Harmony Hospice Care

“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 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 and interview. In 3 of 19 (16%) clinical records reviewed revealed that the agency did not ensure that the documented comprehensive assessment included a drug profile that contained the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The agency’s policy, Medication Orders (10/24/2024) read in part, “Upon admission, a comprehensive medication reconciliation will be conducted. The nurse completing the admission will review and document all medication including prescription medications, over-the-counter medications, vitamins, and herbal supplements. The nurse will verify medication doses, routes, and frequencies with the patient, family/caregivers, and/or facility staff and coordinate with the prescribing physician if there are any discrepancies or concerns. The Hospice Care Team will perform medication reconciliation for each patient every 30 days to verify, review, and document all medications that the patient is currently taking.” Clinical Record 7: The comprehensive assessment completed on 10/24/2023 included Oxygen at 3.5 LPM. Oxygen was not included in the medication profile (effective on 10/24/2023) and as a result, Oxygen was not included in the medication review. Clinical Record 9: The comprehensive assessment dated 05/02/2024 included an order for Oxygen. Oxygen was not included in the medication profile (effective on 05/02/2024) and as a result, oxygen was not included in the medication review. Clinical Record 15: The comprehensive assessment dated 10/20/2023 included an order for Oxygen. Oxygen was not included in the medication profile (effective on 10/20/2023) and as a result, was not included in the medication review. In an interview with the Director of Nursing (DON)and the Assistant Director of Nursing (ADON) on 11/07/2024, the DON and ADON, after reviewing the medication profiles agreed that the medication reconciliation/reviews did not include all medications.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness, including medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure that each patient’s individualized written plan of care included medical supplies and appliances necessary to meet the needs of the patient. Clinical Record 2: The patient was admitted on 08/21/2024 with a diagnosis of Senile Degeneration of the Brain. The Plan of Care (POC) dated 08/21/2024 to 11/18/2024 documented bowel and bladder incontinence as functional limitations, however, the incontinence supplies and appliances necessary to meet the needs of the patient were not included. During an interview with the Administrator and Director of Nursing (DON) on 11/07/2024, the DON agreed that the supplies should have been in the plan of care but were not included.”

“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 and interview. In 11 of 19 (58%) clinical records reviewed revealed that the agency did not ensure that the RN provided specific care instructions for the aide to follow. Clinical Record 1: The patient was admitted on 09/10/2024 with a diagnosis of Dysphagia, Esophageal Stricture, Atrial Fibrillation (on an anticoagulant), and was on oxygen. The aide care plan effective 09/10/2024 to 11/08/2024 did not include aspiration, bleeding, or oxygen precautions. Clinical Record 2: The patient was admitted on 08/21/2024 with a diagnosis of Senile Degeneration of the Brain, Vascular Dementia, and Congestive Heart Failure, and was on Oxygen. The aide care plan, dated 08/21/2024, did not include oxygen precautions. Furthermore, that aide care plan included the following aide tasks that were assigned to be performed, “as needed” with no indication and no identified decision maker: dressing the patient, assisting with elimination, making the bed. Clinical Record 3: The patient was admitted on 03/20/2024 with diagnoses that included Senile Dementia, Atrial Fibrillation (on an anticoagulant), and Chronic Obstructive Pulmonary Disease (COPD) and was on oxygen. The aide care plan for the certification period of 09/16/2024 to 11/14/2024 did not include bleeding precautions or oxygen precautions. Clinical Record 5: The patient was admitted on 05/13/2024 with a diagnosis of Hypertensive Heart Failure and taking the antiplatelet, Aspirin 81 mg. Bleeding precautions were not included in the aide care plan, dated 05/13/2024. Clinical Record 6: The patient was admitted on 04/12/2024 with diagnoses that included End Stage Dementia and Heart Failure with oxygen and anticoagulation therapy. The aide care plan for the certification period of 10/09/2024 to 12/07/2024, did not include bleeding or oxygen precautions. Clinical Record 9: The patient was admitted on 05/02/2024 with a diagnosis of protein-calorie malnutrition. The patient also had an order for oxygen therapy, however, the aide care plan for the certification period of 07/31/2024 to 10/28/2024 did not include oxygen precautions. Furthermore, that aide care plan included the following aide tasks that were assigned to be performed, “as needed” with no indication and no identified decision maker: hair care, peri care, and oral care. Clinical Record 10: The patient was admitted on 07/18/2024 with a diagnosis of Cerebral Infarction affecting the dominant right side and was on oxygen therapy. For the certification period of 07/18/2024 to 10/15/2024 the aide care plan did not include oxygen precautions. Clinical Record 11: The patient was admitted on 07/13/2024 with diagnoses that included Unspecified Cerebral Infarction, Dysphagia, Atrial Fibrillation with anticoagulation therapy. The aide care plan for the certification period of 07/13/2024 to 10/10/2024. did not include bleeding or aspiration precautions. Clinical Record 12: The patient was admitted on 06/25/2024 with diagnoses that included Dementia and Seizure Disorder. For the certification period of 09/23/2024 to 12/21/2024, the aide care plan did not include seizure precautions. Furthermore, that aide care plan included the following aide tasks were assigned to be performed, “as needed” with no indication and no identified decision maker: ambulation, commode, and elimination. Clinical Record 14: The patient was admitted on 07/15/2024 with diagnoses that included Malignant neoplasm of the Cerebrum except lobes and ventricles and was on dexamethasone. For the certification period of 07/15/2024 to 10/12/2024 the aide care plan did not include seizure precautions. Clinical Record 18: The patient was admitted on 06/24/2024 with diagnoses that included Hypertensive Heart Disease with Failure, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease with oxygen therapy, Atrial Fibrillation with anticoagulation therapy, and Dysphagia. The aide care plan effective 06/24/2024 to 09/16/2024 did not include aspiration, bleeding, or oxygen precautions. In an interview with the Director of Nursing (DON) on 11/07/2024, the DON stated after reviewing the aide care plans that the care plans did not include the safety measures but was unable to state why the safety measures had not been included. All precautions were noted on the plan of care but not included in the information provided to the hospice aides on their care plan.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. This standard was not met as evidenced by document review and interview. A review of the Volunteer Cost Savings document and interview revealed the agency did not ensure that volunteers were used in day-to-day administrative and/or direct patient care roles that, at a minimum, equaled five percent of the total patient care hours of all paid hospice employees and contract staff. The reported Volunteer Cost Savings were: January 2024 (1.06%); February 2024 (1.35%); March 2024 (1.74%); April 2024 (2.24%); May 2024 (1.91%); June 2024 (2.52%); July 2024 (2.11%); August 2024 (2.01%); September 2024 (1.71%); and October 2024 (2.53%). During an interview, on 11/08/2024, the Volunteer Coordinator stated that they lost several volunteers after COVID-19; many of whom retired and are not volunteering at this time.”