Elevate Hospice

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 7 of 19 (37%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. Clinical Record 1: The patient was admitted on 07/18/2024 with a diagnosis of Lung Cancer. The clinical record lacked evidence that an initial bereavement assessment was completed by any discipline. Clinical Record 2: The patient was admitted on 06/13/2024 with a diagnosis of protein-calorie malnutrition. The clinical record lacked evidence that an initial bereavement assessment was completed by any discipline. Clinical Record 3: The patient was admitted on 10/23/2024 with a diagnosis of protein-calorie malnutrition. The clinical record lacked evidence that an initial bereavement assessment was completed by any discipline. Clinical Record 8: The patient was admitted on 09/27/2024 with a diagnosis of Multiple Sclerosis. The clinical record lacked evidence that an initial bereavement assessment was completed by any discipline. Clinical Record 6: The patient was admitted on 11/05/2024 with a diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record lacked evidence that an initial bereavement assessment was completed by any discipline. Clinical Record 13: The patient was admitted on 03/12/2024 with a diagnosis of protein-calorie malnutrition. The clinical record lacked evidence that an initial bereavement assessment was completed by any discipline. Clinical Record 19: The patient was admitted on 01/20/2024 with a diagnosis of Secondary Systemic Amyloidosis. The clinical record lacked evidence that an initial bereavement assessment was completed by any discipline. In an interview conducted on 11/14/2024 and following record reviews, the Administrator/Clinical Director agreed that the initial bereavement assessments were not conducted and thus were not included in the initial comprehensive assessments for these patients.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role, under the supervision of a designated hospice employee, and noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical record reviews revealed that the agency did not ensure patients who accepted volunteer services were noted in the care plan. Clinical Record 1: The Skilled Nurse (SN) performed a volunteer assessment on 07/18/2024, and the patient accepted the service. However, the Plan of Care (POC) for the certification period 07/18/2024 to 09/15/2024 did not include volunteer services nor were they discussed in the interdisciplinary team meetings. The clinical record lacked evidence that the volunteer services had been provided to the patient as requested nor was there evidence that the patient had later declined them. Clinical Record 4: The SN performed a volunteer assessment on 09/12/2024, and the patient accepted the service. However, the Plan of Care (POC) for the certification period 09/12/2024 to 12/10/2024 did not include volunteer services nor were they discussed in the interdisciplinary team meetings. The clinical record lacked evidence that the volunteer services had been provided to the patient as requested nor was there evidence that the patient had later declined them. The Administrator/Clinical Director was interviewed on 11/15/2024 and agreed volunteer services were not included in the plan of care.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper and includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed revealed that the agency did not ensure that the clinical record included physician orders. Clinical Record 2: The patient elected hospice on 06/13/2024 with diagnoses of protein-calorie malnutrition and emphysema. The Skilled Nurse (SN) visit note, dated 07/30/2024, documented that the patient had loose stools on 07/20/2024 and the caregiver gave the patient Imodium. The clinical record lacked evidence of a physician’s order for the Imodium. Clinical Record 7: The patient elected hospice on 06/01/2024 with a diagnosis of CVA with left-side hemiparesis and hemiplegia. A phone note dated 09/15/2024 from the patient’s daughter to the Licensed Vocational Nurse (LVN) stated, “the patient had been having a large amount of loose stools for two days and the daughter administered Imodium.” The LVN made a home visit at which time the daughter administered Imodium again. The LVN instructed the daughter not to give the Imodium longer than 24 hours before notifying hospice. The clinical record lacked evidence of a physician’s order for the Imodium. Clinical Record 11: The patient elected hospice on 12/08/2023 with a diagnosis of Alzheimer’s Disease. In the recertification Interdisciplinary Group meeting dated 10/02/2024, the Registered Nurse reported that the patient required oxygen at 2 liters per minute due to oxygen saturation dropping into the 80s. The clinical record lacked evidence of a physician’s order for the oxygen. Clinical Record 15: The patient elected hospice on 02/20/2024 with a diagnosis of Prostate Cancer with metastases to the lung and liver. The Interdisciplinary Group note dated 02/21/2024 included a note by the Physician that oxygen would be ordered. The clinical record included three oxygen checklist forms dated 02/21/2024, 02/23/2024, and 02/24/2024 that confirmed the presence of oxygen. The SN visit note dated 02/24/2024 stated that the oxygen was at 2 LPM and that the patient had a Foley catheter (placed 02/23/2024 per SN visit note). The clinical record lacked evidence of a physician’s order for the oxygen or Foley catheter. Clinical Record 16: The patient elected hospice on 08/30/2024 with a diagnosis of Cerebral Infarction with paraplegia and Dysphagia. The patient had a Foley catheter on admission to hospice. The clinical record lacked evidence of a physician’s order for the Foley catheter. In interviews on 11/14/2024 and 11/15/2024 following a review of the clinical records, the Administrator/Clinical Director agreed that these clinical records did not include all physician orders.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) live discharge clinical records reviewed it was revealed that the agency did not ensure that the patient’s attending physician was sent a copy of the hospice discharge summary Clinical Record 18: The patient was discharged on 10/02/2024. The clinical record lacked evidence that the discharge summary was sent to the patient’s attending physician. Following a clinical record review and interview, on 11/15/2024, the Administrator/Clinical Director agreed there was no evidence that the discharge summary was sent.”

“Based on policy review, record review, and interview, the hospice provider failed to promote and protect the following patient rights: - Immediately investigate all alleged violations involving anyone furnishing services on behalf of the hospice and immediately take action to prevent further potential violations while the alleged violation is being verified. Investigations and/or documentation of all alleged violations must be conducted in accordance with established procedures (L509); and Be free from mistreatment, neglect, or verbal, mental, and physical abuse (L517). The cumulative effect of these deficient practices has the potential to affect all patients served by the provider.”

“Based on policy review, record review, and interview, the hospice provider failed to document the investigation of an alleged violation of possible abuse and immediately take action to prevent further potential violations in accordance with established procedures in one of three records reviewed (Record/Patient #1). This deficient practice has the potential to affect the investigation of complaints and/or grievances of all patients served by the provider. Findings included: Review of the providers policy titled, “Abuse, Neglect, Mistreatment and Exploitation,” dated 2021, showed in part, that the administrator immediately (as soon as possible and not more than 24 hours after discovery of the incident) investigates alleged violations involving persons providing services on behalf of the hospice and immediately takes action to prevent further violation(s) during the investigation. If necessary, the Administrator will seek consultation to ensure an alleged violation is thoroughly investigated in order to verify whether or not it occurred and that it constituted abuse, neglect, mistreatment, or exploitation. RECORD/PATIENT #1: Review of the registered nurse (RN A) supervisory visit note, dated 12/26/2023 at 3:35 PM, showed the following: - Primary diagnosis was senile degeneration of the brain; -Alert to person and place and confused; -“The social worker and clinical director were notified of concerns of possible abuse as evidenced by recurring bruising to forearms and reports of tying patient to bed”; -The patients left forearm was bruised “;though” caregiver states the patient was scratching at his/her dry skin; and -The documentation failed to include any further information about the bruising or tying the patient to the bed and if this included staff or caregiver. During an interview on 01/03/2024 at 10:08 AM, RN A stated that he/she told the administrator, medical director, and social worker on 12/27/2023 about the patient. The patient was not in “immediate harm” and went to respite the next day. He/she did not feel the patient was abused. He/she was worried about the caregivers ability to care for the patients (the patients spouse was also on hospice). During an interview on 01/04/2024 at 8:28 AM, the administrator stated that the hospice nurse did a home visit on 12/26/2023, discussed concerns with interdisciplinary group (IDG) on 12/27/2023 and the patient had a new respite stay scheduled 12/29/2023. He/she did not complete an investigation.”

“Based on state statue review, policy review, clinical record review and interview, the hospice provider failed to immediately report to the state agency a concern of possible abuse as evidenced by recurring bruising to forearms and reports of tying the patient to the bed in one of three records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patient’s receiving hospice services. Findings included: 192.2405. Mandatory reporters--penalty for failure to report. — 1. The following persons shall be required to immediately report or cause a report to be made to the department under sections 192.2400 to 192.2470:   (1) Any person having reasonable cause to suspect that an eligible adult presents a likelihood of suffering serious physical harm, or bullying as defined in subdivision (2) of section 192.2400, and is in need of protective services; and   (2) Any adult day care worker, chiropractor, Christian Science practitioner, coroner, dentist, embalmer, employee of the departments of social services, mental health, or health and senior services, employee of a local area agency on aging or an organized area agency on aging program, emergency medical technician, firefighter, first responder, funeral director, home health agency, home health agency employee, hospital and clinic personnel engaged in the care or treatment of others, in-home services owner or provider, in-home services operator or employee, law enforcement officer, long-term care facility administrator or employee, medical examiner, medical resident or intern, mental health professional, minister, nurse, nurse practitioner, optometrist, other health practitioner, peace officer, pharmacist, physical therapist, physician, physician’s assistant, podiatrist, probation or parole officer, psychologist, social worker, or other person with the responsibility for the care of an eligible adult who has reasonable cause to suspect that the eligible adult has been subjected to abuse or neglect or observes the eligible adult being subjected to conditions or circumstances which would reasonably result in abuse or neglect. Notwithstanding any other provision of this section, a duly ordained minister, clergy, religious worker, or Christian Science practitioner while functioning in his or her ministerial capacity shall not be required to report concerning a privileged communication made to him or her in his or her professional capacity.   2. Any other person who becomes aware of circumstances that may reasonably be expected to be the result of, or result in, abuse or neglect of an eligible adult may report to the department.   3. The penalty for failing to report as required under subdivision (2) of subsection 1 of this section is provided under section 565.188. Review of the provider’s policy titled, “Abuse, Neglect, Mistreatment and Exploitation,” dated 2021, showed in part, the following: - If an alleged violation is verified, the Administrator: *Takes appropriate corrective action in accordance with state laws; and *Ensures that verified violations are reported to the accrediting organization, state and local bodies having jurisdiction (including the state survey and certification agency) within five days of becoming aware of the violation, unless state laws are more stringent. RECORD/PATIENT #1: Review of the registered nurse (RN) A supervisory visit note, dated 12/26/2023 at 3:35 PM, showed the following: - Primary diagnosis was senile degeneration of the brain; -Alert to person and place and confused; -“The social worker and clinical director were notified of concerns of possible abuse as evidenced by recurring bruising to forearms and reports of tying patient to bed”; and -The patients left forearm was bruised “;though” caregiver states the patient was scratching at his/her dry skin. During an interview on 01/04/2024 at 8:28 AM, the administrator stated that the hospice nurse did a home visit on 12/26/2023, discussed concerns with interdisciplinary group (IDG) on 12/27/2023 and the patient had a new respite stay scheduled 12/29/2023. He/she did not make a report to the Department of Health and Senior Services. During an interview on 01/04/2024 at 10:09 AM, RN A stated that he/she was a new nurse and did not know why he/she documented concerns of abuse all he/she wanted was staff to be more observant and painting a picture that the patients and caregiver were emotional. The hospice provider was working on respite placement. He/she was worried about the caregiver and his/her ability to provide care. He/she discussed the note during the IDG meeting on 12/27/2024. He/she did not make a report to the Department of Health and Senior Services.”