Lake Valley Hospice LLC

“It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) records reviewed it was revealed that the agency did not ensure the written plan of care included specific interventions based on the problems identified in the comprehensive assessments. Clinical Record 1: The Election of hospice benefit form was dated 8/22/23. A nursing comprehensive assessment dated 10/6/23 documented, “The patient’s care planning process have included nutrition/intake concerns, respiratory issues, psychosocial issues.” Furthermore, the nutrition section of the assessment documented “Nutritional assessment score is 2 (0-7 is malnourished), severe decrease in food intake over the past three months possibly due to issues such as loss of appetite, digestive problems, chewing difficulties, or swallowing problems.” It was also documented the patient had a pain level of 2 out of 10. The hospice plan of care, effective 10/6/23 to current, did not include problems, goals, or interventions related to nutritional needs or pain management. Clinical Record 2: The initial nursing assessment dated, 10/25/23 documented “Patient has had multiple falls in the last six months.” Further documentation noted, “Patient was falling 1-2 times a month and in the previous 5 months he fell 6 times, 3 with injury.” Plan of care, effective 10/25/23 to current, did not contain any problems, goals, or interventions related to fall precautions or safety. Personnel Record 5: On 12/6/23 a joint record review and interview was conducted with the clinical manager who agreed that the plans of care did not include specific interventions to meet the patient’s needs.”

“It is required that the bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) records reviewed, in which bereavement services were accepted, it was revealed that the agency did not ensure services listed on the plan of care were provided as ordered. Clinical Record 9: Per the bereavement plan of care, the date of death was 8/19/23 and included orders that the bereaved member was to receive a 2-month phone call. The clinical record did not contain evidence that the phone call was completed or attempted, nor did the record contain evidence that the bereaved had declined phone contact. Clinical Record 10: Per the bereavement plan of care, the date of death was 9/7/23 and included orders that the bereaved member was to receive a 2-month phone call. The clinical record did not contain evidence that the phone call was completed or attempted, nor did the record contain evidence that the bereaved had declined phone contact. Personnel Record 5: The clinical manager and administrator both confirmed, during the interview conducted on 12/8/23, that the above records did not contain evidence that the phone call had been conducted nor were they able to provide documentation to support why the plan of care was not followed.”

“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 2 of 12 (17%) records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure the RN provided specific instructions for the hospice aides to follow. Clinical Record 1: The documentation included a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The hospice aide care plan, effective 8/22/23 to current, included the relevant task of “provide sponge bath and personal care at sink.” The initial nursing assessment (8/22//23) documented “mobility status: fully limited and confined to bed/chair.” The care plan did not provide the aide with instructions specific to transporting the patient to the bathroom via wheelchair. The aide care plan did not state that the patient was able to make decisions. Clinical Record 5: Clinical record documentation included a terminal diagnosis of vascular dementia; thus the patient was not able to make decisions. The hospice aide care plan, effective 11/26/23, ordered visits three (3) times per week and listed the relevant tasks, “Assist with feeding and drinking, if necessary, including setting up their meal tray, feeding them, or assisting with feeding devices. “A nursing visit on 11/13/23 documented the patient “was changed to a mechanical soft diet with nectar-thickened fluids.” The aide’s care plan did not alert the aide that the patient required dietary modifications. Personnel Record 5: On 12/6/23 the clinical manager reported during the joint clinical record reviews that neither of these care plans were specific enough and stated, “I understand that those items should have been clear, they are fixed now.””

“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 1 of 12 (8%) records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure the hospice aide visits were completed per orders. Clinical Record 1: Physician order effective for the week beginning 10/8/23 increased hospice aide visit frequency to two visits per week. For the week of 10/8/23, there was one documented visit on 10/13/23. The record did not contain any documentation to support the missed visit. Personnel Record 5: On 12/6/23 a joint record review was conducted with the clinical manager who confirmed that there “should have been 2 visits made that week” and reported there was no further documentation to support why the order was not followed.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) records reviewed it was revealed that the agency did not ensure the clinical record contained a copy of the initial certification of terminal illness signed by both the attending physician and hospice physician. Clinical Record 6: The initial certification of terminal illness (CTI), for the benefit period 11/8/23-2/5/23, listed the hospice medical director and an attending physician who was a medical doctor. The CTI was signed by the hospice medical director on 11/9/23. A nurse practitioner signed for the attending physician on 11/24/23. Clinical Record 14: The initial CTI, for the benefit period 11/22/23-2/19/23, listed the hospice medical director and a nurse practitioner as the attending physician. The hospice medical director and the nurse practitioner both signed and dated the CTI on 11/24/23. Personnel Record 5: During an interview, conducted on 12/8/23, the clinical manager and administrator reported that in this state the nurse practitioners can work independently, and they thought this allowed them to sign the CTI’s.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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 1 of 14 (7%) records reviewed it was revealed that the agency did not ensure that the clinical records contained physician orders for all services provided specifically wound care. Clinical Record 11: The initial nursing assessment, dated 9/29/23, documented, “Wound 1: Wound care cleanse with normal saline pat dry, apply betadine, and leave OTA (open to air). Facility staff to complete daily.” and “Wound 2: Cleanse with normal saline, pat dry, apply dime size amount Medihoney to wound bed and cover with border foam dressing.” The Plan of Care, effective 9/29/23 to date of death 10/17/23, documented an intervention of “wound care per orders.” The clinical record did not contain any physician order for wound care. Personnel Record 5: During an interview with the clinical manager on 12/7/23 it was stated, “At the time we thought putting the wound care in the assessment generated an order we have since changed the process to ensure we write the full wound care order under the plan of care as an intervention.””

“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 described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) record reviewed, in which a patient was discharged to the hospital it was revealed that the agency did not ensure that the discharge summary was provided to the receiving facility. Clinical Record 6: The patient elected the hospice benefit on 11/8/23 and was discharged on 11/26/23. The coordination of care note dated 11/26/23 documented, “Writer received call from ED (emergency department) doctor at 10:13 am and spent approx. 10 minutes updating them on the patient’s condition and history. Writer updated the MD on medication administration history from the previous 24 hours and the scheduled medications the patient was taking. Writer further updated the MD on the medication dosage history, to help them understand the patient’s responses to opioids and the gastric complication she had experienced.” The record did not contain evidence that the discharge summary had been generated and sent to the hospital. Personnel Record 5: During an interview, on 12/8/23, the clinical manager confirmed that the “verbal report was the only thing that was provided to the hospital” and acknowledged that the verbal information provided did not include all the required elements of the discharge summary.”

“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/IDF 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, document review and interview. In 14 of 14 (100%) records reviewed of patients who resided in a SNF/NF, it was revealed that the agency did not ensure the plans of care delineated the responsibility for the care and services provided. From licensure to date, all patients served by the agency resided in a SNF. The clinical manager confirmed that the agency had a contract addendum that delineated responsibility, but that this information was not incorporated into the individual patient plans of care. This impacted all records reviewed, and all patients served by the agency. Document 1: Skilled facility contracts contained an addendum titled, “delineation of responsibility of services provided to hospice patients within the skilled nursing facility.” The document contained areas that checked which party was responsible for the following items: Room and board, medications, oxygen, Durable Medical Equipment (DME), Physical/occupational/speech/dietary therapies, laboratory or imagining, ambulance/transportation, medical supplies, air mattress, tube feeding formula/supplies, special duty nursing, suction supplies/equipment, telephone, personal care supplies, food/snacks/special diet, television/internet, laundry services, linen services, and incontinence supplies. Clinical Record 1: The election of hospice benefit was dated 8/22/23. The patient resided in a SNF (skilled nursing facility). Clinical Record 2: The election of hospice benefit was dated 10/25/23. The patient resided in a SNF. Clinical Record 3: The election of hospice benefit was dated 10/27/23. The patient resided in a SNF. Clinical Record 4: The election of hospice benefit was dated 11/3/23. The patient resided in a SNF. Clinical Record 5: The election of hospice benefit was dated 11/11/23. The patient resided in a SNF. Clinical Record 6: The election of hospice benefit was dated 11/8/23, and 11/30/23. The patient resided in a SNF for both election periods. Clinical Record 7: The election of hospice benefit was dated 11/30/23. The patient resided in a SNF. Clinical Record 8: The election of hospice benefit was dated 12/4/23. The patient resided in a SNF. Clinical Record 9: The election of hospice benefit was dated 8/7/23. The patient resided in a SNF. Clinical Record 10: The election of hospice benefit was dated 8/26/23. The patient resided in a SNF. Clinical Record 11: The election of hospice benefit was dated 9/29/23. The patient resided in a SNF. Clinical Record 12: The election of hospice benefit was dated 9/29/23. The patient resided in a SNF. Clinical Record 13: The election of hospice benefit was dated 11/17/23. The patient resided in a SNF. Clinical Record 14: The election of hospice benefit was dated 11/22/23. The patient resided in a SNF. Personnel Record 5: On 12/6/23 an interview was conducted with the clinical manager and administrator both of whom reported that the plan of care in the electronic medical record (EMR) did not contain a place where they can select/document if the hospice or facility is responsible for specific care or services being provided. The clinical manager further stated that they would write specific orders related to wound care which would specify when the facility needed to complete this task and when hospice would provide it. Other than the delineation of responsibilities noted in the facility contracts the clinical manager confirmed that there were no other documents that contained this information. Clinical records reviewed, for patients who resided in a SNF/NF, revealed the agency did not ensure the plans of care delineated the responsibility for the care and services provided. From licensure to date, all patients served by the agency resided in a SNF. The clinical manager confirmed that the agency had a contract addendum that delineated responsibility, but that this information was not incorporated into the individual patient plans of care. This impacted all records reviewed, and all patients served by the agency.”