Better Together Home Health and 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 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 1 of 11 (9%) clinical records reviewed it was revealed that the agency did not ensure that new medications were added to the medication profile. Document 1: The agency policy stated in part, “Medications are accurately and completely reconciled across the continuum of care. A) Medications are listed on the referral form, B) The RN opening the case reconciles all medications from the referral, discharge instructions, and with the medications in the home and with the patient, C) The RN clarifies discrepancies with the physician, D) The RN completes a current list of reconciled medications, E) The written list of reconciled medications is reviewed every visit and updated with changes. (N-8.19) (2022) Clinical Record 8: The patient was admitted with a diagnosis of Acute Myeloid Leukemia and non-Hodgkin’s Lymphoma. Oxygen was ordered on admission at 2-4 LPM as needed for the shortness of breath the patient experienced per the Comprehensive Assessment dated 06/06/2024. The comprehensive assessment drug profile did not include oxygen. In an interview and clinical record review with the Administrator on 10/24/2024, the Administrator agreed the medication profile did not include the use of oxygen.”

“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 and interview. In 3 of 11 (27%) clinical records reviewed it was revealed that the agency did not ensure that each patients written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 6: The Plan of Care (POC) for the episode dated 04/05/2024 to 07/03/2024 included a diagnosis of Insulin Dependent Diabetes Mellitus. The POC did not include any precautions or interventions for Diabetes Mellitus. Clinical Record 8: The Plan of Care (POC) for the episode dated 06/06/2024 to 09/03/2024 included the medication Dilantin for seizures. The POC did not include seizure precautions. Clinical Record 11: The patient was admitted for a diagnosis of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Atrial Fibrillation. The Plan of Care (POC) for the episode dated 03/22/2024 to 06/17/2024 included the use of oxygen at 4 LPM and Warfarin (anticoagulant). The Plan of Care did not include bleeding or oxygen precautions. In an interview with the Administrator and a review of the Quality Assurance Performance Improvement (QAPI) program on 10/24/2024, this problem was identified and a plan of correction implemented in July 2024.”

“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 8 of 10 (80%) clinical records reviewed and interviews of patients receiving hospice aide services, it was revealed that the agency did not ensure that written patient care instructions were provided for the hospice aide that included care precautions. Clinical Record 1: The patient was admitted with a diagnosis of Senile Degeneration of the Brain. The Plan of Care (POC) for the episodes dated 07/03/2024 to 09/30/2024 and 10/01/2024 to 12/29/2024 included fall precautions and aspiration precautions. The aide care plan did not include fall and aspiration precautions. Clinical Record 2: The patient had a diagnosis of Alzheimer’s Disease with noted difficulty swallowing at times. The Hospice Aide Care Plan for the episode dated 05/07/2024 to 08/04/2024 did not include aspiration precautions. Clinical Record 3: The patient had a diagnosis of Atrial Fibrillation and was taking the anticoagulant, Apixaban 5mg PO twice daily (12/28/2023) The hospice aide care plan did not include bleeding precautions. The patient required assistance with ambulation and used furniture and railings for balance per the IDG note dated 07/31/2024. Fall precautions were not included in the care plan for the hospice aide. The patient had wounds to the left lower extremity. There were no instructions for the aide for the wound care dressings (if the dressing came off or was soiled). Clinical Record 4: The patient had a diagnosis of Cardiac Disease and Dementia. The Plan of Care (POC) for the episode dated 10/03/2024 to 12/31/2024 included fall precautions. The aide care plan did not include fall precautions. Clinical Record 5: The patient had a diagnosis of Senile Degeneration of the brain. The Plan of Care for the episode dated 06/04/2024 to 09/01/2024 included aspiration precautions and a history of falls. Fall and aspiration precautions were not included in the aide care plan. Clinical Record 6: The patient had a diagnosis of Senile Degeneration of the brain, Insulin Dependent Diabetes Mellitus, Prostate cancer, and a history of falls. The aide care plan did not include fall or diabetic care precautions. Clinical Record 8: The patient had a diagnosis of seizure disorder and was treated with Dilantin. Seizure precautions were not included in the hospice aide care plan. The patient was on oxygen and utilized a walker. Functional limitations included ambulation limitations. Oxygen safety and fall precautions were not included in the hospice aide care plan. Clinical Record 9: The patient was admitted with a diagnosis of Senile Degeneration of the Brain. The Plan of Care for the episode dated 02/18/2024 to 05/17/2024 include aspiration precautions. The aide care plan did not include aspiration precautions. In an interview with the Administrator on 10/23/2024 and a review of the clinical records, the Administrator confirmed the written precautions had not been added to the hospice aide care plan.”

“It is required a hospice aide provides services: Ordered by the Interdisciplinary Group, and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed and interviews for patients receiving hospice aide services it was revealed that the agency did not ensure that the hospice aide services were provided as ordered on the plan of care. Clinical Record 3: For the episode dated 07/01/2024 to 09/28/2024, the aide care plan assignment was a frequency once weekly for a shower. On 10/10/2024, the aide documented that she performed a bed bath on the patient. There was no evidence that the RN was notified. In an interview with the Administrator on 10/24/2024 and clinical record review, the Administrator agreed a bed bath was given and not the assigned shower.”