Alliance Home Health Care, LLC DBA Ambercare

“Based on policy review, record review, and interview, the Hospice Agency failed to provide education on symptom management, end-of-life signs and symptoms and safety precautions for three of 10 sampled patients (Patient (P) 2, P3, and P16) reviewed for care plan education. This deficient practice had the potential to affect all 40 patients receiving service at the Hospice agency. Review of the agency’s undated policy titled, “Patient Education Policy” revealed, “...6. Unless otherwise ordered by the physician (or other authorized licensed independent practitioner), the patient and family/caregiver will receive verbal, and as appropriate, written instructions on: A. Hospice philosophy and the nature of palliative care B. The patient’s disease process and prognosis C. The medical regimen D. Medication management and administration E. Food and drug interactions F. Nutrition interventions, modified diets, and oral health G. Prescribed treatments 7. Documentation of patient and family/caregiver education will consist of A. Describing what was taught to the patient (if using preprinted materials, document the name of the handout) B. Describing the patient’s response to the teaching, including the level of understanding and the ability to repeat or demonstrate what was taught C. Describing any additional learning needs not currently met ... 1. The patient’s and family/caregiver’s knowledge, skills, and behaviors will be assessed during hospice visits. Re-education, when appropriate, will be provided. 12. individual needs and learning styles will be evaluated when identifying appropriate methods and resources for patient education. H. Pain management ... K. Personal hygiene and grooming ...” 1. Review of P2’s “Patient Information Report,” dated 06/19/24, found in P2’s Electronic Medical Record (EMR) under the “Patient Information” tab, indicated that P2 had a diagnosis of “nicotine dependence.” Review of P2’s “Narrative Note,” completed by a Registered Nurse (RN) on 06/20/24 found in P2’s EMR under the “Skilled Nursing Note” tab revealed, “... Patient in bed smoking ...” There was no documentation from the RN that education was provided on the dangers of smoking in bed. Review of P2’s “Hospice Skilled Nursing Care Plan,” dated 06/19/24, found in P2’s EMR under the “Care Plan” tab, did not reveal documentation that nursing started a care plan for education on safety precautions regarding the dangers of smoking in bed. During an interview on 07/17/24 at 2:20 PM, the Area Vice President/ Registered Nurse (AVP/RN) confirmed education on the dangers of smoking in bed was not documented in P2’s EMR. The AVP/RN stated the nurse should have provided P2 education on the dangers of smoking in bed. 2. Review of P3’s “Skilled Nursing Note,” dated 02/09/24, found in P3’s EMR under the “Skilled Nursing” tab revealed, “Patient had large loose bowel movement. Deep stage 4 wound 4 cm [centimeter] x 4 cm, wound care provided. Receives 1 bottle Jevity [liquid nourishment] BID [two times a day] through PEG [a feeding tube placed into the stomach] tube.” There was no documentation indicating the nurse educated P3’s caregivers about the body’s decreasing nutritional needs at the end of life; and how tube feedings could cause skin breakdown due to frequent loose stools. Review of P3’s “Skilled Nursing Note,” dated 07/10/24, found in P3’s EMR, revealed, “Two stage 4 ulcers to right lateral hip, two stage 4 ulcers to sacrum ... Receiving Jevity twice daily. Incontinent bowel, patient has been having discolored green discharge appears to be vaginally.” There was no documentation indicating that the nurse educated P3’s caregivers about the body’s decreasing nutritional needs at the end of life; and how tube feedings could cause skin breakdown, and urinary tract infections due to frequent loose stools. Review of P3’s “Skilled Nursing Note,” dated 07/12/24 found in P3’s EMR, revealed, “PEG tube feedings twice a day. Patient has been having short periods of apnea [absence of breathing] and shallow abdominal breathing.” There was no documentation indicating that the nurse educated P3’s caregivers about the respiratory signs of end of life. . During an interview on 07/17/24 at 2:20 PM, the AVP/RN confirmed P3’smedical record lacked documentation of education to caregivers and stated the nurse should have educated P3’s caregivers on tube feedings, end of life signs and symptoms, and decreased nutritional needs at the end of life. 3. Review of P16’s “Skilled Nursing Note,” dated 08/21/23 found in P16’s EMR, revealed, “Primary diagnosis of malignant neoplasm of colon ... Patient having pain of 8 – 9 [indicates severe pain on scale of one to 10], unable to elaborate ...” There was no documentation indicating the nurse educated the patient or the patient’s caregiver on the use of pain medications and the importance of not waiting until the pain reaches a level of 8 or 9 before taking prn (as needed) pain medications. During an interview on 07/18/24 at 12:30 PM, the AVP/RN confirmed the nurse did not provide education to P16 or P16’s caregiver regarding the use of prn pain medications when pain is identified at a lower manageable level and before the pain escalates to a higher level.”

“Based on policy review, record review, and interview, the Hospice Agency failed to ensure that patient care plans incorporated measurable data elements to assess if progress toward expected outcomes of care plan goals were being met for five of 19 sampled patients (Patient (P) 3, P9, P12, P14, and P16) reviewed for care plan development. This deficient practice had the potential to affect all 40 patients receiving services from the Hospice Agency. Review of the agency’s policy dated 01/12/23 titled, “Monitoring Patient’s Response/Reporting to Physician,” revealed, “...Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each hospice visit. Progress of goals will be measured at regular intervals ...1. During each hospice visit, the clinician will monitor the patient’s response to care against established goals including, but not limited to: A. Care interventions for pain and symptom management B. Medications C. Teaching. ...” 1. Review of P3’s “Hospice POC (Plan of Care) Report,” found in P3’s Electronic Medical Record (EMR) under the “Care Plan” tab, indicated the Registered Nurse (RN) started P3’s care plan on 12/15/23 that included altered comfort, altered cardiac/circulatory system, and altered respiratory status. The care plan did not include measurable data elements to monitor progress toward the expected outcomes and goals. 2. Review of P9’s “Hospice POC Report,” found in P9’s EMR, indicated the RN started P9’s care plan on 06/26/24 that included altered comfort, altered endocrine (diabetes), and altered mental status. The care plan did not include measurable data elements to monitor progress toward the expected outcomes and goals. 3. Review of P12’s “Hospice POC Report,” found in P12’s EMR, indicated the RN started P12’s care plan on 06/19/24 that included altered comfort, altered mental status, altered nutrition/hydration, and altered gastrointestinal system. The care plan did not include measurable data elements to monitor progress toward the expected outcomes and goals. 4. Review of P14’s “Hospice POC Report,” found in P14’s EMR, indicated the RN started P14’s care plan on 06/28/24 that included altered cardiac/circulatory system, and altered respiratory status. The care plan did not include measurable data elements to monitor progress toward the expected outcomes and goals. 5. Review of P16’s “Hospice POC Report,” found in P16’s EMR, indicated the RN started P16’s care plan on 07/06/24 that included altered comfort, altered cardiac/circulatory system, altered respiratory status, and altered gastrointestinal status. The care plan did not include measurable data elements to monitor progress toward the expected outcomes and goals. During an interview on 07/18/24 at 3:00 PM, the Area Vice President/Registered Nurse (AVP/RN) confirmed that measurable data elements were not incorporated in P3’s, P9’s, P12’s, P14’s, and P16’s care plans.”