Robert Wood Johnson Visiting Nurse, Inc.

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by clinical record reviews, document reviews, and interviews with the Administrator, Clinical Manager and Quality Team which revealed the hospice failed to ensure that the Registered Nurse (RN) coordinated care, continuously assessed the patient’s needs, and implemented the plan of care (POC) in 3 of 19 (16%) clinical records reviewed [HCPC.19.I/L540]; Failed to ensure that each patient’s individualized written plan of care included the treatments and drugs necessary to meet the patient’s needs in 6 of 19 (32%) clinical records reviewed [HCPC.21.I/L549]; and Failed to ensure that the plan of care documented planned interventions based on problems identified in the initial and updated comprehensive assessments in 6 of 19 (32%) clinical records reviewed [HCPC.21.i/L545]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, observation, and interview. Agency policy # H3.01 “Comprehensive Assessment” stated in part, “Drug profile a review of the entire patient’s prescription and over-the-counter medications, herbal remedies and any other alternative that could affect drug therapy.” In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a review of the patient’s medications. Clinical Record 8/Home Visit 1: The patient elected hospice care on 11/11/2022 with a primary diagnosis of pulmonary disease. The patient resided in a skilled nursing facility (SNF). A facility medication list was obtained and reviewed during the home visit with the Registered Nurse (RN) [Personnel Record 2] on 07/15/2024. The facility medication list documented: Mirtazapine 1 tablet daily at bedtime for appetite with an order date of 04/12/2024 and Pepcid 20 mg two times a day with an order date of 05/07/2024. These medications were not documented on the hospice medication profile. There was no evidence that the Mirtazapine and Pepcid were reviewed during the patient’s medication regimen review. Additionally, the hospice medication profile documented Claritin 10 mg orally every am dated 06/23/2023, which was not included on the facility medication list as of the review on 07/16/2023. Clinical Record 18: The patient elected hospice care on 05/16/2024 with a primary diagnosis of senile dementia. The nursing assessment dated 05/23/2024 documented that wound care was provided and that Dakin Solution was ordered for wound care. The Dakin Solution was not documented on the medication profile as of review on 07/18/2024. There was no evidence that the Dakin Solution was reviewed during the patient’s medication regimen review. During an interview, the Quality Team agreed that the medication profiles had not been updated completely and that this was a current process improvement process.”

“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, document review, and interview. Agency policy #H3.01 “Comprehensive Assessment” stated in part, “The comprehensive assessment must take into consideration the following: An initial bereavement assessment of the needs of the patient’s family and other individuals that focuses on the social, spiritual and cultural factors that may impact their ability to cope with the patient’s death. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the initial bereavement assessment was completed. Clinical Record 14: The patient elected hospice care on 05/07/2024. The Registered Nurse (RN) completed the comprehensive assessment on 05/07/2024. The attempted visits of the social worker (SW) and spiritual care were documented and declined by the patient for various reasons. A pre-bereavement risk assessment was not documented as of the clinical record review on 07/17/2024. There was no documented pre-bereavement assessment to evaluate the family’s coping with the impending death. During an interview, the Quality Team agreed that the assessment had not been completed.”

“It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; [and] ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #5.32 “Wound Care, Assessment and Measurement” stated in part, “Measure wound on admission, resumption of care or first visit of the week (preferred) and prn, any change in wound status /condition, and documented.” In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the Registered Nurse (RN) coordinated care, continuously assessed the patient’s needs, and implemented the plan of care (POC). Clinical Record 8/Home Visit 1: The patient elected hospice care on 11/11/2022 with a diagnosis of chronic pulmonary disease (COPD). The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 2] on 07/15/2024, the patient continuously wore oxygen and stated that they had been wearing it. The current plan of care documented: “Instructed patient caregiver to post the No Smoking signs on entry doors and or windows.” During the home visit to the SNF, there were numerous patient rooms with posted oxygen safety signs on the door frame. The entry door to the patient’s room had no oxygen safety sign posted. No oxygen safety sign was posted in the patient’s room. The RN [Personnel Record 2] stated in the interview, “I don’t see a sign posted.” Clinical Record 15: The patient elected hospice care on 06/17/2024 with a diagnosis of Alzheimer’s Disease. The RN completed the initial comprehensive assessment on 06/17/2024, documenting that the patient’s identified wounds were measured. No further wound measurements or descriptions were documented as of the clinical record review on 07/16/2024, with four (4) weeks outstanding. Clinical Record 18: The patient elected hospice care on 05/16/2024 with a diagnosis of senile dementia and sacral and heel wounds. The RN comprehensive assessment dated 05/16/2024 documented measurements for the sacral and heel wounds. No heel wound measurements were documented. On 07/11/2024, the heel wound was documented as healed. The sacral wound measurements were documented on 05/16/2024, 05/31/2024, 06/06/2024, and 06/282024. A clinical record review revealed that the wound measurements were not documented weekly or on the recommended first visit of the week per the agency policy. The sacral wound, which had tunneled and undermined, had improved by 07/11/2024. During an interview, the Quality Team confirmed that the measurements had not been documented and stated that this was self-identified with a current process improvement plan.”

“It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy # H3.03 “Interdisciplinary Plan of Care” stated in part, “Patient and family goals and interventions based on the identification of the needs of the patient, family and caregiver in the initial, comprehensive and updated comprehensive assessment. And Individualized interventions to assist with end of life care.” In 6 of 19 (32%) clinical records reviewed, the agency did not ensure that the plan of care documented planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice care on 03/08/2024. The Registered Nurse (RN) initial comprehensive assessment dated 03/08/2024 documented the patient’s nutritional problems and use of Glucerna and a lidocaine swish. The assessment dated 03/10/2024 documented the patient’s excessive secretions that required suctioning with a yankauer suction catheter. The POC documented, “educated patient/caregiver on measures to decrease excess secretions.” The POC did not document an intervention(s) to address the patient’s identified problem with excessive secretions. Clinical Record 6/Home Visit 2: The patient elected hospice care on 06/01/2024 with a primary diagnosis of Alzheimer’s Disease. During the home visit on 07/17/2024, the patient was wearing hand protectors. The patient’s daughter stated that the hand protectors had been used since the patient’s admission to hospice to protect the patient’s skin at night. The RN initial comprehensive assessment documented the patient’s problems with skin integrity. The daughter stated that all the medications were in a locked box as they have a toddler who opens everything. The POC, dated 06/28/2024, documented the intervention to address the altered skin integrity: “educated and instructed patient caregiver on when to notify the nurse of changes.” The POC did not document the patient’s nightly use of gloves to protect the patient from picking at and tearing the skin as part of the intervention. The POC did not document an intervention to address the safety problem of the toddler in the home and the lockbox. Clinical Record 8/Home Visit 1: The patient elected hospice care on 11/11/2022 with a primary diagnosis of pulmonary disease. The patient had a documented eye infection/irritations from 04/07/2024 through 04/27/2023 that was treated with Tobradex (antibiotic eye drop) eye drops, Claritin (treats allergies), and later Benadryl (treats allergies) for the symptoms. The POC was not updated to include interventions to address the patient’s identified problem with the eye infection/irritations. During the home visit with the Registered Nurse (RN) [Personnel Record 2] on 07/15/2024, the patient described a skin irritation and rash on their right arm that the patient had for over a week. The RN [Personnel Record 2] evaluated the rash to see if it improved. The plan of care did not document interventions for the patient’s identified problem with skin irritation and rash, which had been described as a problem for over a week. Clinical Record 10: The patient elected hospice care on 06/24/2024 with a primary diagnosis of vulva cancer. The RN initial comprehensive assessment dated 06/24/2024 documented the patient’s problems with constipation. The patient was prescribed senna (stool softener). The POC did not include documentation of interventions for the identified constipation problem. Clinical Record 11: The patient elected hospice care on 06/06/2024 with a primary diagnosis of senile dementia. The RN initial comprehensive assessment dated 06/06/2024 documented that the patient required maximal assistance for transfers. The updated assessment dated 07/02/2024 documented the patient’s urinary incontinence and the addition of Macrobid (an antibiotic), which was ordered to treat the patient’s urinary tract infection. The plan of care did not document interventions for patient safety related to the patient’s requiring maximum assistance. The POC was not updated to include documentation of interventions related to the patient’s identified problems with urinary incontinence and urinary tract infection as of the clinical record review on 07/18/2024. Clinical Record 12: The patient elected hospice care on 06/21/2024 with a primary diagnosis of copper malabsorption. The patient was a five-year-old child. The RN initial comprehensive assessment dated 06/21/2024 documented the patient’s tube feedings and problems with gastroesophageal reflux disease (GERD) and constipation. The POC did not include documentation of interventions for the identified problems of GERD and constipation. During the interview, the Quality Team stated that the details and updates of interventions were part of a current process improvement project.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met, as evidenced by clinical record review, observation, and interview. In 6 of 19 (32%) clinical records reviewed, the agency did not ensure that the plan of care included all drugs and treatments necessary to meet the patient’s needs. Clinical Record 2: The patient elected hospice care on 11/23/2023 with a diagnosis of cervical cancer. The RN initial comprehensive assessment dated 11/23/2023 documented the patient’s bilateral nephrostomy tubes, colostomy, and PICC (peripherally inserted central catheter) line with a continuous infusion of PCA (patient-controlled anesthesia). The nursing visit note dated 11/23/2023 documented the patient’s arm measurement and amount of external length of the PICC line as well as the dressing. The skilled nursing visit notes documented that the sterile dressing was changed every 7 days and prn (as needed) and that the nephrostomy tubes had split 4 x 4 gauze dressings which were changed daily and prn. Additionally, the nephrostomy tubes were flushed on occasion. The plan of care did not include orders and interventions for the PICC line and nephrostomy tube care and maintenance as of the clinical record review 07/18/2024. Clinical Record 6/Home Visit 2: The patient elected hospice care on 06/01/2024 with a primary diagnosis of Alzheimer’s Disease. During the home visit on 07/17/2024, the daughter reported that the patient had trouble with dysphagia, requiring her to sit up during meals and use Thick-It. The problem list for altered nutrition documented on 06/28/2024 documented the intervention: “educated patient /caregiver on risks for aspiration.” The POC did not document orders and interventions regarding the use of the Thick-It, who is to use it, and the positioning of the patient during and following the feedings. Clinical Record 8/Home Visit 1: The patient elected hospice care on 11/11/2022 with a primary diagnosis of pulmonary disease. The patient resided in a skilled nursing facility (SNF). During the home visit on 07/15/2024, a facility medication list was obtained and reviewed. The facility medication list documented: Mirtazapine 1 tablet daily at bedtime for appetite with an order date of 04/12/2024 and Pepcid 20 mg two times a day with an order date of 05/07/2024. These medications were not documented in the plan of care. Clinical Record 12: The patient elected hospice care on 06/21/2024 with a primary diagnosis of copper malabsorption. The patient was a five-year-old child. The RN initial comprehensive assessment dated 06/21/2024 documented the patient’s tube feedings and problems with gastroesophageal reflux disease (GERD) and constipation. The plan of care did not document orders for the care and maintenance of the feeding tube, including site care and feeding instructions, including head of bed directions, flushing of the tube, rate of flow for the tube feeding, and maintenance and safety of the solution. Clinical Record 17: The patient elected hospice care on 06/02/2024 with a primary diagnosis of Parkinson’s disease. The RN initial comprehensive assessment dated 06/02/2024 documented that the patient had a 16 French 10cc catheter in place that required flushing, changing, drainage, and cleaning, and “Instructed patient/caregiver on the proper care of the indwelling catheter.” The plan of care did not include documentation of orders or interventions for the care and maintenance of the Foley catheter. Clinical Record 18: The patient elected hospice care on 05/16/2024 with a primary diagnosis of senile dementia. The nursing assessment dated 05/23/2024 documented that wound care was provided and that Dakin Solution was ordered for wound care. However, as of the clinical record review on 07/18/2024, the Dakin Solution was not documented on the plan of care. During the interview, the Quality Team stated that the details and updates of interventions were part of a current process improvement project.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; [and] the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy # H10.01 “Bereavement Program Services,” stated in part, “The Bereavement Coordinator and /or assigned MSW will review the Bereavement Risk Assessment after notification of the patient’s death, determine the risk category and develop an individualized Plan of Care...” In 4 of 4 (100%) clinical records reviewed in which the hospice patient died, the agency did not ensure that patient’s bereavement plan of care included bereavement services reflecting the needs of the bereaved and the frequency of service delivery. Clinical Record 1: The patient elected hospice care on 03/08/2024 and died on 03/29/2024. The bereavement plan of care (POC) included a standard form letter for 13 months, information/referral to community support quarterly correspondence, and an annual memorial event. The first successful contact was documented as 05/01/2024, and the last was 05/22/2024. The contact was with the son, who responded for the bereaved mother, who was not available at the time. There was no further documentation. The plan did not document a specific timeline and details of the mailings to be provided. Clinical Record 2: The patient elected hospice care on 11/23/2023 and died on 11/28/2023. The bereavement plan of care documented that after the initial contact, correspondence would be provided at three, six, nine, and twelve months, up to 13 months. The risk level was identified as low. The documented contact was 12/29/2023, with no further documentation. The patient was young with three (3) young children and a spouse surviving. The plan did not clearly document the kind of contact and if more frequent contact was made. During an interview, the Bereavement Coordinator revealed that they had a calendar in another software that documented contacts and mailings with greater frequency, every two weeks. The continued plan was not clear, and the information in the other software was not part of the clinical record. Clinical Record 3: The patient elected hospice care on 06/23/2023 and died on 07/11/2024. The bereaved score was documented as low. The bereavement plan of care included an initial contact, a standard bereavement form letter sent for 13 months, information for referrals to community support, and quarterly correspondence with notification of the annual memorial event. The plan did not document a specific timeline and details of the mailings to be provided. The bereaved score was documented as low. Clinical Record 4: The patient elected hospice care on 09/23/2023 and died on 09/29/2023. The bereavement plan of care was for 13 months with the interventions: referral to community support, quarterly correspondence, and an invitation to an annual memorial event. This bereavement plan did not document details of contact and frequency of services to be provided. During an interview with the bereavement coordinator, it was shared that in another software, a different schedule of contacts and mailings was documented with different timelines than the plans documented. She agreed that this was not in the clinical record and that plans would be updated for the specific information and frequency.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 16 (6%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA received clear and specific patient care instructions from the Registered Nurse (RN). Clinical Record 2: The patient elected hospice care on 11/23/2023 with a diagnosis of cervical cancer. The Aide Care Plan documented on 11/23/2023 and updated on 11/25/2023 assigned the HA the relevant tasks: bed bath and empty urinary drainage bag every visit. The patient had nephrostomy tubes, a colostomy, and a PCA (patient-controlled anesthesia) pump infusing continuously with a sterile dressing over the PICC (peripherally inserted central catheter) line. The Aide Care Plan did not provide the HA with instructions for the nephrostomy tubes or the colostomy to be emptied. Additionally, the Aide Care Plan did not identify and provide the HA specific instructions for the PCA pump with a dressing over the PICC line site and the care of the dressing during personal care. The Aide Care Plan was non-specific regarding the patient’s dietary needs. Offering fluids was an assigned task, but the care plan did not provide specifics regarding the consistency of the liquids. It was unclear if all liquids were ordered to be “sips” or “Thick IT” added. The patient’s plan of care documented the safety measures, aspiration precautions, and oxygen precautions, which were not identified in the HA Care Plan. During an interview, the Quality Team stated that the aide plan lacked specific information but the clinical leadership for the aides did orient the aide to the plan of care.”

“It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 16 (6%) clinical records reviewed, the agency did not ensure that the Hospice Aide (HA) provided services included in the plan of care. Clinical Record 6/Home Visit 2: The patient elected hospice care on 06/01/2024 with a diagnosis of Alzheimer’s Disease. The HA care plan documented on 06/01/2024 assigned the HA the relevant task of a bed bath every visit. During the home visit with the Hospice Aide (HA) [Personnel Record 2] on 07/17/2024, the HA performed hand hygiene and then helped the patient out of bed and to the bathroom. The HA stated that they had been giving the patient a shower using the shower chair. All items for the shower were organized prior to the patient being moved to the bathroom. The HA documented a bed bath every visit in the visit notes but stated during interview that was related to technology and a shower had been provided. During an interview, the Quality Team stated that the Case Manager had been contacted and the HA care plan was updated to fit the bathing care.”

“It is required that each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, observation, and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that the patient’s clinical record contained physician orders for wound care. Clinical Record 14/Home Visit 3: The patient elected hospice care on 05/07/2024 with a primary diagnosis of rectal cancer. During the home visit with the Registered Nurse (RN) [Personnel Record 10] on 07/16/2024, it was revealed that each visit wound care was provided to the nephrostomy including cleaning with wound cleanser, application of 4 x 4 split gauze, and covering with a gauze dressing. A clinical record review revealed no orders for nephrostomy wound care. Clinical Record 15: The patient elected hospice care on 06/17/2024 with a primary diagnosis of Alzheimer’s disease. On 06/19/2024, the physician ordered wound care: “Medihoney topical gel applied to the wound” and “Wound cleanser irrigation spray” to cleanse the wound 3 times a week and prn. Additionally, a nursing visit note documented that Optifoam was used to cover the wound. The physician’s order did not document the location of the wound or the type of dressing to cover the wound. Clinical Record 16: The patient elected hospice care on 05/28/2024 with a primary diagnosis of prostate cancer. On 05/30/2024, the physician ordered wound care: “Cleanse the wound with wound spray, apply hydrogel, skin prep, and cover with Optifoam dressing” change 3 times a week. The physician’s order did not document the location of the wound until 06/18/2024. Clinical Record 18: The patient elected hospice care on 05/16/2024 with a primary diagnosis of senile dementia. The patient had a sacral wound and a heel wound. The plan of care orders for wound care did not document the location of the wounds or the frequency of the wound care, as of the clinical record review on 07/19/2024. During an interview, the Quality Team agreed that the physician orders were not complete.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The plan of care reflects the participation of the hospice, the SNF/NF or ICF/IDF, and the patient and family to the extent possible. All hospice care is provided in the facility in accordance with the hospice plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients residing in a skilled nursing facility (SNF), the agency did not ensure that care was coordinated with the facility to the extent possible. Clinical Record 8/Home Visit 1: The patient elected hospice care on 11/11/2022 with a primary diagnosis of pulmonary disease. The patient resided in a skilled nursing facility (SNF). A facility medication list was obtained and reviewed during the home visit with the Registered Nurse (RN) [Personnel Record 2] on 07/15/2024. The facility medication list documented: Mirtazapine 1 tablet daily at bedtime for appetite with an order date of 04/12/2024 and Pepcid 20 mg two times a day with an order date of 05/07/2024. These medications were not documented on the hospice medication profile. There was no evidence that the Mirtazapine and Pepcid were reviewed during the patient’s medication regimen review. Additionally, the hospice medication profile documented Claritin 10 mg orally every am dated 06/23/2023, which was not included on the facility medication list as of the review on 07/16/2023. There was no evidence of coordination of the patient’s medication regimen between the facility and the agency. During an interview, RN case manager stated that they did not realize the medication lists were different.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by personnel record review, document review, and interview. In 1 of 5 (20%) contracts reviewed, the agency did not ensure that the contract documented the requirement for criminal background checks on all hospice employees who have direct patient contact or access to patient records. Personnel Record 4/Contract 2: The Medical Director (MD) contract was signed on 08/01/2023 and addended on 07/18/2024. The contract did not document that all contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. The MD had a criminal background completed. During the interview and a joint review of the contract, the Management Team confirmed the finding and the contract was addended during the site visit to include the criminal background requirement.”