Christian Hospice

“It is required that the hospice Interdisciplinary Group (IDG), 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 1 of 14 (7%) clinical records reviewed, the agency did not ensure the IDG completed the initial comprehensive assessment no later than five calendar days after the election of hospice care. Clinical Record 6: The patient elected the hospice benefit on 02/24/2024 with a diagnosis of atherosclerotic heart disease. The initial nursing assessment dated 02/24/2024 noted “Declined SC [Spiritual Counselor] and MSW [Medical Social Worker]. Not needed at this time. Instructed to notify hospice when they are ready for services.” The Social Worker and the Spiritual Counselor did not complete a psychosocial assessment and a spiritual assessment since their services were declined. The clinical record contained no documented evidence that a spiritual assessment and a psychosocial assessment were completed as part of the initial comprehensive assessment. During an interview and joint record review on 05/08/2024, the Administrator/Director of Nursing and the Alternate Administrator confirmed the Social Worker and Spiritual Counselor had been listed as declined and initial spiritual and psychosocial assessments had not been completed.”

“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, 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 3 (67%) home visit observations, the agency did not ensure the 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. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 03/15/2024 with a diagnosis of heart failure. The patient resided at a skilled nursing facility. During the home visit observation with the Hospice Aide (Staff 7), a medication review was completed by comparing the hospice medication profile and the facility active medication list. The facility active medication list included the following medications that were not listed on the hospice medication profile, Lactulose 20 gm as needed for constipation dated 11/12/2018, Linzess for constipation dated 11/12/2018, Cranberry tablet dated 02/19/2019, Dulcolax suppository dated 02/19/2019, Melatonin dated 02/19/2019, Acetaminophen 325 mg 2 tabs for pain also for fever dated 11/14/2019, Artificial tears dated 11/14/2019, Guaifenesin ER 2 times a day for congestion dated 01/06/2020, Ibuprofen 800 mg 1 tablet every 8 hours as needed for pain dated 01/01/2021, Lidocaine patch for pain dated 04/15/2021, and Multi Vitamin dated 12/11/2023. The hospice medication profile had the following medications that were not listed on the facility active medication list Buspirone 10 mg 2x daily as needed for anxiety/agitation dated 03/15/2024, Morphine 20mg/ml dated 03/17/2024, and Senna S 2 tabs at bedtime. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 12/13/2023 with a diagnosis of Alzheimer’s disease. The patient resided in an assisted living facility. During the home visit observation with the Registered Nurse (RN) (Staff 4), a medication review was performed with the RN by comparing the hospice medication profile with the facility medication profile. The hospice medication profile contained the following medications that were not on the facility medication profile Phenazopyridine 200 mg three times a day as needed dated 01/19/2024, and Fluconazole 100 mg dated 03/05/2024. The facility medication profile had an order dated 11/25/2023 for Trazadone 50 mg, give 0.5 to 2 tabs nightly and the hospice medication order was 2 tabs nightly. During an interview and joint record review with the Administrator/Director of Nursing and Alternate Administrator on 05/08/2024, it was confirmed that the facility medication profiles, and the hospice medication profiles had not been reconciled.”

“It is required that Hospice Aides are assigned to a specific patient by a Registered Nurse (RN) 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 4 of 14 (29%) clinical records reviewed with Hospice Aide services provided, the agency did not ensure the Registered Nurse provided specific patient care instructions for the Hospice Aide. Clinical Record 2: The patient elected the hospice benefit on 03/15/2024 with a diagnosis of heart failure. The initial nursing assessment dated 03/15/2024 included documentation that the patient had a Stage IV wound to the coccyx with a wound vac in place. The aide care plan dated 03/15/2024 and the revised aide care plans dated 03/28/2024 and 05/07/2024 assigned the aide the tasks of a bed bath, assisting to dress, and inspecting the skin. The aide care plan did not notify the aide of the wound and the wound vac and did not provide the aide with specific instructions on how to care for the wound and wound vac while providing care to the patient. Clinical Record 6: The patient elected the hospice benefit on 02/24/2024 with a diagnosis of atherosclerotic heart disease. The Initial nursing assessment dated 02/24/2024 included documentation that the patient had pressure ulcers on the buttock and coccyx covered with silicone dressing. The aide care plan dated 02/24/2024 assigned the aide the tasks of bed bath, assisting with dressing, and inspecting the skin. The aide care plan did not notify the aide of the patient’s wounds and did not provide the aide with specific instructions on how to care for the wounds while providing care to the patient. Clinical Record 8: The patient elected the hospice benefit on 04/15/2024 with a diagnosis of heart failure. The initial nursing assessment dated 04/15/2024 included documentation that the patient had a pressure ulcer to the left hip-covered with island dressing. The aide care plan dated 04/15/2024 assigned the aide the tasks of bed bath, assisting with dressing, and inspecting skin. The aide care plan did not notify the aide of the patient’s wound and did not provide the aide with specific instructions on how to care for the wound while providing care to the patient. Clinical Record 10: The patient elected the hospice benefit on 04/09/2024 with a diagnosis of hemiplegia. The initial nursing assessment dated 04/09/2024 included documentation that the patient had a stage III pressure ulcer to coccyx covered with foam dressing. The aide care plan dated 04/09/2024 assigned the aide the tasks of bed bath, assisting with dressing, and inspecting the skin. The aide care plan did not notify the aide of the patient’s wound and did not provide the aide with specific instructions on how to care for the wound while providing care to the patient. During an interview and joint record review on 05/08/2024, the Administrator/Clinical Director and the Alternate Administrator confirmed the aide care plans did not identify the wounds nor include specific instructions for the wounds.”

“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. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed with aide services provided, the agency did not ensure the aide reported changes to the Registered Nurse. Clinical Record 9: The patient elected the hospice benefit on 02/05/2024 with a diagnosis of chronic obstructive pulmonary disease. The aide care plan assigned the aide the task of assisting with bedpan with a frequency of every visit. Review of the Aide visit notes dated 02/12/2024, 03/20/2024, 03/26/2024, and 04/05/2024 revealed the assist with bed pan task was “refused” and there was no documented evidence that the Aide reported the refused task to the Registered Nurse. During an interview and joint record review on 05/08/2024, the Administrator/Director of Nursing and the Alternate Administrator confirmed documentation that the Aide reported to the Registered Nurse was not included in the clinical record.”

“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. 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 a copy of the discharge summary was forwarded to the attending physician. Clinical Record 11: The patient elected the hospice benefit on 02/07/2024 with a diagnosis of Alzheimer’s disease. The patient revoked the hospice benefit on 02/13/2024 to seek aggressive treatment. The clinical record contained no documented evidence that the discharge summary was sent to the patient’s attending physician. During an interview and joint record review on 05/08/2024, the Administrator/Director of Nursing and the Alternate Administrator confirmed the discharge summary had not been forwarded to the attending physician.”

“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. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with patient discharge, the agency did not ensure the discharge summary included at least a summary of the patient’s hospice stay. Clinical Record 12: The patient elected the hospice benefit on 06/14/2023 with a diagnosis of atherosclerotic heart disease. The patient was discharged for extended prognosis on 08/25/2023. The discharge summary narrative included in its entirety “Patient is discharged from hospice; stabilized no longer hospice appropriate.” The hospice discharge summary did not include a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. During an interview and joint record review on 05/08/2024, the Administrator/Director of Nursing and the Alternate Administrator confirmed the discharge summary did not include a summary of the hospice stay.”

“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. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which the patient resided in a Skilled Nursing Facility/Nursing Facility (SNF/NF); the agency did not ensure the hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. Clinical Record 14: The patient elected the hospice benefit on 06/05/2023 with a diagnosis of congestive heart failure. The patient was admitted to a SNF/NF and on 06/06/2023 and was changed to the GIP (general in-patient) level of care in the same SNF. Clinical record review revealed the hospice plan of care did not include which provider was responsible for performing the hospice care and service functions outlined in the plan of care and did not include how care would be coordinated between the hospice and the SNF for either the routine or GIP levels of care. During an interview and joint record review on 05/08/2024, the Administrator/Director of Nursing and the Alternate Administrator confirmed that facility coordination of care had not been added to the hospice plan of care.”