Medi-Plex Hospice, LLC

“Based on policy review, record review, and interview, the hospice provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in two of four home visit observations (Records/Patients #1 and #4). This deficient practice has the potential to affect the hospice provider’s ability to ensure safe and effective use of medications for all patients served by the provider. RECORD/PATIENT #4: During a home visit observation on 05/29/2024 beginning at 10:02 AM showed the following medication discrepancy with the current medication profile: - The providers medication profile showed an order for vitamin D3 50000 international units (IU) by mouth monthly. The patients caregiver stated he/she takes vitamin D3 50000 IU weekly and has been since 02/16/2024. Findings included: Review of the provider’s policy titled, “;Medication Profile,” revised 06/2019, showed in part: - The nurse will add all new/changed medication(s) to the medication profile; - Discontinued (D/C) medications will be documented and dated; and - The medication profile will be reviewed every home visit, updated as changes occur and reviewed by the interdisciplinary group (IDG). RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted on 02/03/2024 with senile degeneration of the brain. The patient resided in a long-term care facility (LTCF). Review of the hospice providers medication list and the LTCFs medication orders, showed the following discrepancies:- The hospice providers medication list, for benefit period 05/03/2024 to 07/31/2024, showed metoprolol succinate (a long acting medication used to treat high blood pressure) 50 milligram (mg) oral tablet extended release twice daily. The LTCFs medication orders, dated 05/28/2024, failed to contain this order and showed metoprolol tartrate (a short acting medication used to treat high blood pressure) 50 mg tablet twice daily; - The hospice providers medication list, for benefit period 05/03/2024 to 07/31/2024, showed Milk of Magnesia (used to treat constipation) 30 milliliters (ml) every four hours as needed. The LTCFs medication orders, dated 05/28/2024, showed Milk of Magnesia 30 ml every 24 hours as needed; - The hospice providers medication list, for benefit period 05/03/2024 to 07/31/2024, showed triamcinolone acetonide (used to treat rash) topical ointment 0.1 % three times daily. The LTCFs medication orders, dated 05/28/2024, showed triamcinolone acetonide topical ointment 0.1 % once daily; and - The LTCFs medication orders, dated 05/28/2024, showed permethrin (used to treat head lice and scabies) external cream 5% applied to entire body topically one time only for scabies for one day in the evening for 12 hours then shower in the morning with a start date of 5/30/2024. The hospice providers medication list did not have an order for permethrin. During an interview on 05/30/2024 at 5:30 PM, the hospice administrator stated that he/she was not aware of the need for the treatment of scabies and did not know about the medication order. The administrator stated that medication lists should be reconciled at every visit.”

“Based on policy review, record review, and interview, the provider failed to complete an initial bereavement risk assessment in one of five full records reviewed (Record/Patient #4.) This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy, “Bereavement Services,” revised 02/2022, showed an initial Bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment and bereavement assessment and clinical notes are documented in the patient’s permanent clinical records. RECORD/PATIENT #4: Review of the clinical record showed: -Patient was admitted to hospice services on 07/21/2023; and -Review of the clinical record failed to show an initial bereavement risk score. During an interview on 05/29/2024 at 1:30 PM, the registered nurse coordinator stated there was no bereavement assessment completed.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the patient’s plan of care (POC) was individualized in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Initial Assessment/Comprehensive Assessment,” dated 02/2021, showed in part, the initial assessment gathers essential information necessary to begin the plan of care and provide the immediate necessary care and services. RECORD/PATIENT #2: Review of the clinical record showed patient admitted to hospice services on 5/22/2024 with a terminal diagnosis of protein calorie malnutrition (state of inadequate food intake). The patient resided in a long-term care facility (LTCF). Review of the document titled, “Registered Nurse (RN) Initial/ Comprehensive Assessment,” dated 05/22/2024, showed the patient wore a cardiac monitoring vest and was at an increased risk for falls. Review of the document titled, “Initial Plan of Care,” dated 05/22/2024-08/19/2024, failed to show any interventions related to the patient’s cardiac devices or risk for falls. During an interview on 05/30/2024 at 10:00 AM, the hospice administrator stated that he/she could not find where the items were care planned.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that the care and services were provided in accordance with the plan of care in, but not limited to, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy “Coordination of Patient Care” revised 06/2019, showed in part the provider ensured that care and services are provided in accordance with the plan of care and are based on all assessments of the patient and family needs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted on 02/03/2024 with senile degeneration of the brain (mental deterioration or loss of intellectual ability). The patient resided in a long-term care facility (LTCF). Review of the patients plan of care, dated 02/03/2024 to 05/02/2024, showed the following: - Skilled Nurse one visit per week for 14 weeks; - Medical Social Worker three visits per month for four months; and - Spiritual Counselor three visits per month for four months. Review of the patients clinical record showed the following: - One medical social worker visit during the month of April; and - One spiritual counselor visit during the month of April. The clinical record failed to show any skilled nurse visits for the weeks of 04/21/2024 and 04/28/2024. Review of the patients plan of care, dated 05/03/2024 to 07/31/2024, showed the following: - Skilled Nurse one visit per week for 14 weeks; - Medical Social Worker one visit per month for three months; and - Spiritual Counselor one visit per month for three months. Review of the patients clinical record failed to show the following: - Any skilled nurse visits for the weeks of 05/05/2024 and 05/19/2024; - Any medical social worker visits for 05/03/2024 to 05/30/2024; and - Any spiritual counselor visits for 05/03/2024 to 05/30/2024. During an interview on 05/30/2024 at 9:50 AM, the administrator stated that the plan of care should not include three visits per month for the medical social worker and the spiritual counselor, because “;everyone” got one visit per month.”

“Based on policy review, contract review, and interview, the hospice provider failed to ensure professional management responsibility for services under arrangement when the long-term care facility (LTCF) for respite services and general inpatient care (GIP; short-term care for symptom management) contracts failed to include the following: - Required services to be authorized by the hospice; - Required services to be furnished in a safe and effective manner by qualified personnel; - Hospice must retain administrative management for oversight of services; and - Hospice must retain financial management responsibility for services. This deficient practice has the potential to affect all patients that receive respite care or GIP care that are on service with the provider. Review of the hospice provider’s policy titled, “Written Agreements/Contracts with Providers,” dated 02/2021, showed that when hospice has a written agreement with another agency, individual, or organization to furnish any services under arrangement, hospice will retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged services are supported by written agreements that require that all services be authorized by hospice, furnished in a safe and effective manner by qualified personnel, and delivered in accordance with the patient’s plan of care. Review of the Skilled Nursing and Respite Facility Agreement, dated 09/11/2023, showed the contract failed to include that required services were to be furnished in a safe and effective manner by qualified personnel and that hospice must retain administrative management for oversight of services. Review of the Nursing Facility Services Agreement (Basic, Respite, and General Inpatient Care for Hospice Patients), dated 12/17/2014, showed the contract failed to include that hospice must retain financial management responsibility for services. Findings included: During the survey entrance on 05/29/2024 at 3:00 PM the long-term care respite contract and GIP contract was requested from the hospice administrator. Review of a Skilled Nursing Facility Agreement for respite services dated 10/10/2018, and a GIP contract showed no delineated information regarding the required services to be authorized by the hospice and for required services to be furnished in a safe and effective manner by qualified personnel and hospice administrative management for oversight of services. During an interview 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still and he/she has new contracts prepared but did not have them signed for those providers reviewed. The provider failed to ensure written contracts/agreements included all the required components to ensure professional management responsibility for services under arrangement.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that a discharge order was received for all patients in one of two discharge records reviewed (Record/Patient #7). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Discharge Summary,” dated 06/2019, showed in part, the hospice discharge summary will include discharge orders, instructions, medication profile and allergies, if discharge is other than patients death. RECORD/PATIENT #7: Review of the discharge record showed the patient discharged from hospice services on 04/22/2024. Review of the record showed a physician’s order for discharge dated 05/30/2024. During an interview on 05/30/2024 at 12:00 PM, the administrator stated that the order dated 05/30/2024 was the only discharge order they had for the patient.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure all record entries were appropriately authenticated and dated in three of ten records reviewed (Records/Patients #1, #5, and #10). This deficient practice has the potential to affect all patients served by the provider. Findings included: RECORD/PATIENT #1: Review of the patients initial plan of care electronically signed by the physician on 02/14/2024 and the recertification plan of care electronically signed by the physician on 05/26/2024 showed no known allergies. Review of the patients order summary report from the long term care facility (LTCF) dated 05/28/2024 showed the following allergies: codeine, hydrochlorothiazide, and Aleve. During an interview on 05/30/2024 at 9:50 AM, the administrator stated that it was an “oversight” to not include the patient’s allergies on the hospice plan of care. RECORD/PATIENT #10: Review of the patients initial plan of care electronically signed by the registered nurse on 12/07/2023 showed bacitracin (used to treat bacterial skin infections) 500 units/gram topical ointment daily for wound care to peri wounds. Review of the patients initial plan of care electronically signed by the registered nurse on 12/07/2023 failed to address peri wounds. Review of the patients physician order electronically signed by the registered nurse on 12/07/2023 showed attending physician ordered bacitracin 500 units/gram topical ointment daily to peri wounds. During an interview on 05/30/2024 at 3:30 PM, the administrator stated that the patient had no peri wounds at the time of admission on 12/07/2023. He/She could not explain why there was an order for treatment if there were no wounds. Findings included: Review of the hospice provider’s policy titled, “Timely Submission of Patient Documentation,” dated 06/2019, showed itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding two business days. Review of the hospice provider’s policy titled, “Patient Record Content,” dated 06/2019, showed, in part, the following: -Hospice will initiate and maintain an individual and accurate patient record containing past and current findings for each patient receiving care in compliance with all federal/state laws and regulations; and -All entries must be legible, clear, complete, and appropriately authenticated. RECORD/PATIENT #5: Review of the psychosocial visits showed the following: -A visit, dated 04/18/2024, where the family expressed an interest in respite; -A visit, dated 04/26/2024, where the patient’s son discussed that the family members are exhausted; and -A PRN (as needed) visit, dated 05/22/2024, that stated it was a routine followup visit to discuss client’s caregiver services. During an interview on 05/30/2024 at 12:00 PM, the social worker (SW) provided a hand written visit addendum, dated 04/21/2024, that discussed further communication with the patient’s family from 04/21/2024 to 05/22/2024. The social worker then stated that he/she wrote the note prior to the interview on 05/30/2024. During an interview on 05/30/2024 at 3:00 PM, the administrator stated that he/she would expect communication with patients and caregivers to be documented when completed.”

“Based on policy review, record review, and interview, the hospice provider failed to provide the discharge summary in, but not limited to, one of five discharged patients (Record/Patient #10). This deficient practice has the potential to affect all patients discharged by the provider. Findings included: Review of the provider’s policy “Patient Record Content” revised 06/2019, showed in part, the following: - Each patient record will contain a discharge summary when patient is discharged from Hospice; and - Any summaries of the patient’s care, treatment and services furnished to patient’s physician. RECORD/PATIENT # 10: Review of the clinical record showed the patient was discharged on 02/27/2024 and a copy of the discharge summary was sent to the attending physician. During an interview on 05/30/2024 at 3:30 PM, the administrator failed to provide the discharge summary for Patient #10.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that the 24 hour nursing services that meet the needs of the patient in accordance with the plan of care (POC) be contained in the respite contract in one of one respite contract reviewed. This deficient practice has the potential to affect all patients that receive respite care. Findings included: Review of the provider’s policy titled, “Written Agreements/Contracts with Providers,” dated 02/2021, showed: -The written agreement with an outside agency or individual providing contracted services for Hospice includes: *Identification of the scope of services to be provided; and *A stipulation that services will be delivered in accordance with the patient’s plan of care. Review of the Skilled Nursing and Respite Facility Agreement showed the contract failed to contain the verbiage that the facility must provide 24-hour nursing services that meet the needs of the patient in accordance with the POC. During an interview on 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know that there were old contracts still in circulation and the provider had new contracts prepared.”

“Based on contract review and interview, the hospice provider failed to ensure that the respite contract included that the inpatient provider would establish patient care policies that were consistent with hospice and that the inpatient provider agreed to abide by the palliative care protocols and plan of care established by hospice in one of one respite contract reviewed. This deficient practice has the potential to affect all patients that receive short-term inpatient care. Findings included: Review of the Skilled Nursing and Respite Facility Agreement, dated 09/11/2023, showed the contract failed to contain the following elements: -The inpatient provider would establish patient care policies that were consistent with hospice; and -The inpatient provider agreed to abide by the palliative care protocols and plan of care established by hospice. During an interview on 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still in circulation and there were new contracts already prepared.”

“Based on contract review and interview, the hospice provider failed to ensure that the respite and general inpatient (GIP) contracts failed to contain elements regarding the clinical record in two of three contract reviewed. This deficient practice has the potential to affect all patients that receive respite or GIP services. Findings included: RESPITE CONTRACT: Review of the Skilled Nursing and Respite Facility Agreement, dated 09/11/2023, showed the contract failed to contain the following verbiage: -Inpatient clinical record includes all inpatient services furnished and events regarding care that occurred at the facility; and -Copy of the discharge summary and/or clinical record to be supplied to hospice at the time of discharge. GIP CONTRACT: Review of the Nursing Facility Services Agreement, dated 12/17/2014, showed the contract failed to contain the following verbiage: -Inpatient clinical record includes all inpatient services furnished and events regarding care that occurred at the facility; and -Copy of the discharge summary and/or clinical record to be supplied to hospice at the time of discharge. During an interview on 05/30/2024 at 4:30 PM, the administrator stated that he/she did not realize there were old contracts still in circulation and the provider had new contracts prepared.”

“Based on contract review and interview, the provider failed to specify the process in which the facility and provider are to communicate with each other and document to ensure the needs of the patient are met 24 hours per day/7 days per week. This deficient practice has the potential to affect care of any patient on hospice service that receives care in a long-term care facility (LTCF). Findings included: Review of the providers contract titled, “Skilled Nursing and Respite FACILITY AGREEMENT,” dated 10/10/18 with a contracted LTCF failed to specify the process in which the facility and provider were to communicate with each other and document to ensure the needs of the patient were met 24 hours per day/7 days per week. The provider failed to ensure written contracts/agreements included all the required components to ensure professional management responsibility for services under arrangement. During an interview 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still and he/she had new contracts prepared but did not have them signed for the providers reviewed.”

“Based on contract review and interview, the written agreements between the provider and the skilled nursing facility (SNF) failed to specify the required provision of addressing when to immediately notify the hospice provider. This deficient practice has the potential to affect care of any patient on hospice service that receives care at a long-term care facility (LTCF). Findings included: Review of the respite contract dated 10/10/2018, showed the contract failed to include the provision that the hospice would be notified if: - Significant change in a patient’s physical, mental, social or emotional status occurs; - Clinical complications appear that suggest a need to alter the plan of care; - A need to transfer from the facility - hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care related to the terminal illness and related conditions; and - A patient dies. The provider failed to ensure written contracts/agreements included all the required components to ensure professional management responsibility for services under arrangement. During an interview on 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still and he/she had new contracts prepared but did not have them signed for the providers reviewed.”

“Based on contract review and interview, the respite contract failed to specify the required provision addressing the extent of using facility staff to assist in the care of the patient. This deficient practice has the potential to affect care of any patient that is on hospice services and receives care at a long-term care facility (LTCF). Findings included: During the survey entrance on 05/29/2024 at 3:00 PM the respite contract was requested from the hospice administrator. The administrator provided a signed contract for respite dated 10/10/2018. Review of the respite contract, dated 10/10/2018, showed the contract failed to include the provision stating that the hospice may use facility nursing personnel for administration of prescribed therapies that a hospice family member would normally provide. The provider failed to ensure written contracts/agreements included all the required components to ensure professional management responsibility for services under arrangement. During an interview on 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still and he/she had new contracts prepared but did not have them signed for the providers reviewed.”

“Based on contract review and interview, the provider respite contract failed to specify the provision that hospice must report all alleged violations. This deficient practice has the potential to affect care of any patient on hospice service that receives care in a long-term care facility (LTCF). Findings included: During the survey entrance on 05/29/2024 at 3:00 PM the respite contract was requested from the hospice administrator. The administrator provided a signed contract for respite dated 10/10/2018. Review of the respite contract, dated 10/10/2018, showed the contract failed to include a provision stating that the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source and misappropriation of patient property by anyone unrelated to the hospice to the SNF (skilled nursing facility) administrator within 24 hours of the hospice becoming aware of the alleged violation. The provider failed to ensure written contracts/agreements included all the required components to ensure professional management responsibility for services under arrangement. During an interview on 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still and he/she had new contracts prepared but did not have them signed for the providers reviewed.”

“Based on contract review and interview, the provider respite contract failed to specify the provision that delineated the responsibilities of the hospice and the long-term care facility (LTCF) for bereavement for facility staff. This deficient practice has the potential to affect care of any patient on hospice service that receives care at a LTCF. Findings included: During the survey entrance on 05/29/2024 at 3:00 PM the respite contract was requested from the hospice administrator. The administrator provided a signed contract for respite dated 10/10/2018. Review of the respite contract, dated 10/10/2018, showed the contract failed to include and specify a provision to delineate the responsibilities of the hospice and the facility to provide bereavement services to facility staff. The provider failed to ensure written contracts/agreements included all the required components to ensure professional management responsibility for services under arrangement. During an interview 05/30/2024 at 4:30 PM, the administrator stated that he/she did not know there were old contracts still and he/she had new contracts prepared but did not have them signed for the providers reviewed.”

“Based on policy review, home visit observation, and interview, the hospice provider failed to provide the long-term care facility (LTCF) with a copy of the physician certification of terminal illness (CTI) in, but not limited to, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients on hospice service that receive care at a LTCF. Findings included: Review of the provider’s policy, “Patient Record Content”, revised June 2019, showed in part that Hospice initiated and maintained an individual and accurate patient record containing past and current findings for each patient receiving care including certification and recertification of terminal illness statements . RECORD/PATIENT #1: Review of the clinical record showed a physician certification of terminal illness for hospice, dated 02/14/2024 and a physician second certification dated 05/17/2024. Observation on 05/28/2024 at 1:20 PM, showed the LTCF hospice binder failed to contain a copy of the CTI. During an interview on 05/30/2024 at 9:50 AM, the administrator stated that the CTI should have been in the hospice binder at the LTCF.”