Three Oaks Hospice

“Based on policy review, clinical record review, and interview, the hospice provider failed to ensure the social workers comprehensive assessments were completed within five days of election of hospice care in one of five records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;PC.30 Plan of Care Process,” last reviewed 09/01/2024, showed in part: - A comprehensive assessment will be completed by the Hospice Interdisciplinary Group/Team (IDG/IDT) no later than five calendar days after the election of hospice care and consultation with attending physician; and - The contents of the comprehensive assessment will identify the patients physical, psychosocial, emotional, and spiritual needs related to the terminal illness that will be addressed to promote the hospice patients well-being, comfort and dignity throughout the dying process. RECORD/PATIENT #5: Review of the hospice election statement showed the effective date of election was 07/26/2023. Review of the record failed to show an initial MSW evaluation visit within five days of hospice election. During an interview on 10/23/2024, at 4:17 PM, the administrator stated that there was no initial assessment completed by the MSW for July 2023. He/she expects it to be completed within five days after the admission.”

“Based on policy review, clinical record review, home visit observation, and interview, the hospice provider failed to ensure clinicians maintained an accurate/updated medication profile/POC (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 the providers patients. Findings included: Review of the providers policy titled, “;PC.85 Medication List and Monitoring,” last reviewed 09/01/2024, showed in part: - A medication/drug profile will be maintained on all patients; - Medication monitoring will include appropriate data/information to develop an accurate patient medication history and a current, complete medication profile; - The Hospice will review, monitor and maintain a current, accurate list of all prescription and over the counter medications, herbal remedies and other alternative treatments that could affect drug therapy taken by patient; - The medication will be documented on the medication/drug profile; - Changes in the medication/drug regimen will be documented in the medical record either on the medication profile, or a verbal order plan of care, as well as communicated to the patient and/or caregiver; and - The medication/drug profile will be updated as frequently as necessary to reflect changes in the medication regimen, keeping the profile accurate. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/25/2024 with a primary diagnosis of Alzheimers disease (a disease marked by progressive loss of mental capacity). The patient resided in a long-term care facility (LTCF). Observation on 10/22/2024, starting at 10:00 AM, the patients medications were reconciled utilizing the current medication profile report supplied to the surveyor by the provider and the 10/01/2024 through 10/22/2024 physician order report provided by the LTCF. The following discrepancies were noted: - The physician order report showed the patient took melatonin (needed for insomnia) 5 milligrams (mg) take one tablet by mouth at bedtime as needed. The current medication profile report failed to include melatonin; - The physician order report showed the patient took polyethylene glycol (needed for constipation) mix 17 gram (gm) in eight ounces (oz) liquid daily as needed for constipation. The current medication profile report failed to include polyethylene glycol; - The physician order report showed the patient took acetaminophen (treats minor aches and pains) tablets 325 mg take two every four hours as needed. The current medication profile report failed to include acetaminophen; - The physician order report showed the patient took Norvasc (treats high blood pressure) 10 mg take one tablet by mouth daily. The current medication profile report failed to include Norvasc; - The physician order report showed the patient took mirtazapine (antidepressant) 45 mg take one tablet at bedtime. The current medication profile report failed to include mirtazapine; - The physician order report showed the patient took paxil (antidepressant) 10 mg take one tablet by mouth daily. The current medication profile report failed to include paxil; and - The physician order report showed the patient took acetaminophen tablet, chewable 325 mg take one by mouth two times a day. The current medication profile report failed to include acetaminophen. During an interview on 10/24/2024 at 12:10 PM, the administrator stated that he/she would expect medications to be reconciled every visit and in the interdisciplinary team meetings and expected all medications the patient was taking to be on the medication profile.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure an individualized plan of care (POC) when it included interventions for a Macy catheter (a rectally inserted catheter for medication administration) and the patients did not have a Macy catheter in, but not limited to, two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect the individualized care of all patients served by the provider. Findings included: Review of the providers policy titled, “;Plan of Care Process,” last reviewed 09/01/2024, showed in part: - All hospice care and services furnished to patients and their families will follow an individualized written POC established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician, the patient or representative, and the primary caregiver, in accordance with the patients needs; - The hospice will develop an individualized written POC for each patient; and - The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. RECORD/PATIENT #2: Review of the clinical record showed the patient elected hospice on 09/16/2024, with a terminal diagnosis of sepsis (a life-threatening infection in the bloodstream) and a secondary diagnosis of urinary tract infection. The patient lived in an assisted living facility and his/her adult children were involved in his/her care. Review of the initial comprehensive assessment dated 09/06/2024, showed the patient was alert and oriented to person, place, and situation. He/she did not have any trouble swallowing and was on a regular diet. He/she required maximum assistance with feeding and total assistance with dressing, bathing, and toileting. The patient did not have a Macy catheter for medication administration and medications were ordered to be administered orally. Review of the POC, dated 09/16/2024, showed in part the following interventions: - SN will collaborate with MD for order for and utilize Macy catheter for medication and the date the intervention was updated was 09/17/2024; and - SN will educate family/patient/facility RN in regard to usage of Macy catheter with return demonstration and the date the intervention was updated was 09/17/2024. Review of IDG meeting notes showed in part: - On 10/01/2024, the IDG noted the patient lived in a facility, the facility managed all medications, continue current POC and goals; and - On 10/15/2024, the IDG noted the patient fed himself/herself finger foods but did cough with thin liquids. The facility requested an order to crush medications as needed. The current POC problems included SN will educate the family/patient/facility RN in regard to usage of Macy catheter with return demonstration and the outcome was documented as “;effective” and the patient/family engagement was documented as “;engaged”. Per an interview conducted prior to home visit observation on 10/22/2024 at 10:00 AM, RN – A stated that the patient did not have a Macy catheter. The nurse who develops the POC chooses the interventions in the computer based on the patients diagnoses and this was one of the canned interventions that come up as a choice. The admitting nurse usually selects all the interventions associated with that particular diagnosis. He/she stated that the POC should be individualized, and the Macy catheter should not be on the patients POC. During an interview on 10/24/2024 at 11:45 AM, the administrator and governing body appointee A stated that the Macy catheter is an optional intervention that shows up in their system and it sounded like some of their staff did not know to not choose those options on every patient. Both the administrator and governing body appointee - A stated that the POC interventions should be individualized. Record/Patient #1: Review of the clinical record showed the patient elected hospice on 06/25/2024, with a terminal diagnosis of Alzheimers (a disease marked by progressive loss of mental capacity). The patient lived in a long-term care facility (LTCF). Review of the initial comprehensive assessment dated 06/25/2024, showed the patient was oriented to self only and disoriented. He/she did not have any trouble swallowing and was on a diet as tolerated. He/she required maximum to extensive assistance with feeding, dressing, bathing, toileting, ambulation, and transfers. The patient did not have a Macy catheter for medication administration and medications were ordered to be administered orally. Review of the POC, dated 07/08/2024, showed in part the following interventions: - Skilled nurse (SN) will collaborate with MD (Doctor of Medicine) for order for and utilize Macy catheter for medication and the date the intervention was updated was 07/11/2024; and - SN will educate family/patient/facility registered nurse (RN) in regard to usage of Macy catheter with return demonstration and the date the intervention was updated was 07/11/2024. Review of IDG meeting notes showed in part: - On 10/15/2024, the IDG noted the patient lived in a LTCF, the facility managed all medications, no changes in POC; and - On 10/01/2024, the IDG noted the patient lived in a LTCF, the facility provides primary care and administers medications, patient on pureed diet; and - On 09/17/2024, the IDG noted the patient lived in a LTCF, the facility administers medications and provides 24/7 care. Observation on 10/22/2024, starting at 10:00 AM, showed the patient had no Macy catheter present during his/her total bed bath by the hospice aide”

“Based on provider policy review, clinical record review, and interview, the hospice provider failed to ensure that care and services were provided in accordance with the plan of care in 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 providers policy titled, “;PC.30 Plan of Care Process,” last reviewed 09/01/2024, showed in part: - To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patients and familys special needs; and - All hospice care and services furnished to patients and their families will follow an individualized written POC established by the Hospice Interdisciplinary Group/Team (IDG/IDT) in collaboration with the attending physician, the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patient’s needs. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to hospice services on 06/25/2024, with an admitting terminal diagnosis of Alzheimers (a disease marked by progressive loss of mental capacity). Review of the initial plan of care dated 07/08/2024, showed skilled nurse (SN) visits were to be once weekly and three as needed visits every 14 days. Review of the clinical record showed: -The record failed to show documentation of a SN visit for the week of 09/29/2024 through 10/05/2024; and -The IDG/IDT failed to ensure SN visits were provided as ordered. During an interview on 10/24/2024 at 10:57 AM, after requesting SN visit notes for 09/29/2024 through 10/05/2024, the governing body appointee A stated that there was no visit completed, and he/she would expect it to be completed.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure all disciplines were informed of the patients complaint of painful urination during a chaplain visit 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 providers policy titled, “;Coordination of Care,” last reviewed 09/01/2024, showed the hospice will develop and maintain a system of communication and integration to ensure that the care and services provided are based on all assessments of the patient and family needs and to provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. RECORD/PATIENT #2: Review of the clinical record showed the patient elected hospice on 09/16/2024, with a terminal diagnosis of sepsis (a life-threatening infection in the bloodstream) and a secondary diagnosis of urinary tract infection. The patient lived in an assisted living facility and his/her adult children were involved in his/her care. Review of the skilled nurse (SN) note, dated 10/07/2024, showed the SN received a telephone call notification that the patient was started on amoxicillin (an antibiotic) 500 milligrams (mg) twice daily for five days on 10/05/2024 for a urinary tract infection. Review of the chaplain visit note, dated 10/10/2024, showed: - The patient complained of pain with urination (five days after the antibiotic was started); - Coordination of care was documented as “;Facility nurse denied concerns”; and - The visit note failed to show the chaplain notified the facility care team, the interdisciplinary group (IDG), or the registered nurse (RN) case manager of the patients continued complaint of painful urination. Review of the IDG meeting notes, dated 10/15/2024, showed the chaplain failed to inform the RN case manager or IDG members of the patients complaint of painful urination on 10/10/2024. During an interview on 10/23/2024 at 4:40 PM, the administrator stated that he/she spoke with the chaplain, and he/she stated that it was discussed in the “;stand up meeting” but there was no documentation that showed the patients complaint was reported to the RN case manager or the IDG. The administrator stated that he/she expected the chaplain to have documented their communication with the nurse.”

“Based on policy review, clinical record review, and interview, the hospice provider failed to ensure the bereavement services reflect the needs of the bereaved in one of one bereavement record reviewed (Record/Patient #11). This deficient practice has the potential to affect all the bereaved served by the provider. Findings included: Review of the providers policy titled, “;Bereavement Coordinator Job Description,” last reviewed 06/01/2020, showed in part, the bereavement coordinator provided continued bereavement support to hospice families evidenced by documentation. Review of the providers policy titled, “;Administrative Policy Manual: Bereavement,” last reviewed 09/01/2024, showed in part, the bereavement services will reflect the needs of the bereaved and the provider will make bereavement services available to the family for up to one year following the death of the patient. RECORD/PATIENT #11: Review of the clinical record showed the patient was admitted to hospice services on 05/31/2024 with a principal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient passed on 06/05/2024. Review of the skilled nurse (SN) comprehensive assessment dated 05/31/2024 showed “;moderate risk” level of complications to normal grief process. Review of the Bereavement Care Plan, dated 06/08/2024 failed to show a completion date for the following interventions with timeline dates: -By 07/05/2024 complete 30-day phone call for follow up and to set up bereavement visit; - -By 07/20/2024 complete bereavement visit to assess risk; - - By 08/09/2024 complete Hospice Survey notice letter; - - By 09/03/2024 complete three-month letter with grief support information; and - - By 10/03/2024 complete additional bereavement encounter. Review of the social workers notes dated 07/22/2024 showed the bereavement coordinator left a voice mail message offering support and did not offer to visit because the bereaved lived out of state. The social worker failed to follow the timeline of the care plan and document attempts to offer bereavement support and services. During an interview on 10/24/2024 at 12:00 PM, the registered nurse coordinator (RNC) stated that the social worker was expected to document in the plan of care the efforts to provide bereavement services and limitations to bereaved family members that were out of state.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the hospice aide provided patient visits as ordered by the interdisciplinary group (IDG) in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients receiving aide services from the hospice provider. Findings included: Review of the providers policy titled, “;Hospice Aide,” last reviewed 10/01/2024, showed in part: - A hospice aide care plan is completed by the registered nurse (RN). This identifies the patients care needs and the hospice aide can only perform the tasks that are checked; - It is very important to check the care plan every visit as the RN may have updated and changed the plan; - A hospice aide note is completed for each visit; - Notify the RN if the patient refuses care or the visit; - A communication note, or similar electronic format is used if a visit is attempted and not completed; and - Notify the RN and the office if the patient declines care or if it is discovered that a visit was missed and document the specifics on a communication note. RECORD/PATIENT #2: Review of the plan of care (POC), dated 09/16/2024, showed an order for hospice aide visits two times weekly. Review of the IDG meeting notes, with dates ranging from 09/17/2024 through 10/15/2024, showed the hospice aide visits were increased to three times weekly effective 10/02/2024. Review of the hospice aide visit notes showed: - A hospice aide visit on 10/01/2024; - A missing aide visit for the week of 09/29/2024 through 10/05/2024 (this is the week the visit frequency increased to three times weekly); and - The visit notes failed to include missed visit notes or communication notes explaining the reason for the missed visit. During an interview on 10/23/2024 at 3:06 PM, the administrator stated that they reached out to the hospice aide, and he/she was currently dealing with a family emergency, so they were not able to reach him/her. They did not have any information about the missed visit. The system showed the visit was scheduled, but they did not have any documentation about why the visit was missed. The administrator and governing body appointee A both stated that the expectation was for the aide to fill out a missed visit form, then it would be forwarded to the nurse, and the nurse would notify the physician.”

“Based on policy review, record review, and interview, the hospice provider failed to forward a discharge summary to the patients attending physician in one of one revocation record reviewed (Record/Patient #8). This deficient practice has the potential to affect the coordination of care of all patients who revoke the hospice benefit. Findings included: Review of the hospice providers policy titled, “;Patient Discharge,” last reviewed 09/01/2024, showed in part: - The hospice will follow federal, state, and local regulations related to patient discharge; and - The hospice will forward, upon revocation and discharge, copies of a summary of the patients care, the patients current plan of care (POC) including the current medication profile, the latest physician orders, and any other documentation requested or that may assist with the patients post-discharge continuity of care. RECORD/PATIENT #8: Review of the clinical record showed in part, the following: - The patient elected hospice on 01/31/2024; - The patient made the decision to revoke hospice because he/she felt he/she no longer needed hospice; - The patient revoked hospice on 06/21/2024; and - The provider failed to send a summary of the patients stay, the patients POC, current medication list or the latest physician orders to the patients attending physician. During an interview on 10/23/2024 at 1:00 PM, the administrator stated that they did not have evidence that a discharge summary was sent to the attending physician because that doctor did not want the hospice provider to send anything to his/her office. The administrator stated that they did not have any documentation that showed the physicians request.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure safe disposition of narcotics upon discharge in one of three discharge records reviewed (Record/Patient #10). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the hospice providers policy titled, “;Disposal of Controlled Substances,” last reviewed 09/01/2024, showed in part the following: - The disposal of controlled substances is at the discretion of the patient and/or caregivers; - The hospice will follow all applicable state and local regulations regarding disposal of controlled substances. The more stringent regulations will be followed; - After disposal by the hospice staff and/or assistance with disposal, the hospice staff will document the occurrence in the clinical record; and - Documentation in the patients record should include the type of controlled substance, dosage, route of administration, quantity disposed, and the time, date, and way the disposal occurred. RECORD/PATIENT #10: Review of the clinical record showed in part, the following: - The patient elected hospice on 04/02/2024 with a terminal diagnosis of dementia due to Alzheimers disease (a disease marked by progressive loss of mental capacity); - The patient lived in an assisted living facility (ALF); - Patients medications included hydrocodone – acetaminophen (a narcotic pain reliever), lorazepam concentrate (a narcotic used for anxiety/agitation), and morphine sulfate concentrate (a narcotic medication used for severe pain); - On 08/07/2024, the hospice nurse documented the hospice was notified on 08/06/2024 that the patients power of attorney took the patient out of the ALF for a visit and did not bring the patient back to the ALF. The POA moved the patient to Arizona without notification to the ALF or the hospice provider (this occurred “;last Friday” which was 08/02/2024); - The patient was discharged on 08/06/2024 for moving out of the service area; and - The record failed to show the disposition of the patients narcotic medication. During an interview on 10/23/2024 at 1:00 PM, the administrator stated that he/she called the ALF and asked about the disposition of the patients narcotics. The ALF told him/her that the patients POA told them they were only going to be out for a “;few days” and the ALF sent a “;few days” of the patients medications with the POA. When the ALF discovered the POA moved the patient to Arizona, the ALF destroyed the medications left behind by the patient. The ALF told the administrator that they could not send the hospice proof of the medication destruction because it was too long ago, and those records were sent to a storage location. The administrator stated that since the patient lived in an ALF and not in a contracted skilled nursing facility, the hospices policy on narcotic destruction would apply to this patient.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure the long-term care facility (LTCF) hospice patient record contained a copy of all required hospice documents in one of one applicable records of patients that resided in a LTCF (Record/Patient #1). This deficient practice has the potential to affect all patients that resided in a LTCF. Findings included: Review of the providers policy titled, “;PC.125 Hospice Care in a SNF/NF or ICF/ID,” last reviewed 09/01/2024, showed in part: - A Hospice plan of care (POC) will be developed based on the patient/familys needs. The POC will be written in collaboration with the Interdisciplinary Group/Team (IDG/IDT), facility staff, patient and/or the family, and the attending physician. A copy of the POC, which includes services furnished, will be provided to the facility; - The Hospice will provide the facility with the following hospice information/documentation on admission and on-going: * The most recent Hospice POC specific to each patient; * The Hospice election form and any advance directives specific to each patient; * The physician certification and recertification of the terminal illness specific to each patient; * The Hospice medication information specific to each patient; * The Hospice physician and attending physician orders specific to each patient; * The manner in which communication will occur to ensure that the needs of the patients are addressed and 24 hours a day, with specific instructions on how to access the Hospice’s 24-hour on-call system; and * Names and contact information for the Hospice personnel involved in the care of each patient. Review of the providers policy titled, “;PC.125-MO Hospice Care in a SNF/NF or ICF/ID,” last reviewed 10/20/2023, showed in part: - There will be a coordinated single plan of care (POC) in the nursing facility which may be multiple documents, that: * Reflects coordination and input from both the Hospice and the nursing facility; * Identifies the care and services which each will provide; * Is updated to reflect changes in patient/family condition, needs, and care; - A registered nurse (RN) is designated from the Hospice to: * Coordinate the implementation of the POC; and * Respond to questions and concerns from the nursing facility. RECORD/PATIENT #1: Review of the hospice record maintained at the long-term care facility (LTCF), during a home visit observation on 10/22/2024 beginning at approximately 10:00 AM, showed the hospice binder failed to contain: - The current hospice POC; - The hospice election form; - The physician certification and re-certification; - The name of the case manager involved in the patients care; - The current medication profile; - The hospice and attending physician orders; and - Complete written coordination that identified the care and services required. During an interview on 10/24/2024 at 10:59 AM, the registered nurse coordinator stated that: - The hospice staff did not use the LTCFs computer system; and - The binder in the LTCF should have been completed and include the missing documents.”

“Based on policy review, review of the providers patient roster and facility in-service records, and interview, the hospice provider failed to ensure facility staff were offered education on the hospice philosophy in 11 of 11 skilled nursing/long-term care facilities (SNF/LTCF) providing care to hospice patients. This deficient practice has the potential to affect the care provided to all SNF/LTCF patients served by the hospice provider. Findings included: Review of the hospice providers policy titled, “;Hospice Care in a SNF/NF (Nursing Facility) or ICF/IID (Intermediate Care Facility/Individuals with Intellectual Disabilities),” last reviewed 09/01/2024, showed the hospice will “;assure the orientation of staff who provides that care, in the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements”. Review of the providers current patient list showed 23 of 74 patients lived in a SNF/LTCF. On 10/24/2024, the administrator provided a three-ring binder titled, “;Facility Inservice 2024” that showed: - A sign-up sheet for (named assisted living facility) for “;Death and Dying,” dated 01/15/2024; - A sign-up sheet for (named memory care assisted living facility), “;Hospice 101,” dated 01/15/2024; - A sign-up sheet for (named assisted living facility) for “;Hospice 101,” dated 02/02/2024; and - The provider failed to maintain documentation that education was offered to any SNFs/LTCFs On 10/24/2024 at 9:45 AM, the administrator stated that they did not have documentation to show education on the hospice philosophy was offered to the SNFs.”