Phoenix Home Care and Hospice

“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, two of five full records reviewed (Records/Patients #3 and #4). This deficient practice has the potential to affect all the providers patients. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 08/09/2024 with primary diagnosis of other specified degenerative diseases of nervous system (neurodegenerative disease), dementia (decline in mental capacity), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), and hypertension (Elevated arterial blood pressure). The patient lived at home with his/her spouse as primary caregiver. Observation and interview on 10/01/2024 at 11:00 AM, during the patient’s home visit, showed the following discrepancies: - The medication profile showed the patient took metoprolol (treats high blood pressure) extended release (ER) 24 hour 25 milligrams (mg) one half a tablet daily. Review of the medication bottle showed 50 mg take a half a tablet daily. The spouse stated he/she takes it like the medication bottle directions; - The medication profile showed the patient took cyanocobalamin (vitamin B12) 100 micrograms (mcg) tablet daily. Review of the medication bottle showed 2500 mcg daily. The spouse stated he/she takes it like the medication bottle; - The medication profile showed the patient took Vitamin D3 25 mcg tablet daily. Review of the medication bottle showed 125 mcg daily. The spouse stated he/she takes it like the medication bottle; - The medication profile showed the patient took Vitamin C chewable 500 mg daily. Review of the medication bottle showed vitamin C 2000 mg, zinc 40 mg, rose hip 50 mg daily. The spouse stated he/she takes one a day; - The medication bottle showed Sentry Senior Vitamin (comparable to Centrum Silver) one daily. The spouse stated he/she takes one daily. The medication profile failed to include the sentry Senior Vitamin; and - The spouse stated the patient takes Dulcolax (laxative) suppositories as needed for constipation. The spouse stated he/she administered two suppositories to the patient this morning and one on Sunday. The medication profile failed to include the Dulcolax suppositories. Per interview conducted during the observation, RN B stated that he/she would notify the physician and get the discrepancies clarified. During an interview on 10/03/2024 starting at 4:59 PM, the administrator stated that he/she would expect medications to be reconciled every visit and expected all medications the patient was taking to be on the medication profile. 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; - The medication/drug profile will also include: ** Dosage, frequency, and route; and **administration schedule. - 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 #3: Review of the clinical record showed the patient was admitted to hospice services on 07/11/2024 with a primary diagnosis of Parkinson’s disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided in a long-term care facility (LTCF). Review of SN (skilled nurse) visit note dated 07/30/2024 showed “;received call from facility nurse that the patient had a bleeding, open wound to his/her groin. The medical director was notified and was okay with barrier cream (a product applied directly to the skin surface to help maintain the skins physical barrier, providing protection from irritants and preventing the skin from drying out) application and to reassess at the next routine SN visit 7/31/2024”. (A physician order for the barrier cream failed to be documented). Review of the SN visit note dated 7/31/2024 showed “;redness in groin, barrier cream present in perianal area upon assessment”. Review of the SN visit note dated 8/3/2024 showed “;redness in groin improved- barrier cream present- education provided”. Review of POC order dated 08/15/2024 showed under the GU (genitourinary)/Urinary elimination problem section in the POC: barrier cream present- education provided (it failed to have any further directions). Further review of the clinical record failed to show a physician order for barrier cream. Review of the provider’s current medication profile report provided to the surveyor failed to show Cetaphil moisturizing cream (a cream used to heal and soothe extremely dry skin, chapped lips, cracked hands and heels and other minor skin irritations), nystatin powder (anti-fungal used to treat fungal infections of the skin), or barrier cream. Observation on 10/01/2024, starting at 2:00 PM, the patients medications were reconciled utilizing the current medication profile report supplied to the surveyor by the provider and the 10/01/2024 physician order review provided by the LTCF. The following discrepancies were noted: - Each failed to show barrier cream listed; - The LTCF physician orders dated 10/01/2024 showed Cetaphil moisturizing cream apply to back twice daily as needed and Nystatin powder apply to abdominal folds topically twice daily as need. (These failed to be listed on the providers current med profile report. During an interview on 10/03/2024 at 1:30 PM the administrator stated that he/she: - Was unable to find an order for the barrier cream; - The physician had been notified and an order was received and the facility was notified of the new order; and - The medications should match. (facility/hospice provider)”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to follow an individualized plan of care (POC) in, three of five full records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 03/29/2024 with a primary diagnosis of malignant neoplasm (a cancerous tumor) of upper lobe of the right lung. The patient resided at his/her home with his/her daughter. Review of the patients “;Plan of Care” dated for benefit period 06/27/2024 to 09/24/2024 and 09/25/2024 to 11/23/2024 showed in part, the patient/caregiver was able to administer tube feeding and provide care for tube insertion site. Observation on 10/01/2024 at 11:35 AM showed that the patient did not have a feeding tube. Review of the patient’s interdisciplinary group (IDG) meeting notes dated 09/12/2024 showed in part RN (registered nurse) recertification details that bottom was excoriated and barrier cream applied daily as needed. Review of the patients “;Plan of Care” dated 09/26/2024 failed to show orders for zinc oxide (a barrier cream used to protect skin from moisture) and application instructions. Review of the patients “;Aide Care Plan Instructions” dated 10/01/2024 failed to show instructions to apply zinc oxide. Observation on 10/01/2024 at 11:45 AM showed the hospice aide (HA)-A applied zinc oxide to the patients coccyx wound. As the HA-A applied the zinc oxide he/she stated that he/she would “;let the nurse know.” HA-A failed to contact the case manager nurse before applying the zinc oxide. Review of the patients “;Plan of Care” dated 09/26/2024 for the benefit period of 09/25/2024 to 11/23/2024 showed the hospice aide frequency for two times per week. Review of the patients interdisciplinary group meeting notes dated 09/26/2024 showed the hospice aide frequency for two times per week. Review of the patients “;Aide Care Visit” notes dated 10/01/2024 showed the hospice aide frequency for three times per week. During an interview on 10/01/2024 at 12:15 PM, the HA-A stated that the patient is scheduled for a bed bath three times per week. HA-A stated that he/she reads the care plan to know how many times a week he/she visits the patient. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice service on 12/28/2023 with a primary diagnosis of Wernickes encephalopathy (a degenerative brain disorder caused by the lack of vitamin B1). The patient resided at a long term care facility (LTCF). Review of the patients “;Plan of Care” dated 12/29/2023, 08/15/2024, 08/29/2024, 09/12/2024, and 09/26/2024 showed in part the following the patient/caregiver was able to administer tube feeding and provide care for tube insertion site. During an interview on 10/01/2024 at 10:35 AM, the assistant director of nursing (ADON)-A stated that the patient was never administered tube feeding. Findings included: Review of the hospice provider’s policy titled, “PC.P50 Plan of Care,” with a copyright date of 2021, showed in part: - The interdisciplinary written plan of care is based on initial and updated patient specific comprehensive assessments by members of the IDG (interdisciplinary group) and is developed with measurable goals and outcomes for planned interventions; - The care and services provided/delivered to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the patients attending physician, the patient and/or his or her representative and the primary caregiver in accordance with the patients needs if any of them so desire; and - Care provided to an individual patient is in accordance with the plan of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 07/11/2024 with a primary diagnosis of Parkinson’s disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided in a long-term care facility. Review of the POC orders dated 07/18/01 and 08/01/2024 showed: cleanse area to medial back with wound cleanser, pat dry, apply xeroform gauze (a nonadherent primary dressing that maintains a moist wound environment) to wound bed and cover with dry dressing once daily. Review of the SN (skilled nurse) visit notes dated 07/22/2024 and 08/02/2024 failed to show documentation that the wound care was performed. During an interview on 10/03/2024 at 4:56PM, the administrator stated that he/she would expect the wound care to be completed/documented. During an interview on 10/03/2024 at 5:22PM, the RN/Regional Executive Director stated that documentation that wound care was provided would be expected.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure coordination of care when the on-going sharing of information between all disciplines providing care failed to be provided in a discharge summary during a respite stay in, one of one record reviewed for respite care (Record/Patient #6) and failed to involve the interdisciplinary group (IDG) when one patient chose to revocate for aggressive treatment in, one of two records reviewed for revocation (Record/Patient #8). This deficient practice has the potential to adversely affect communication and care to all the provider’s patients in respite care and patients that choose to revocate. Findings included: Review of the policy titled, “;PC.C90 Coordination of Services” dated 2012, showed in part: - The hospice will maintain a system of communication and integration, in accordance with the hospice’s own policies and procedures, 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; and - An assigned hospice registered nurse (RN) Case Manager coordinates the patients plan of care (POC) and facilitates the ongoing sharing of information with the attending physician, contracted facilities, vendors, other members of the IDG and non-hospice healthcare providers. RECORD/PATIENT #6: Review of the clinical record, showed in part: - The patient was admitted to hospice services on 02/06/2024 with a primary diagnosis of alcohol dependence with alcohol-induced persisting dementia; - The patient lived at home with his/her spouse as primary caregiver; - The patient was admitted to a long-term care facility (LTCF) for a respite stay on 03/26/2024 to 03/30/2024; and - The clinical record failed to include record that the discharge summary was provided to the hospice provider after discharge from his/her respite stay at the LTCF. During an interview on 10/02/2024 at 3:35 PM, the Regional Executive Director (Governing Body Designee)-A, stated that the discharge summary was missing, and they should have already had it from the LTCF. During an interview on 10/03/2024 at 1:25 PM, the hospice team coordinator stated no facility sends discharge summaries to the provider when they go in for respite. RECORD/PATIENT #8: Review of the clinical record, showed in part: - The patient was admitted to hospice on 08/29/2024 with a primary diagnosis of hypertensive heart disease without heart failure (long-term high blood pressure, which causes the heart to work harder and thicken over time); and - The patient lived at a LTCF. Review of the Medicare Hospice Benefit Revocation dated 08/30/2024, showed the reason for revoking the benefit was for aggressive treatment. Review of the revocation statement documented by the skilled nurse (SN) dated 08/30/2024, showed in part: - Comments: Patient was being transported to his/her daughter’s home by family in a private vehicle from a LTCF, when the family decided to take the patient to the hospital for aggressive treatment; - The SN coordinated with the pharmacy and the durable medical equipment (DME) provider; and - The SN coordinated with the patients daughter and the hospital emergency department staff. Review of the clinical record failed to show the SN coordinated the revocation information with the IDG. During an interview on 10/03/2024 at 12:56 PM, the hospice team coordinator stated an email was sent to the billing department on 08/30/2024, but did not include the entire IDG.”

“Based on policy review, record review, and interview the hospice provider failed to ensure nursing followed policy and procedure for wound care in one of five full records reviewed (Patient/Record #3). This deficient practice has the potential to adversely affect wound management for all the provider’s patients with wounds. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 03/29/2024 with a primary diagnosis of malignant neoplasm (a cancerous tumor) of upper lobe of the right lung. The patient resided at his/her home with his/her daughter. Review of the electronic wound assessments provided by the administrator dated 07/03/2024, 07/18/2024, 07/31/2024, 08/14/2024, 08/28/2024, 09/11/2024, and 09/25/2024 showed the registered nurse failed to document wound measurements every 14 days. Findings included: Review of the hospice providers undated policy titled, “;PC.C60.1 Skin Assessment Policy- Addendum”, showed, in part: - “;Named Hospice” will assess/evaluate any wound/skin issues in coordination with patient/caregiver/facility staff; - Any skin impairment issues will be evaluated/assessed by the hospice skilled nurse at lease every 14 days and as needed; - Wound measurements are to be completed on any skin impairment issue at time of admission and at least with every comprehensive nursing assessment to assess response to ordered interventions; and - Documentation of wounds/skin issues will be documented per the wound assessment provided via the electronic medical record system. Review of the hospice providers policy titled, “;PC.D25 Documentation Requirements”, with a copyright date of 2021, showed, in part: - Members of the interdisciplinary group document the interventions provided to the patient/caregiver, their response to care, services provided, and the goals or outcomes achieved; - Documentation is completed by all Hospice staff and volunteers whenever patient/caregiver visits occur; and - The patient record documentation provides patient information specific to care and services/products provided, current patient status, and progress toward goals and outcomes of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 07/11/2024 with a primary diagnosis of Parkinson’s disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided in a long-term care facility (LTCF). Review of the SN (skilled nurse) visits dated 07/22/2024 and 08/03/2024 failed to show any wound description documented. During an interview on 10/03/2024 at 5:15PM, the RN/regional executive director stated that: - The providers policy was for wound measurements to be documented every 14 days; and - He/She would expect some sort of wound description documented at each SN visit.”

“Based on volunteer record review and interview, the provider failed to provide volunteer administrative and/or direct patient care services in the amount at a minimum, equaling five percent of the total patient care hours of all paid hospice employees and contract staff during 2023/2024 (the past 12 months). This deficient practice has the potential to affect the provider’s ability to provide volunteer services to patients. Findings included: Review of the policy titled, “;Volunteers - Services” dated 2021, showed in part: - The Volunteer Program is designed to meet Federal regulations for the provision of volunteer services to hospice patients and their caregivers. The Volunteer Program is monitored on a continuous basis to ensure it is functioning as intended and meeting the needs of the hospice program and its patients; - Volunteers are used in defined roles to support ancillary, administrative and/or patient care services and are treated as employees; and - Active and ongoing recruitment and retention efforts are sufficient to ensure that the hospice has enough volunteers to meet the needs of patients and families and the requirements of Federal regulations. Documentation is kept regarding these efforts. Review of the volunteer records for 2023 and 2024 (combined total for the past 12 months) showed the actual combined percentage of administrative and direct patient care by trained volunteers equaled 1.6% of the total patient care hours of all paid hospice employees and contracted staff. During an interview on 10/03/2024 at 10:30 AM, the administrator stated that he/she had noticed a problem with the volunteer program when he/she started as the administrator approximately two months ago and he/she educated the volunteer coordinator. The volunteer coordinator did not do what was required and a new volunteer coordinator was hired. The new coordinator is doing good and is reaching out to increase the volunteer program.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure all visit entries were completed and authenticated 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 “;Documentation Requirements” copyright 2021, showed in part, documentation was: - Completed by all hospice staff whenever the patient visit occurred; and - Accurate and timely. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 03/29/2024 with a primary diagnosis of malignant neoplasm (a cancerous tumor) of upper lobe of the right lung. The patient resided at his/her home with his/her daughter. Review of the skilled nursing (SN) visit dated 09/20/2024 showed the right buttock wound was “;resolved” on 09/29/2024 (nine days after visit date) and treatment to the coccyx (tailbone) wound and left hip wound was “;performed” on 09/29/2024. The registered nurse failed to use accurate dates. Review of the SN visit notes dated 09/23/2024 showed the catheter was “;inadvertently” removed and left out. Review of the “;Aide Care Plan Instructions” comments dated 09/25/2024 showed catheter care was “;completed.” Review of the “;Aide Care Plan Instructions” comments dated 10/01/2024 showed the catheter care was “;declined”, and the patient did not have a catheter. During an interview on 10/03/2024 at 1:30 PM the administrator stated that he/she would expect the aide care plan to be updated and the provider’s policies to be followed.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure a discharge summary was provided to the patients attending physician upon discharge from the hospice when a patient moved out of the hospice service area and was admitted to a non-contracted facility, in one of one applicable record reviewed (Record/Patient #10). This deficient practice has the potential to adversely affect the post discharge continuity of care for all the live patients discharged by the provider. Findings included: Review of the provider’s policy titled, “;Patient Discharge” last reviewed on 09/01/2024, showed in part: - The Hospice will forward copies of the following to the patients attending physician upon discharge from the Hospice’s services; * The Hospice discharge summary which includes but is not limited to: * A summary of the patient’s care (pain management, symptoms and treatments); * The patient’s 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 #10: Review of the clinical record, showed in part: - The patient was admitted to hospice services on 04/23/2024 with a primary diagnosis of malignant neoplasm of upper lobe, right bronchus or lung (cancer of the right bronchus or lung); - The patient resided at a long-term care facility (LTCF); - The patient was transported via emergency medical systems (EMS) to a medical center after attempting suicide by cutting his/her wrists; - Hospice was notified at 10:30 AM on 05/28/2024; - The hospital verbalized the patient was now under admitted status as of 05/28/2024 for suicide observation with no outside contact; and - The clinical record failed to include record that the discharge summary was provided to the patients attending physician after discharge from hospice services. During an interview, on 10/03/2024, beginning at 1:23 PM the hospice team coordinator stated that there was no proof the discharge summary had been sent to the attending physician.”

“Based on policy review, record review, observation, and interview the hospice provider failed to ensure coordination of responsibility for wound care between the hospice provider and the long-term care facility (LTCF) in one of two records reviewed of patients that resided in a LTCF (Record/Patient #3). This deficient practice has the potential to adversely affect all hospice patients residing in a LTCF. Findings included: Review of the hospice providers policy titled, “;Hospice care in a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facilities for individuals with intellectual disabilities,) dated last reviewed 09/01/2024, showed in part: - The hospice will assume responsibility for professional management of the patient’s hospice services provided, in accordance with the hospice plan of care (POC) and the hospice conditions of participation and make any arrangements necessary for hospice related inpatient care; - A Hospice POC will be developed based on the patient’s/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; and - The POC will identify the care and services that are specifically needed and identify which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 07/11/2024 with a primary diagnosis of Parkinson’s disease without dyskinesia, without mention of fluctuations (a neurological disorder that causes unintended or uncontrollable movements or stiffness, but currently without involuntary muscular movements or fluctuations). The patient resided in a LTCF. Review of the POC orders dated 07/18/2024 and 08/01/2024 showed: cleanse area to medial back with wound cleanser, pat dry, apply xeroform gauze (a nonadherent primary dressing that maintains a moist wound environment) to wound bed and cover with dry dressing once daily. (The POC failed to show who was responsible for the dressing changes (hospice or the facility). Review of the coordinated task plan dated 07/11/2024, in the facility binder, showed the portion under the wound care schedule was left blank. Per interview conducted during observation, on 10/01/2024 at 2:00 PM RN A stated that he/she did not see where the coordinated task plan identified who was changing the dressing or when. During an interview on 10/03/2024 at 4:56 PM, the administrator stated that he/she would expect the wound portion on the coordinated task plan to be filled out and who was responsible and when.”

“Based on policy review and interview, the provider failed to ensure orientation of long-term care facility (LTCF) staff caring for hospice patients on the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principals about death and dying, individual responses to death, patient rights, appropriate forms and record keeping requirements. This deficient practice has the potential to affect all patients residing in a LTCF. Findings included: Review of the policy titled “;PC.H50 Hospice Care for Nursing Facility Residents – Coordination of Services” dated 2021, showed in part: - The hospice provider ensures that mechanisms are in place to provide for the coordination of all hospice services provided to patients residing in facilities; - Hospice staff provide orientation to skilled nursing facility (SNF) staff furnishing care to hospice patients which includes: * Hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control and symptom management; * Principles about death and dying and individual responses to death; * Patient rights; * Appropriate forms; and * Record keeping requirements. During the survey entrance on 09/30/2024 at 10:30 AM, evidence that hospice philosophy training was offered to SNF/nursing facilities (NF) was requested from the provider administrator. The provider failed to provide evidence of training offered to the SNF/NF facilities. During an interview on 10/03/2024 at 2:35 PM, the administrator stated there was nothing prior to the SNF/NF being offered education on hospice philosophy. He/she did not know it was to be done, and it should have been done.”