Creekway Healthcare LLC

“It is required that written patient care instructions for a hospice aide are prepared by a registered nurse (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 3 of 9 (33%) clinical records reviewed in which aide services were accepted revealed that the agency did not ensure specific written patient care instructions were provided for the hospice aide. Clinical Record 1: The patient elected hospice benefit was dated 6/3/2023 for a diagnosis of senile degeneration of the brain. The recertification nursing assessment and aide care plan dated 11/29/2023 identified the patient as being on oxygen continuously at 2 liters per minute (LPM). The aide care plan had the relevant tasks of a bedbath and dressing the patient every visit. The aide care plan did not provide specific instructions for the aide to leave the oxygen or remove it during these tasks. Clinical Record 3: The patient elected hospice benefit was dated 10/14/2023 for a diagnosis of Atherosclerosis. The initial nursing assessment dated 10/14/2023 identified the patient as being on oxygen continuously at 2 liters per minute (LPM). The aide care plan dated 12/16/2023 had the relevant tasks of a shower chair and dressing the patient every visit. The aide care plan did not provide specific instructions for the aide to leave the oxygen or remove it during these tasks. Clinical Record 8: The patient elected hospice benefit was dated 8/19/2023 for a diagnosis of chronic obstructive pulmonary disease (COPD). The initial nursing assessment dated 8/19/2023 identified the patient as being on oxygen continuously at 3 liters per minute (LPM). The aide care plan dated 8/19/2023 had the relevant tasks of shower chair and dressing the patient every visit. The aide care plan did not provide specific instructions for the aide to leave the oxygen or remove it during these tasks. A joint clinical record review and interview was conducted with the Alternative Director of Nursing (ADON) on 1/4/2024 during which she confirmed specific instructions for the oxygen had not been included in the aide care plans.”

“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 6 of 9 (67%) clinical records reviewed in which aide services were accepted revealed that the agency did not ensure the services were provided per the plan of care (POC). Clinical Record 1: The patient elected hospice benefit was dated 6/3/2023 for a diagnosis of senile degeneration of the brain. The aide care plan dated 11/29/2023 assigned the aide frequency of visits two times a week and the tasks of “shampoo 1x weekly and shave 1x weekly.” A review of the aide visit notes for visits provided twice weekly dated 12/4/2023, 12/8/2023, 12/11/2023, and 12/15/2023 revealed the aide documented “shampoo and shaving” completed at each visit indicating shampooing and shaving were completed twice a week instead of weekly as assigned. Clinical Record 2: The patient elected hospice benefit was dated 10/14/2023 for a diagnosis of Atherosclerosis. The aide care plan dated 12/2/2023 assigned the aide frequency of visits three times a week and the tasks of “shampoo 1x weekly and shower 1x weekly, preferably Friday mornings.” A review of the aide visit notes for visits provided three times weekly dated 12/5/2023, 12/8/2023, 12/9/2023, 12/12/2023, 12/14/2023, and 12/15/2023 revealed the aide documented “shampoo and shower” completed at each visit indicating shampoo and shower were completed three times weekly instead of weekly as assigned. Clinical Record 3: The patient elected hospice benefit was dated 12/16/2023 for a diagnosis of chronic obstructive pulmonary disease (COPD). The aide care plan dated 12/16/2023 assigned the aide frequency as two times a week and the task of “shampoo 1x weekly”. A review of the aide visit notes provided twice weekly on 12/19/2023 and 12/22/2023 revealed the aide documented “shampoo” completed at each visit indicating shampoo was completed twice weekly instead of weekly as assigned. The aide care plan assigns the following tasks every visit: “comb hair, brush teeth, apply deodorant, apply lotion, and provide peri care. “ The aide visit on 12/26/2023 revealed these tasks were not marked as completed. Clinical Record 6: The patient elected hospice benefit was dated 7/10/2023 for a diagnosis of atherosclerotic heart disease. The aide care plan dated 7/10/2023 assigned the aide frequency as two times a week and the tasks of “shampoo and shave 1x weekly’. A review of the aide visit notes provided twice weekly on 9/11/2023, 9/15/2023, 9/18/2023 and 9/22/2023 revealed the aide documented “shampoo and shave” completed at each visit indicated shampoo and shave was completed twice weekly instead of weekly as assigned. Clinical Record 7: The patient elected hospice benefit was dated 8/24/2023 for a diagnosis of cerebrovascular disease. The aide care plan dated 8/24/2023 assigned the aide frequency as three times a week and the task of “shampoo 1x weekly.” A review of the aide visit notes provided three times weekly on 9/5/2023, 9/7/2023, and 9/9/2023 revealed the aide documented “shampoo” completed at each visit indicated shampoo was completed three times weekly instead of weekly as assigned. Clinical Record 8: The patient elected hospice benefit was dated 8/19/2023 for a diagnosis of chronic obstructive pulmonary disease (COPD). The aide care plan dated 8/19/2023 assigned the aide frequency as two times a week and the tasks of “shampoo 1x weekly’. A review of the aide visit notes provided twice weekly on 8/29/2023 and 9/2/2023 revealed the aide documented “shampoo” completed at each visit indicated shampoo was completed twice weekly instead of weekly as assigned. A joint record review and interview was conducted with the Director of Nursing (DON) on 1/5/2024 in which DON confirmed the aide did mark “completed” during more than one visit throughout the week. The DON stated, “they were supposed to put a note on the bottom on the days they did not complete the tasks.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview, and personnel record review. In 2 of 8 (25%) of personnel records reviewed revealed the agency did not ensure the skills and competencies of individuals providing care were assessed. Agency Policy: HR.CR 10 Competency Assessment dated 2021 stated in relevant part “Policy: A hospice must assess the skills and competence of all individuals providing care. 8. Any skill which is technical must be observed. These should be assessed immediately upon hire and annually.” Personnel Record 3: The Director of Nursing (DON) with a hire date of 9/9/2022 had an initial orientation competency skills checklist dated 9/14/2022 and an annual competency checklist dated 9/12/2023. The checklist was blank under every competency where the employee was to be evaluated as “competent? (yes, no, n/a) for the initial and annual competency. Personnel Record 7: The hospice aide who has direct patient contact who was hired on 9/16/2022 had an Initial orientation competency skills checklist dated 9/17/2022 which stated, “boxes with * must be with patient” These technical skills were checked off as verbal instead of observation. There was no documented evidence that the aide’s technical skills were observed. A joint personnel record review was completed with the Director of Nursing (DON) on 1/5/2024. The DON confirmed the skills competency checklists had not been completed per agency policy.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which the patient was eligible for recertification, revealed that the agency did not ensure the recertification of the terminal illness was completed in the required time frame. Clinical Record 1: The patient elected hospice benefit was dated 6/3/2023 for a diagnosis of senile degeneration of the brain. A clinical record review on 1/4/2024 revealed there was no documented evidence of the signed recertification of terminal illness (CTI) for the benefit period beginning 11/30/2023 and no verbal order was present. Clinical Record 2: The patient elected hospice benefit was dated 10/14/2023 for a diagnosis of Atherosclerosis. A clinical record review on 1/4/2024 revealed that there was no documented evidence of the signed recertification of terminal illness (CTI) for the benefit period beginning on 12/13/2023 and no verbal order was present. A joint clinical record review and interview was conducted with the Director of Nursing (DON) on 1/5/2024. DON confirmed the CTIs did not contain the hospice medical director’s signature.”

“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 3 of 3 (100%) clinical records reviewed for hospice patients that revoked the hospice benefit or were discharged for extended prognosis, revealed that the agency did not forward the attending physician a copy of the discharge summary. Agency Policy: Discharge from hospice policy PC. D 20 dated 2021 states in relevant part “when a patient is discharged from hospice the hospice provides a copy of the patient’s clinical record (if requested) and a copy of the discharge summary to the patient’s attending physician and any new agency providing care. Clinical Record 5: The patient elected hospice benefit was dated 9/13/2023 for senile degeneration of the brain. The patient was discharged by the hospice agency for extended prognosis on 9/30/2023. There was no documented evidence in the clinical record that a discharge summary was provided to the attending physician. Clinical Record 6: The patient elected hospice benefit was dated 7/10/2023 for a diagnosis of atherosclerotic heart disease. The patient was discharged by the hospice agency on 9/23/2023 for extended prognosis. There was no documented evidence in the clinical record that a discharge summary was provided to the attending physician. Clinical Record 9: The patient elected hospice benefit was dated 6/9/2023 for a diagnosis of atherosclerotic heart disease. The patient revoked the hospice services on 8/23/2023 There was no documented evidence in the clinical record that a discharge summary was provided to the attending physician. A joint record review and interview with the Administrator was conducted on 1/4/2024. The Administrator confirmed the discharged summaries had not been provided to the attending physician(s).”