A+ Hospice Care

“It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient live discharge, the agency did not ensure the patient was involved in the development of his or her plan of care. Clinical Record 15: The patient elected the hospice benefit on 03/20/2023 for the diagnosis of chronic obstructive pulmonary disease and was discharged for extended prognosis on 09/15/2023. Clinical record review revealed the Notification of Medicare Non-Coverage was signed by the patient on the day of discharge dated 09/15/2023. Medicare guidance for completion of the NOMNC form documented, The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Clinical record review did not include documentation that the patient was provided with discharge information in advance of the discharge and was not allowed to participate in the plan of care. During an interview and joint record review on 07/24/2024, the Administrator/Director of Nursing and Alternative Director of Nursing looked at the date on the form and stated it was signed too late.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure the Interdisciplinary Group completed the initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 07/02/2024 for the diagnosis of senile degeneration of the brain. The Spiritual Counselor’s initial comprehensive assessment was completed on 07/08/2024, six days after the election of the hospice benefit and one day outstanding. Clinical Record 8: The patient elected the hospice benefit on 02/02/2024 for the diagnosis of chronic obstructive pulmonary disease. The Spiritual Counselor’s initial comprehensive assessment was completed on 02/10/2024, eight days after the patient’s election of the hospice benefit and three days outstanding. Clinical Record 15: The patient elected the hospice benefit on 03/20/2023 for the diagnosis of chronic obstructive pulmonary disease. The Spiritual Counselor’s initial comprehensive assessment was completed on 03/27/2023, seven days after the patient’s election of the hospice benefit and two days outstanding. Clinical Record 17: The patient elected the hospice benefit on 06/23/2023 for the diagnosis of malignant neoplasm of the esophagus. The Spiritual Counselor’s initial comprehensive assessment was completed on 06/30/2023, seven days after the election of benefits and two days outstanding. During an interview and joint record review on 07/24/2024, the Administrator/Director of Nursing and Alternative Director of Nursing confirmed that the Spiritual Counselor’s initial assessments had been completed after the 5-day requirement and the clinical records did not include an explanation for the delay in service. The Administrator stated the agency has an active Performance Improvement Project regarding this issue.”

“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 the hospice populations are anticipated, and as appropriate, preventive measurements 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, observation, and interview. In 2 of 4 (50%) home visit observations, the agency did not ensure the patient’s drug profile contained the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy, in order to complete a review of the patient’s current medications. Home Visit 1/Clinical Record 1: During the home visit observation with the Hospice Aide (HA) (Personnel Record 7), the patient resided at a skilled nursing facility and a medication review was completed by comparing the facility medication record to the hospice medication profile. The facility medication record included the following medications not listed on the hospice medication profile, Atorvastatin 20 mg daily dated 07/07/2024, Aspirin 81 mg daily dated 07/07/2024, Fleet enema 1 bottle every 24 hours as needed for constipation dated 07/02/2024, Tramadol 50 mg every four hours as needed for pain dated 07/02/2024, and Zinc 50 mg daily dated 07/02/2024. Home Visit 4/Clinical Record 4: During the home visit observation with the Spiritual Counselor (Personnel Record 6), the patient resided at an assisted living facility and a medication review was completed by comparing the facility medication record with the hospice medication profile. The facility medication record included the following medications not listed on the hospice medication profile, Hyoscyamine 0.125 as needed for secretions, and Tramadol 50 mg every 6 hours as needed for pain. During an interview and joint record review on 07/24/2024, the Alternative Director of Nursing confirmed the differences in the facility medication records and the hospice medication profiles.”

“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 measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did ensure the individualized plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 2: The patient elected the hospice benefit on 12/19/2023 for the diagnosis of malignant neoplasm of the prostate. The plan of care included a pain goal established on 12/19/2023 that stated, “Patient will have acceptable level of pain within ongoing.” The goal was not measurable when it did not include a patient specific acceptable level of pain for the patient and did not include a measurable timeframe for achievement. During an interview and joint record review on 07/24/2024, the Administrator/Director of Nursing and Alternative Director of Nursing agreed that the plan of care did not include measurable outcomes and just stated “acceptable” and “ongoing.””

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the plan of care was updated as frequently as the patient’s condition required. Clinical Record 1: The patient elected the hospice benefit on 07/02/2024 for the diagnosis of senile degeneration of the brain. The initial plan of care dated 07/02/2024 included a problem for “potential for impaired skin integrity and noted the patient had 2 wounds.” A physician order dated 07/07/2024 included documentation that the patient had “6 wounds, including 2 that were Stage IV and also a right below knee amputation.” The plan of care was not updated or revised to include the new wounds and management of the wounds. Clinical Record 14: The patient elected the hospice benefit on 05/17/2024 for the diagnosis of malignant neoplasm of the bronchus or lung. The nursing visit noted dated 05/20/2024 included documentation that the patient “continues to be SOB (short of breath) despite interventions.” The nursing visit dated 07/15/2024 included documentation that the patient had “No SOB during the visit but remains oxygen dependent at 2 liters per minute.” The initial plan of care dated 05/17/2024 did not include a respiratory problem, goal or intervention for the patient that was assessed to have shortness of breath. The subsequent updates to the plan of care did not include respiratory problems, goals or interventions for the patient with oxygen therapy. During an interview and joint record review on 07/25/2024, the Administrator/Director of Nursing and Alternative Director of Nursing agreed the plans of care “had not been updated with changes and the nurses would need to have another in-service.””

“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, observation, and interview. In 1 of 8 (12%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provided patient specific written instructions for the Hospice Aide. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 07/02/2024 for the diagnosis of senile degeneration of the brain. During the home visit observation with the Hospice Aide (HA) (Personnel Record 7), the HA was observed to ask the patient if he/she wanted a bed bath or shower today. The aide provided a bed bath during the visit. The hospice aide care plan assignment dated 07/02/2024 assigned the aide to provide a “bed bath or shower, most likely bed bath” but did not provide the HA with patient specific parameters or instructions to determine the type of bath to perform. The aide care plan assignment also included documentation that the patient was “confused.” During the home visit observation, it was observed that the patient had a right below knee amputation (RBKA) and the RBKA was documented on the aide assignment. The aide care plan assignment did not include directions for the aide on how to safely provide a shower to the patient with RBKA. The patient was also observed to have 6 large wounds with foam dressings on the left leg, hip, ankle, and coccyx. The wounds were documented in the skilled nursing visit notes, but the aide care plan assignment did not include patient specific instructions to the aide on how to care for the wound dressings while providing the bath and provisions of care. The aide care plan assignment did not include written instructions for the aide of when to notify the nurse of changes in the wound dressings or what to do if the dressings become soiled, dislodged, or wet during care. During an interview and joint record review on 07/24/2024, the Administrator/Director of Nursing and Alternative Director of Nursing looked at the date on the form and stated it was signed too late.”

“It is required that volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed in which volunteer services were accepted, the agency did not ensure volunteer services were included in the patients’ plan of care. Clinical Record 3: The patient elected the hospice benefit on 06/07/2023 for the diagnosis of atherosclerotic heart disease. Clinical record review revealed documentation that the patient accepted volunteer services and volunteer visits were provided to the patient, but the patient’s plan of care did not include an order for volunteer services. Clinical Record 10: The patient elected the hospice benefit on 06/03/2024. Clinical record review revealed documentation that the patient accepted volunteer services and volunteer visits were provided to the patient, but the patient’s plan of care did not include an order for volunteer services. Clinical Record 12: The patient elected the hospice benefit on 01/19/2024. Clinical record review revealed documentation that the patient accepted volunteer services and volunteer visits were provided to the patient, but the patient’s plan of care did not include an order for volunteer services. Clinical Record 19: The patient elected the hospice benefit on 05/03/2023. Clinical record review revealed documentation that the patient accepted volunteer services and volunteer visits were provided to the patient, but the patient’s plan of care did not include an order for volunteer services. During an interview on 07/24/2024, the Volunteer Coordinator stated she “just met with the patients and determined their plans of care.” She thought the nurse put them (the plans of care) in. The Administrator was interviewed on 07/24/2024 and stated, “We need to put companionship, respite, and what the volunteers are doing with the patients in the plans of care.””

“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, 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 and interview. In 1 of 2 (50%) clinical records reviewed with patient live discharge, the agency did not ensure the hospice discharge summary included the patient’s current plan of care. Clinical Record 16: The patient elected the hospice benefit on 07/11/2023 for the diagnosis of cerebral infarction. The patient elected to revoke their hospice benefit on 10/08/2023. The discharge summary dated 10/08/2023 included documentation that the “Patient/guardian is choosing to reclaim their Medicare benefits from hospice in order to pursue aggressive medical treatments.” The discharge summary did not include the patient’s current plan of care. During an interview and joint record review on 07/24/2024, the Administrator/Director of Nursing and Alternative Director of Nursing, the Administrator/Director of Nursing asked if “all live discharges had to include a summary of the patient’s stay and a plan of care or just extended prognosis patients.” The Administrator further stated that he thought it was “just required for patients discharged for extended prognosis.””