Ohio Valley Hospice

“It is required that the comprehensive assessment includes consideration of symptoms and symptom severity, including skin integrity. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy #1-014.1, “Comprehensive Assessment” (revised October 2019), stated in part, “During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s record, including four (4) skin integrity. In 1 of 4 (25%) clinical records reviewed where a wound was identified, the hospice agency did not ensure the comprehensive assessment included consideration of symptoms and symptom severity, including skin integrity. Clinical Record 3: The patient elected hospice care on 5/2/2023. The comprehensive assessment the Registered Nurse (RN) completed on 12/12/2023 documented the patient’s wound and “Wound care completed by the facility nurse.” The wound assessment tool dated 12/12/2023 documented: “Wound not assessed.” The wound assessment tool dated 12/19/2023 documented: “Wound was assessed” and included documentation of the wound: measurement, exudate, odor, shape, granulation tissue, undermining and tunneling, and pain signs and symptoms associated with the wound. The wound assessment tool dated 12/26/2023 stated: “Wound not assessed.” The wound assessment tool dated 1/2/2024 stated: “Wound not assessed.” The wound assessment tool dated 1/8/2024 stated: “Wound was assessed and included documentation of the wound: measurement, exudate, odor, shape, granulation tissue, undermining and tunneling, and pain signs and symptoms associated with the wound. During a joint record review and interview on 1/16/2024, the Executive Director confirmed the wound was not assessed by the hospice agency when it was first identified. In addition, the hospice agency did not evaluate the wound from 12/19/2023 to 1/8/2024, with twenty (20) days outstanding.”

“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; 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, document review, interview, and observation. Agency policy #2-004.1, “Medication Profile” (revised October 2019), stated in part, “Upon admission, the admitting nurse will initiate a medication profile to document the current medication regimen, including over-the-counter (OTC) medications, nutritional supplements, herbal remedies, vitamins and minerals, and oxygen therapy...a drug regimen review will be performed at the time of the initial and comprehensive assessment when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication.” In 1 of 4 (25%) home visits observed, the hospice agency did not ensure that the patient’s medication profile contained the patient’s current medications. Home Visit 3/Clinical Record 4: The patient elected hospice care on 12/7/2023. During the home visit on 1/17/2024, a medication reconciliation was performed comparing the hospice agency’s medication profile dated 1/16/2024 to the patient’s current medication regimen. The patient’s caregiver provided a medication bottle that read in part, Butalbital/Acetaminophen/Caffeine (Fioricet) 50-325- 40, take one (1) tablet every six (6) hours as needed (PRN) for pain.” The medication prescription date/fill date was 12/28/2023. The caregiver confirmed the patient had taken the medication Butalbital/Acetaminophen/Caffeine recently “in the past month.” Butalbital/Acetaminophen/Caffeine was not documented on the hospice agency’s medication profile and was not included in the review of the patient’s medication regimen. During a joint record review, observation, and interview on 1/17/2024, the Executive Director, who was present for the visit, confirmed the hospice agency’s medication profile did not match the patient’s current regimen.”

“It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; [and] ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy #1-014.1 “Comprehensive Assessment” (revised October 2019) stated in part, “During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s record, including four (4) skin integrity.” In 1 of 19 (5%) clinical records reviewed, the hospice agency did not ensure that the Registered Nurse provided coordination of care and ensured the continuous assessment of each patient’s needs. Clinical Record 3: The patient elected hospice care on 5/2/2023. The comprehensive assessment the Registered Nurse (RN) completed on 12/12/2023 documented the patient’s wound and “Wound care completed by the facility nurse.” The wound assessment tool dated 12/12/2023 documented: “Wound not assessed.” The wound assessment tool dated 12/19/2023 documented: “Wound was assessed” and included documentation of the wound: measurement, exudate, odor, shape, granulation tissue, undermining and tunneling, and pain signs and symptoms associated with the wound. The wound assessment tool dated 12/26/2023 stated: “Wound not assessed.” The wound assessment tool dated 1/2/2024 stated: “Wound not assessed.” The wound assessment tool dated 1/8/2024 stated: “Wound was assessed and included documentation of the wound: measurement, exudate, odor, shape, granulation tissue, undermining and tunneling, and pain signs and symptoms associated with the wound. During a joint record review and interview on 1/16/2024, the Executive Director confirmed the wound was not assessed by the Registered Nurse for twenty (20) days from 12/19/2023 to 1/8/2024.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, observation, document review, and interview. Agency policy, “The Plan of Care” (revised October 2019), stated in part, “The plan of care will identify the patient’s needs and services to meet those needs...The written plan of care will contain, but will not be limited to the following, (M) individualized interventions to assist with end-of-life care, (O) Statement of treatment goals and documentation of the progress of outcomes, (P) Information from the patient’s updated comprehensive assessment, (S) pain and symptom management interventions. In 1 of 19 (5%) clinical records reviewed, the hospice agency did not ensure that the plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2/Home Visit 2: The patient elected hospice care on 9/28/2023 and resided in a skilled nursing facility (SNF). The Certificate of Terminal Illness (CTI) dated 10/11/2023 documented, “Patient was evaluated in the emergency department due to aspiration. He now has a suction device due to difficulty handling his secretions.” The initial Registered Nurse (RN) assessment dated 9/28/2023 documented “gastrointestinal....Dysphagia, thickened liquids, pureed diet...Facility Nurse states frequent coughing/choking at meals.” During the home visit on 1/17/2024, the SNF nurse confirmed the patient often used the suction machine at night. The plan of care dated 9/28/2023 through 11/26/2023 did not include documentation of problems, goals, or interventions related to dysphagia or aspiration. During a joint record review, observation, and interview on 1/17/2024, the Executive Director, who was present for the home visit, confirmed the hospice agency plan of care did not contain problems or interventions regarding the suction machine at the patient’s bedside.”

“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 the following: drugs and treatment necessary to meet the needs of the patient includes all drugs and treatments necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, observation and interview. In 1 of 19 (5%) clinical records reviewed, the hospice agency did not ensure that all medications necessary to meet the needs of the patient were included in the plan of care. Clinical Record 4/Home Visit 3: The patient elected hospice care on 12/7/2023. During the home visit on 1/17/2024, a medication reconciliation was performed comparing the hospice agency’s medication profile dated 1/16/2024 to the patient’s current medication regimen. The patient’s caregiver provided a medication bottle that read in part, “Butalbital/Acetaminophen/Caffeine (Fioricet) 50-325- 40, take one (1) tablet every six (6) hours as needed (PRN) for pain.” The medication prescription date/fill date was 12/28/2023. The caregiver confirmed the patient had taken the medication Butalbital/Acetaminophen/Caffeine recently “in the past month.” Butalbital/Acetaminophen/Caffeine was not documented on the plan of care. During a joint record review, observation, and interview on 1/17/2024, the Executive Director, who was present for the visit, confirmed the hospice agency’s plan of care did not include Butalbital/Acetaminophen/Caffeine.”

“It is required that a patient’s clinical record contains physician orders. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the hospice did not ensure the record contained all physician orders. Clinical Record 2/Home Visit 2: The patient elected hospice care on 9/28/2023 and resided in a skilled nursing facility (SNF). The Certificate of Terminal Illness (CTI) dated 10/11/2023 documented, “Patient was evaluated in the emergency department due to aspiration. He now has a suction device due to difficulty handling his secretions.” The initial RN assessment dated 9/28/2023 documented “gastrointestinal...Dysphagia, thickened liquids, pureed diet...Facility Nurse states frequent coughing/choking at meals.” During the home visit on 1/17/2024, the SNF nurse confirmed the patient often used the suction machine at night. A clinical record review revealed no documented physician orders for the suction machine. During a joint record review, observation, and interview on 1/17/2024, the Executive Director, who was present for the home visit, confirmed the clinical record did not contain a physician’s order for the suction machine at the patient’s bedside. Clinical Record 9: The patient elected hospice care on 7/26/2023. The patient had surgical wounds to the left hand and forearm. The physician’s order was obtained from the hospice nurse practitioner and signed by the medical director, who stated, “L hand palm. Clean, rinse, pat dry. Xeroform, Kurlex. The hospice nurse is to change dressing on Monday, Thursday, and Saturday until the issue is resolved. The suture site (25) LFA is open to the air. “ A joint record review and interview with the Executive Director on 1/18/2024 confirmed the record did not contain a physician order for the type of solution/medication to be used to clean or rinse the wound.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the Hospice election form. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 3 (33%) home visits conducted at a Skilled Nursing Facility (SNF), the hospice agency did not ensure the Hospice election form was provided to the SNF. Home Visit 2/Clinical Record 2: The patient elected hospice care on 9/28/2023 and resided in a SNF. During the home visit on 1/17/2024, a review of the patient’s clinical record at the facility revealed no evidence of the patient’s Hospice election form. The Executive Director, present for the home visit, spoke with the SNF Medical Records department. The SNF could not locate a copy of the patient’s hospice election form. During a joint record review, observation, and interview on 1/17/2024, the Executive Director confirmed the Hospice election form was not in the SNF medical record. The Executive director reported the normal process would be to fax a copy of the Hospice benefit election form to the SNF following admission. There was no documentation of this task being completed. The Hospice agency faxed a copy of the Hospice benefit election form to the SNF before the end of the business day on 1/17/2024.”