospice’s 24-hour on-call system, hospice medication information and hospice physician and attending physician (if any) orders. This standard was not met as evidenced by interview and observation. In 2 of 4 (50%) home visit observations conducted at a residential facility it was revealed that the agency did not ensure that the most recent plan of care was provided for each patient. Home Visit 1: The agency’s hospice binder located at the nurse’s station at the skilled nursing facility was reviewed with Personnel Record 1 during the home visit on 08/13/2024. The agency’s hospice binder lacked documentation of any hospice plan of care from the agency. The patient elected hospice 09/07/2023 and had a terminal diagnosis of Parkinson’s Disease. The services provided included skilled nursing, Aide, and Social Work. Home Visit 2: The agency’s hospice binder located at the nurse’s station at the skilled nursing facility was reviewed with Personnel Record 1 during the home visit on 08/13/2024. The agency’s binder lacked documentation of any hospice plan of care from the agency. The patient elected hospice 10/05/2023 and had a terminal diagnosis of Senile Degeneration of the Brain. The services provided included skilled nursing, Aide, Social Work, and Chaplain. The patient was receiving wound care. In an interview on 08/13/2024, the Administrator was informed of the above findings and stated, “We have only provided the plan of care when a skilled nursing facility requests it.””

“Based on record review and interview, the agency failed to provide ongoing assessment of the patient to ensure effective pain and symptom management in 1 (P-1) of 10 records reviewed, resulting in poor patient outcomes. Findings include: P-1: This 89-year-old patient was admitted to this agency on 12/15/23 with the terminal diagnoses of Alzheimer’s Disease, dementia, and hypotension (low blood pressure). During record review on 3/14/24, it was noted on a communication note by the registered nurse (Staff E) on 2/14/24 that he was informed by staff at the assisted living facility (ALF) that the patient fell and was “lowered to the ground” by staff and was experiencing left leg pain. On 2/15/24, it was noted Staff E had another telephone call with staff at the facility at 1:30 PM. This note reported X-rays would be ordered due to complaints of pain, and pain control measures would be continued. On 2/16/24 at 9:30 PM, Staff E documented he had contact with staff at the facility at 9:00 AM who reported the X-rays had not been taken. Staff E reported the X-rays would be ordered again. This was also done via telephone call. This note further explained that results were received at 9:40 PM indicating the patient had a broken hip. Upon further review of the record, it was determined there were no physical visits made to the patient by the agency after her fall to assess her current condition after a change in status. All 3 communication notes by the registered nurse (Staff E) were done by telephone. The Alternate Administrator (Staff A) was interviewed on 3/14/24 at 2:35 PM. During the interview, Staff A was asked what type of event an in-person visit would be expected for. Staff A stated they are “;supposed to” physically assess the patient after a significant change in a condition or “;something that was reported by the family or staff,” like a fall. The Medical Director (Staff D) was interviewed on 3/14/24 at 3:00 PM and agreed a fall would indicate a need for an in-person visit within 24 hours to assess the patient’s needs and comfort. Staff E was interviewed on 3/14/24 at 3:25 PM regarding why he did not make an in-person visit to see the patient. Staff E reported he had good communication with staff at the facility who reported the patient was comfortable. He felt that was sufficient at the time, however Staff E admitted he should have made an in-person visit to within 24 hours of the fall to provide an assessment of her condition. As a result, the patient did not receive on-going assessment by the agency to ensure effective pain and symptom management. The patient’s son was interviewed by telephone on 3/13/24 at 2:15 PM. He reported as a result, P-1 was sent to the hospital on 2/17/24 for evaluation, revoked her hospice benefit, and hospitalized for 3 days. P-1 passed away on 3/1/24. Findings were again reviewed with and acknowledged by the Alternate Administrator (Staff A) and Administrator (Staff B) during the exit interview on 3/14/24 4:00 PM.”