Elara Caring

“Upon patient record review, 1 of 5 (Patient #2) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 2:The plan of care includes problems, goals and interventions for the use and safety of oxygen on admission. There is no evidence in the medical record that the patient requires oxygen therapy.”

“Upon patient record review, 1 of 5 (Patient #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 3:The plan of care on 12/12/24 includes an order for MiraLAX 17 grams daily for constipation and a 4% lidocaine patch to be applied daily. There is no evidence that the order or an update to the order includes the type and amount of diluent or the location for application of the lidocaine patch.”

“Upon patient record review, 4 of 23 (Patient #1,2,6,8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 1: The facility MAR contains an order for Zoloft. This is not on the medication profile. Corrected on site. Patient 2: The medication profile contains an order Brimonidine and Systane eye drops with no directive of which eye to instill. Corrected on site. Patient 6: The medication profile contains Miralax with no diluent. The SN documented on 12/4 “Imodium given”. The Imodium is not listed on the medication profile. Corrected on site. Patient 8: The medication profile on 10/28 contains Miralax with no diluent. Corrected on site.”

“Upon patient record review, 1 of 23 (Patient #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 5: The bereavement assessment was not completed until 7/26/24. There is no evidence of an order or documentation supporting reason for the visit to be later than 5 days.”

“Upon patient record review, 1 of 23 (Patient #20) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 20: The F2F by the NP 11/23 records pt has a “chronic foley in place”. The SN documented on SOC and each visit there after pt was incontinent of bowel and bladder and wears brief. There is no assessment of the foley.”

“Upon patient record review, 5 of 23 (Patient #6,7,12,19,20) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 6: The POC contains orders for Coumadin, there are no goals or interventions for risk for bleeding. Corrected on site. Patient 7: The most recent POC contains orders for Eliquis, there are no goals or interventions for risk for bleeding. Corrected on site. Patient 12: The POC contains Xarelto, there there are no goals or interventions for risk for bleeding. Corrected on site. Patient 19: The SN documented on 5/17/24 patient has a port, however there is no evidence of care instructions for the port and there are no orders for a port on the POC. There is not further documentation regarding the port through transfer. Patient 20: The F2F by the NP 11/23 records pt has a “chronic foley in place”. There is no problems/interventions/goals for foley on the POC.”

“Upon patient record review, 1 of 23 (Patient #10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 10: The SN wrote an order to “decrease nurse visits per request” which is not an appropriate frequency order.”

“Upon patient record review, 7 of 23 (Patient #2,4,6,8,10,14,20) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: The POC contains an order for Polyethylene Glycol with no diluent, Brimonidine and Systane eye drops with no directive of which eye to instill. Corrected on site. Patient 4: The POC 9/16 contains an order for wound care though it is a template with no specific information filled in the blanks therefore, is an incomplete order. Updated for recert corrected on site. Patient 6: The most recent POC 11/03/24 contains Miralax with no diluent. Corrected on site. Patient 8: The medical record contains an order on 10/28 for Miralax with no diluent. Corrected on site. Patient 10: The POC 11/20/24 contains order for dressing “...change daily and as needed if soiled or D” which is an incomplete order. The POC 9/18 contains an order for antibiotic ointment though does not state where to apply. Antibiotic ointment corrected on site. Patient 14: The POC for both 8/27 and 11/25 contains the order for Milk of Mag twice the exact same order. Corrected on site. Patient 20: The F2F by the NP 11/23 records pt has a “chronic foley in place”. There are no orders for foley.”

“Upon patient record review, 10 of 23 (Patient #1,2,3,4,5,6,10,17,18,19) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: Upon home visit finding pt has a hospital bed, over bed table, w/c and walker. These items are not on the POC. Corrected on site. Patient 2: Upon home visit finding, pt has a Broda chair, hospital bed, air mattress and matt on the floor for falls. These are not included on the POC. Corrected on site. Patient 3: Upon home visit finding pt has a Hospital bed and over bed table that were not included on the POC. Corrected on site. Patient 4: Upon home visit finding pt has heel protectors on, a hospital bed, over bed table, and an air mattress these were not included on the POC. Corrected on site. Patient 5: Upon home visit finding pt has a w/c and a hospital bed that are not included on the POC. Corrected on site. Patient 6: Upon home visit finding pt has a hospital bed and over bed table. These are not included on the POC. Corrected on site. Patient 10: The SN documented in comprehensive assessment pt has rollator. This is not ordered on POC. Corrected on site. Patient 17: The recert on 11/18 the nurse documented ordering a bedside commode. The SN documented pt used her walker. There is no evidence of an order for a Bed side commode or a walker. Corrected on site. The POC’s 9/21 and 11/20 have wound care supplies listed under DME and there is no evidence pt has a wound. Patient 18: The RN documented on SOC comprehensive assessment pt uses a walker. This was no included on the POC. Corrected on site. Patient 19: On 5/25 SN documented pt has a hospital bed, this is not on the POC.”

“Upon patient record review, 5 of 23 (Patient #7,8,9,10,18) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 7: The Most recent POC 11/12/24 goals have dates of “by end of July” and “by end of August”. There is no evidence the plan of care is being revised on the progress towards outcome/goals. Corrected on site. Patient 8: The POC 10/2/24 contains an order “Home health aide service for assistance with personal care and ADL’s”. The patient declined aide services at SOC. The recertification POC 10/2/24 contains Goals that are to be achieved “by first recert”. There is no evidence the plan of care is being revised on the progress towards outcome/goals. Corrected on site. Patient 9: The most recent recert POC 10/6 contains goals that are to be achieved by “First recert”. There is no evidence the plan of care is being revised on the progress towards outcome/goals. Corrected on site. Patient 10: The patient has documented difficulty swallowing at recert, there was no risk for aspiration added to POC. Corrected on site. Patient 18: The SN documented on the recertification 11/27 pt is having difficulty swallowing. There was no update to the POC 12/2 to include aspiration risk care plan with goals and interventions. Corrected on site.”

“Upon client record review, 2 of 23 (Patient #7,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 7: The POC contains an order for SN once a week. The weeks of 11/10/24-11/16/24, 10/6-10/12 there were no SN visits made and no evidence of a missed visit notes or pt refusal. Patient 10: POC contains order for daily wound care, on the 11/22 visit the nurse documented wound care was “N/A to routine visit”. There was no further documentation to support the wound care had been completed by caregiver. 12/4 SN documented wound care to right hip by restating the order. 12/4 SN documented wound care to right hip by restating the order. 12/4 SN documented “wound care not provided to left heel, client completed care”. Pt is bedbound and requires total care. There is no evidence the care was completed since client is physically capable and caregivers are to perform wound care when hospice is not there.”

“Upon patient record review 1 of 23 (Patient #19) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 19: The SN documented on 5/17 that pt has a port that is still accessed and pt would like it de-accessed. The visiting nurse was an LPN who informed patient she is not qualified to remove and offered RN visit that day to remove. Family said ok to remove at next visit 5/21. The RN made visit 5/21 there was no mention of any care provided for the port and there are no orders for a port on the POC. There is not further documentation regarding the port through transfer.”

“Upon patient record review 1 of 23 (Patient #7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 7: The medical record contains a supervisory visit completed on 11/7/24, the next supervisory visit was not completed until 12/4/24. This was greater than 14 days.”

“Upon patient client record review, 10 of 23 (Patient #3,4,6,9,10,11,12,14,15,16) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 3: The SN documented on 12/9 “pulse 113 medicated with Roxanol”. There is no evidence the POC was followed as no dose documented. Patient 4: The SN documented on 11/25 “Dc’ing multiple meds”. This is not an approved abbreviation. The SN documented on SOC, in the wound care provided sections for the left shoulder and coccyx, cardiac interventions instead of the wound care interventions performed and then documented “tolerated well but painful”. There is no evidence of what wound care was performed. Patient 6: The SN on 12/4 documented “R/O’D per request.” This is not an approved abbreviation. Patient 9: The medical record contains an aide supervisory visit completed by the RN on 12/9/24, the patient does not have an aide ordered. Patient 10: Pt has an aide. On 12/4 the RN documented in the supervisory visit section that a supervisory visit was not completed due to “no aide”. The supervisory visit was not due that week. 12/9 The nurse documented wound care to rt lower back and hip by restating the order, it was not documented in past tense to provide evidence the care was completed. Patient 11: The SN documented on 11/14 “VSM”. This is not an approved abbreviation. On 11/25 the SN documented “Writer drew up additional syringes of Ativan and Morphine for family”. There is no evidence of how much medication was drawn up. Patient 12: The SN documented on 12/5 “Dau”. This is not an approved abbreviation. Patient 14: The SN documented 11/20 “The facility nurse administered PRN dose of Tylenol”. There is no evidence of what dose was given. The SN documented on 12/9 “Dressing changed per facility staff and writer”. The wound intervention note contains documentation by the nurse of restating the order. The documentation is not in past tense so there is no evidence the wound care was completed. Patient 15: The SN documented “ADVSD” twice in the narrative on 11/29. This is not an approved abbreviation. Patient 16: The SN documented “D/T” 11/21. This is not an approved abbreviation.”

“Upon client record review, 8 of 23 (Patient #2,3,4,5,6,9,17,19) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 2: The POC contains an order for MSW 1 a week for 1 week. The MSW performed visits on 10/25, 11/14, 11/22. There is no order for increased visits. Patient 3: The SN wrote an order for SN visits daily starting 12/2, the SN did not make a visit on 12/7 and there was no evidence of refusal or missed visit documentation. Patient 4: The facility had an order for wound care 11/25 to cleanse wound with Dakins, pack with Dakins soaked gauze and secure with absorbent dressing. The Hospice did not have this order on their POC, the order was written on the recert day 11/25 at the facility and the patient had been seen twice by the hospice nurse since the order was written. Patient 5: The SN documented at SOC that the patient is having TIA’s with difficulty swallowing. There is no risk for aspiration care plan on the POC. Corrected on site. Patient 6: The SN documented on 12/4 “Imodium given”. There is no order for Imodium in the POC. Corrected on site. Patient 9: The POC 10/6 contains an order for SC twice weekly. The weeks of 10/20-10/26, 11/3-11/9, 11/17-11/23, 11/24-11/30 only 1 SC visit was made each of those weeks. There was no order to decrease the visits or missed visit documentation. Patient 17: The SN documented on 12/2 “Pt and staff unsure of when last BM was, so RN instructed to give Dulcolax suppository to check for impaction.” There is no order to check for impaction. Patient 19: The SN documented 5/24 “Foley catheter tried to place but no return,informed family to call if no return in one hour”. There is no order for a foley to be placed.”

“Upon patient record review, 1 of 23 (Patient #4) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice’s 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient 4: The SNF clinical record did not contain the Hospice election form. There is not documentation to support it was left at the facility. The hospice took the election form to the facility the next day.”