Cawley Hospice

“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 actual or potential drug interactions. The assessment includes evidence that common side effects of medication in hospice populations are anticipated, and as appropriate, preventive measures are implemented to manage the side effects. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 13 (8%) clinical records reviewed, the agency did not ensure the drug profile included all of the medications the patient was currently taking. Home Visit 1/Clinical Record 1: The patient elected the hospice benefit on 07/12/2024. During the home visit with the Registered Nurse (Personnel Record 1) on 07/31/2024, a medication review was completed by comparing the hospice medication profile with the medication bottles provided by the patient. The patient confirmed that all medications being reviewed were taken as prescribed. The hospice drug profile current 07/30/2024 did not include Lorazepam 1mg tablet every four hours as needed for anxiety or agitation, Arnicare topical gel applied as needed for sciatic pain, Chloraseptic max sore throat spray two pumps as needed for throat pain, Propranolol 20mg tablet twice a day, Atorvastatin 20mg tablet daily, Acyclovir 400mg twice a day, Lisinopril 10mg daily, Primidone 250mg twice a day, Fluoxetine 20mg daily, and Lidocaine 5% patch on for 12 hours and off for 12 hours. During joint clinical record review and interview on 08/01/2024, the Administrator and Director of Clinical Operations confirmed the patient’s drug profile did not include all the medications presented by the patient, stating the patient had not produced the identified medications on admission and during subsequent visits.”

“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. The documentation in the patient’s record is in accordance with the hospice’s policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 6 of 13 (46%) clinical records reviewed, the agency did not ensure the individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice services on 07/12/2024 with a terminal diagnosis of Malignant neoplasm of overlapping sites of the larynx. The initial nursing assessment dated 07/12/2024 included documentation that the patient had dysphagia and swallowing test results showed aspiration. The written plan of care dated 07/12/2024 did not reflect patient and family goals and planned interventions associated with the patient’s dysphagia and aspiration risk identified in the comprehensive assessment. Clinical Record 5: The patient elected hospice services on 06/30/2024 with a terminal diagnosis of Malignant neoplasm of the rectum. The initial nursing assessment dated 06/30/2024 included documentation that the patient had three to four plus pitting edema to bilateral lower extremities and severe scrotal edema. The written plan of care dated 06/30/2024 did not reflect patient and family goals and planned interventions associated with the patient’s edema identified in the comprehensive assessment. Clinical Record 8: The patient elected hospice services on 06/21/2024 with a terminal diagnosis of Malignant neoplasm of the pancreatic duct. The patient died at home on 06/29/2024. The initial nursing assessment dated 06/21/2024 included documentation that the patient had one plus pitting edema to bilateral lower extremities, abdominal swelling, and dyspnea with moderate exertion. The written plan of care dated 06/21/2024 did not reflect patient and family goals and planned interventions associated with the patient’s edema, abdominal swelling, and dyspnea identified in the comprehensive assessment. Clinical Record 10: The patient elected hospice services on 06/21/2024 with a terminal diagnosis of Malignant neoplasm of the unspecified part of the unspecified bronchus or lung. The patient died at home on 07/01/2024. The initial nursing assessment dated 06/21/2024 included documentation that the patient had three plus pitting edema to the left upper extremity and two plus pitting edema to bilateral lower extremities. The written plan of care dated 06/21/2024 did not reflect patient and family goals and planned interventions associated with the patient’s edema identified in the comprehensive assessment. Clinical Record 11: The patient elected hospice services on 07/18/2024 with a terminal diagnosis of Hypertensive heart and chronic kidney disease with heart failure and unspecified stage 1-4 chronic kidney disease. The patient died at home on 07/26/2024. The initial nursing assessment dated 07/18/2024 included documentation that the patient had two plus pitting edema to bilateral lower extremities, was easily agitated, and was a high fall risk. The written plan of care dated 07/18/2024 did not reflect patient and family goals and planned interventions associated with the patient’s edema, agitation, and fall risk identified in the comprehensive assessment. Clinical Record 13: The patient elected hospice services on 07/11/2024 with a terminal diagnosis of Senile degeneration of the brain. The patient died at home on 07/31/2024. The comprehensive spiritual and psychosocial assessments dated 07/15/2024 and 07/16/2024 respectively included documentation that the chaplain and medical social worker identified spiritual, emotional, and psychosocial issues requiring interventions by the chaplain and MSW. The initial plan of care for the benefit period starting 07/11/2024 did not reflect patient and family goals and planned interventions associated with spiritual, emotional, and psychosocial issues identified in the comprehensive assessments. During joint clinical record reviews and interviews on 08/01/2024, the Administrator and Director of Clinical Operations confirmed the written plans of care identified did not reflect patient and family goals and planned interventions associated with all problems identified in the initial comprehensive assessments including dysphagia, aspiration risks, dyspnea, oxygen safety needs, agitation, and fall risk. The leaders stated that, according to their electronic medical record (EMR) provider, if the ordering physician signs the individual medical diagnoses required to develop the plan of care goals and interventions and to enter the medication and treatment orders before all disciplines complete their respective plans, the EMR finalizes the initial plan of care.”

“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 measurable outcomes anticipated from implementing and coordinating the plan of care. The documentation in the patient’s record is in accordance with the hospice’s policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 4 of 13 (31%) clinical records reviewed, the agency did not ensure the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 4: The patient elected the hospice benefit on 07/28/2024 with a terminal diagnosis of unspecified malignant neoplasm of the stomach. The initial nursing assessment dated 07/28/2024 included documentation that the patient was alert, oriented, and verbal and had pain rated eight out of ten with a reported goal of two out of ten. The plan of care dated 07/28/2024 documented, “Will experience an improvement in pain management as measured by non-verbal pain assessment” as a pain goal reflected by the patient and family. The goal did not include the measurable, numeric outcome identified by and specific to the patient. Clinical Record 5: The patient elected the hospice benefit on 06/30/2024 with a terminal diagnosis of malignant neoplasm of the rectum. The initial nursing assessment dated 06/30/2024 included documentation that the patient had a colostomy to the right abdominal wall draining loose stool and reported daily intermittent nausea and vomiting. The plan of care dated 06/30/2024 documented, “Will realize improved comfort relating to gastrointestinal symptoms as evidenced by subjective patient or caregiver reporting,” as a goal reflected by the patient and family. The goal did not include the measurable subjective data identified by and specific to the patient and family to be reported. Clinical Record 11: The patient elected the hospice benefit on 07/18/2024 with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure and unspecified stage 1-4 chronic kidney disease. The patient died at home on 07/26/2024. The initial nursing assessment dated 07/18/2024 included documentation that the patient was alert, oriented, and verbal and had dyspnea at rest and with talking. The plan of care dated 07/18/2024 documented, “Will realize relief from cardiac-related dyspnea as shown by an improvement in patient-reported symptom control,” as a goal reflected by the patient and family. The goal did not include the measurable subjective data to be reported related to “improvement” as identified by and specific to the patient and family. Clinical Record 13: The patient elected the hospice benefit on 07/11/2024 with a terminal diagnosis of Senile degeneration of the brain, not elsewhere classified. The initial nursing assessment dated 07/11/2024 included documentation that the patient was lethargic, pleasantly confused, bed/chair bound, and was at high fall risk. The plan of care dated 07/11/2024 documented, “Will realize a peaceful and comfortable environment as evidenced by trends in caregiver feedback,” as a goal associated with the patient’s fall risk and reflected by the patient and family. The goal did not include a measurable outcome relevant to the patient’s fall risk as identified by the patient and family. During joint clinical record reviews and interviews on 08/01/2024, the Administrator and Director of Clinical Operations confirmed the written plans of care did not include measurable outcomes as identified by the patient and family for pain, dyspnea, nausea, vomiting, diarrhea, and fall risk.”

“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 medical supplies and appliances necessary to meet the needs of the patient. The documentation in the patient’s record is in accordance with the hospice’s policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed, the agency did not ensure the individualized written plan of care included all medical supplies and appliances necessary to meet the patient’s needs. Clinical Record 5: The patient elected the hospice benefit on 06/30/2024 with a terminal diagnosis of malignant neoplasm of the rectum. The initial nursing assessment dated 06/30/2024 included documentation that the patient had a colostomy to the right abdominal wall. The plan of care dated 06/30/2024 included an order for skilled nursing to “provide wound care for any surgical incisions or ostomies.” The plan of care contained no evidence of orders for ostomy supplies needed, including type, the care required, and the frequency of intended care. During joint clinical record reviews and interviews on 08/01/2024, the Administrator and Director of Clinical Operations confirmed that the plan of care contained no evidence of orders for the medical supplies needed by the patient in the care of the colostomy.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed, the agency did not ensure the individualized written plan of care included orders for all drugs and treatments necessary to meet the patient’s needs. Clinical Record 1: The patient elected the hospice benefit on 07/12/2024 with a terminal diagnosis of Malignant neoplasm of overlapping sites of the larynx. The initial nursing assessment dated 07/12/2024 included documentation that the patient took alprazolam scheduled and as needed for tremors, required the addition of an opioid for throat pain, and drank multiple protein shakes to supplement meals. The plan of care dated 07/12/2024 contained no evidence of orders for alprazolam, opioid pain medication, and protein shakes. During joint review of clinical records and interviews on 08/01/2024, the Administrator and Director of Clinical Operations confirmed the plans of care identified contained no evidence of orders for medications.”