Community Care Hospice

“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 effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. 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, interview and observation. In 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure that the drug profile included the patient’s current medications. Agency Policy IV.-020 Medication Profile revision date 03/2024 read in part “3. The medication profile will be updated with each visit as needed. Additions or discontinuation of any medication or supplement will be noted in the appropriate place on the computerized medication profile and on the paper medication profile in the patient’s home. Each time a change is made a new medication profile will be printed and brought to the patient’s home on the next scheduled visit.” Home Visit 1/Clinical Record 1: The patient elected hospice on 06/04/2024 with a diagnosis of Unspecified Severe Protein Calorie Malnutrition. The assisted living facility (ALF) medication profile was reviewed with the Hospice Manager (Personnel Record 2) and facility nurse during the home visit on 10/09/2024. The medications at the facility did not match the hospice medication profile or the ‘Hospice Skilled Nurse (SN) Interdisciplinary Team (IDT) Meeting’ forms (care plan update) dated 08/21/2024 and 09/04/2024. The hospice medication profile did not include Melatonin 5mg tablet daily at bedtime beginning 08/052024, Oxycodone HCL 5 mg tablet twice daily beginning 08/05/2024, or Oxygen 2 lpm as needed (PRN) beginning 08/15/2024 which were all listed on the ALF medication profile. Home Visit 3/Clinical Record 3: The patient elected hospice on 01/17/2024 with a diagnosis of Alzheimer’s Disease. A skilled nursing visit was completed on 08/05/2024. The documentation read in part: “Equipment in the home: Oxygen, Oxygen Supplies”. The ‘Hospice SN IDT Meeting’ form (care plan update) from 08/07/2024 read in part “Oxygen at 2 LPM via nasal cannula PRN for respiratory comfort or distress”. During the home visit with the chaplain (Personnel Record 4) on 10/09/2024, an oxygen concentrator was observed in the room. The hospice medication profile did not include the prescribed oxygen.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) clinical record reviewed revealed that the agency did not ensure that the Registered Nurse provided coordination of care to ensure continuous assessment of the patient and family needs, and implementation of the interdisciplinary plan of care. Agency Policy: H: 2-032 Interdisciplinary Group Coordination of Care review date: 07/2024 read in part “3. It will be the responsibility of the Hospice Nurse Case Manager/Hospice Registered Nurse (RN) to facilitate communication about changes in the patient’s status between the interdisciplinary group members and the patient’s attending physician. 5. When the patient requires services from the interdisciplinary group, the Hospice Nurse Case Manager will be responsible for cooperative care planning to assure goals, interventions, and outcomes are palliative in nature.” Clinical Record 1: The patient elected hospice care on 06/04/2024 with a diagnosis of unspecified severe protein-calorie malnutrition. The ‘Hospice Skilled Nurse (SN) Interdisciplinary Team (IDT) Meeting’ forms (care plan update) and hospice aide plan of care were updated on 08/21/2024 to include complete bed baths three times a week. The hospice aide documented that the patient refused the complete bad baths for all three visits the week of 09/10/2024 and the week of 09/17/2024. The clinical record lacked evidence that coordination occurred between the registered nurse and hospice aide related to the effectiveness of the hospice aide care plan after two consecutive weeks of the patient refusing complete bed baths. Furthermore, the clinical record included documentation that the patient was treated with antibiotics on 07/08/2024 (Macrobid) and 07/23/2024 (Amoxicillin) for signs and symptoms of a urinary tract infection (UTI). The clinical record lacked evidence that the RN Case Manager coordinated care and ensured the interdisciplinary plan of care was updated to include goals and interventions related to the UTI’s. Clinical Record 2: The patient elected hospice care on 02/07/2024 with a diagnosis of Amyotrophic Lateral Sclerosis. The clinical record included documentation that the patient was treated with antibiotics on 02/08/2024 (Cefuroxime) for signs and symptoms of a urinary tract infection (UTI). The clinical record lacked evidence that the RN Case Manager coordinated care and ensured the interdisciplinary plan of care was updated to include goals and interventions related to the UTI. Clinical Record 3: The patient elected hospice care on 01/17/2024 with a diagnosis of Alzheimer’s disease. A skilled nursing visit dated 06/28/2024 documented in part, “noted thick yellow drainage from left medial calf wound. Dr. (Name) notified; new order given to start this afternoon. Added Keflex 500 mg”. The clinical record lacked evidence that the RN Case Manager coordinated care and ensured the interdisciplinary plan of care was updated to include goals and interventions related to the wound. In a joint record review and interview on 10/09/2024, the Hospice Manager (Personnel Record 2) confirmed that the clinical record lacked evidence that the registered nurse coordinated with the hospice aide after two consecutive weeks of the patient refusing complete bed baths and confirmed the plans of care did not include the patient and family goals and planned interventions for problems identified during the comprehensive assessments.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and 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. In 3 of 14 (21%) clinical records reviewed it was revealed that that agency did not ensure the patient’s individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and comprehensive assessments. Clinical Record 1: The patient elected hospice care on 06/04/2024 with a diagnosis of Unspecified severe protein-calorie malnutrition. A skilled nursing visit dated 07/08/2024, documented in part “Patient was started over the weekend on Macrobid 100 mg po bid (by mouth, twice a day) per MD orders for a urinary tract infection (UTI).” A skilled nursing visit dated 07/23/2024 documented in part, “according to the facility staff the patient showed signs of UTI with cloudy urine but no complaints of symptoms. The nursing staff called Dr.(Name) who ordered urine for C&S results were returned today and given. Start on Amoxicillin 250mg q12 for 7 days (added to MAR)”. There was no documented evidence that the plans of care were updated to include interventions related to the UTI. Clinical Record 2: The patient elected hospice care on 02/07/2024 with a diagnosis of Amyotrophic Lateral Sclerosis. A skilled nursing visit dated 02/08/2024 documented in part, “Patient has had little to no urine since Sunday, took urine sample this am to lab to check for UTI, MD has started patient on Cefuroxime 500 mg q12 h x 10 days”. There was no documented evidence that the plans of care were updated to include interventions related to the UTI. Clinical Record 3: The patient elected hospice care on 01/17/2024 with a diagnosis of Alzheimer’s disease. A skilled nursing visit dated 06/28/2024 documented in part, “noted thick yellow drainage from left medial calf wound. Dr. (Name) notified; new order given to start this afternoon. Added Keflex 500 mg”. There was no documented evidence that the plans of care were updated to include interventions related to the wound. During the joint record review and interview on 10/09/2024, the Hospice Manager (Personnel Record 2) confirmed the plans of care did not include the patient and family goals and planned interventions for problems identified during the comprehensive assessments.”

“It is required that a hospice aide provides services that are ordered by the interdisciplinary group. This standard was not met as evidenced by clinical record review, and interview. In 1 of 8 (12%) clinical records reviewed, for patient’s that received hospice aide services, it was revealed that the agency did not ensure that the hospice aide provided services as ordered by the interdisciplinary group (IDT). Clinical Record 1/Home Visit 1: The patient elected hospice care on 06/04/2024 with a diagnosis of unspecified severe protein-calorie malnutrition. The ‘Hospice Skilled Nurse (SN) Interdisciplinary Team (IDT) Meeting’ form (care plan update) dated 08/21/2024 included a hospice aide visit frequency of three times a week. The hospice aide plan of care was updated on 08/21/2024 to include orders for a complete bed bath every visit. The patient was seen three times a week beginning the week of 08/25/2024. The hospice aide documented that the patient refused the complete bad bath for visits completed on 09/10/2024, 09/11/2024, 09/12/2024, 09/17/2024, 09/18/2024, and 09/19/2024. The hospice aide plan of care was reviewed with the hospice aide (Personnel Record 3) on 10/09/2024 and the aide was asked to explain the refusal of the complete bed baths the weeks of 09/08/2024 and 09/15/2024 and how changes to the hospice plan of care are communicated to the registered nurse. The hospice aide stated in part “Sometimes he (patient) just wants to get washed up at the sink. I just do what he wants done, I haven’t called the nurse.” In a joint record review and interview on 10/09/2024, the Hospice Manager (Personnel Record 2) confirmed that the hospice aide’s plan of care did not include bathing the patient at the sink that the hospice aide verbalized was being provided when a complete bed bath was refused.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities and complete records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 8 (12%) clinical records reviewed, for patient’s that received hospice aide services, it was revealed that the agency did not ensure that the hospice aide reported changes in the patient’s needs to the registered nurse. Agency Policy: H:2-005 Hospice Aide Services revision date: 07/2024 read in part “Hospice aide duties include: D. Reporting changes in the patient’s condition and needs”. Clinical Record 1/Home Visit 1: The patient elected hospice care on 06/04/2024 with a diagnosis of unspecified severe protein-calorie malnutrition. The ‘Hospice Skilled Nurse (SN) Interdisciplinary Team (IDT) Meeting’ form (care plan update) dated 08/21/2024 included a hospice aide visit frequency of three times a week. The hospice aide plan of care was updated on 08/21/2024 to include orders for a complete bed bath every visit. The patient was seen three times a week beginning the week of 08/25/2024. The hospice aide documented that the patient refused the complete bad bath for visits completed on 09/10/2024, 09/11/2024, 09/12/2024, 09/17/2024, 09/18/2024, and 09/19/2024. The hospice aide plan of care was reviewed with the hospice aide (Personnel Record 3) on 10/09/2024 and the aide was asked to explain the refusal of the complete bed baths the weeks of 09/08/2024 and 09/15/2024 and how changes to the hospice plan of care are communicated to the registered nurse. The hospice aide stated in part “Sometimes he (patient) just wants to get washed up at the sink. I just do what he wants done, I haven’t called the nurse.” The clinical record lacked evidence that the hospice aide documentation included complete records of service, including the report of changes in the patient’s needs. The Hospice Manager (Personnel Record 2) confirmed findings during the home visit observation on 10/09/2024 and stated in part “I just realized that last night when I was reviewing his chart, I will get that updated.””

“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, document review and interview. In 1 of 2 (50%) discharged clinical records reviewed it was revealed that the agency did not ensure the patient’s attending physician was forwarded a copy of the hospice discharge summary. Agency Policy: H:2-059 Discharge Summary review date: 07/2024 read in part “3. A copy of the discharge summary will be provided to the patient’s physician when the patient is transferred or discharged in accordance with 418.26 (COPS).” Clinical Record 11: The patient elected hospice care on 09/28/2023 with a diagnosis of malignant neoplasm of unspecified part of bronchus or lung discharge. The patient was discharged on 10/02/2023 due to moving out of the service area. A ‘Hospice Skilled Nurse Discharge’ form was completed on 10/02/2024 that included: discharge reason, reason for revocation, effective date of revocation, hospice discharge date, and notification of discharge. The clinical record lacked evidence that the discharge summary was forwarded to the patient’s attending physician. The Hospice Manager (Personnel Record 2) confirmed the findings in a joint record review and interview on 10/10/2024 and stated in part “I’m sure it was sent to the physician, but I don’t see it in the documentation.””

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) discharged clinical records reviewed, in which a discharge summary was required, it was revealed that the agency did not ensure that the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the attending physician. Agency Policy: H:2-059 Discharge Summary review date: 07/2024 read in part “Hospice personnel who provide care will complete a discharge summary at the time the patient is discharged, which may include, as appropriate: A. The date of discharge B. The reason for discharge, including the name of the organization to which the patient is being transferred, if applicable C. A summary of the patient’s stay including treatments, symptoms and pain management D. The patient’s current plan of care E. The latest physician orders F. Continuing symptom management needs G. The overall status of the patient H. Other documentation facilitating continuity of care and/or requested by the attending physician or receiving physician.” Clinical Record 11: The patient elected hospice care on 09/28/2023 with a diagnosis of malignant neoplasm of unspecified part of bronchus or lung discharge. The patient was discharged from hospice on 10/02/2023 due to moving out of the service area. A ‘Hospice Skilled Nurse (SN) Discharge’ form was completed on 10/02/2024 that included the discharge reason, reason for revocation, effective date of revocation, hospice discharge date, and notification of discharge. The clinical record lacked evidence that the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. Clinical Record 12: The patient elected hospice care on 03/30/2024 with diagnosis of malignant neoplasm of the rectum. The patient discharged from hospice on 06/26/2024 due to moving out of the service area. A ‘Hospice SN Discharge’ form was completed on 10/02/2024 that included the discharge reason, reason for revocation, effective date of revocation, hospice discharge date, and notification of discharge. The clinical record lacked evidence that the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. The Hospice Manager (Personnel Record 2) confirmed the findings in a joint record review and interview on 10/10/2024 and stated in part “We are not currently adding that to the discharge summary, but we can easily add.””