Comforting Hands Hospice of Grove

“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. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient’s date of election was 04/18/2024. The primary hospice diagnosis was chronic kidney disease, unspecified, with comorbidities including diabetes mellitus type 2. The initial nursing assessment on 04/18/2024 documented that the patient had shortness of breath upon exertion, used a CPAP/BiPAP, used insulin, used a blood glucose monitor, had a pain rating of 6/10 to the lower back, and had a fall risk of 9 on the MAHC-10 with a score of 4 or more was considered at risk for falling. The recertification assessment on 07/09/2024 documented that the patient had shortness of breath upon exertion, used a CPAP/BiPAP, used insulin, and used a blood glucose monitor. The plan of care dated 04/18/2024-07/16/2024 and 07/17/2024-10/14/2024 lacked problems, interventions, and goals for altered respiratory status, insulin dependence, glucometer management, potential fall risk, and pain management. Clinical Record 2: The patient’s date of election was 07/01/2023. The primary hospice diagnosis was heart failure, unspecified. The initial nursing assessment on 07/01/2023 documented that the patient had a right lower leg skin tear, bowel and bladder incontinence, and shortness of breath upon exertion. The recertification assessment on 08/25/2023 documented that the patient had bowel and bladder incontinence. The plan of care dated 07/01/2023-08/29/2023 and 08/30/2023-10/28/2023 lacked problems, interventions, and goals for altered respiratory status, wound, and risk for skin breakdown. Clinical Record 3: The patient’s date of election was 06/27/2024. The primary hospice diagnosis was chronic obstructive pulmonary disease with acute exacerbation with comorbidities of diabetes mellitus type 2. The initial nursing assessment on 06/27/2024 documented that the patient had skin tears to the lower left leg, lower right leg, and the left arm/wrist, bladder incontinence, diabetes mellitus type 2 managed by blood glucose monitoring, a recent history of falls, a MAHC-10 score of 8, and the presence of a cardioverter-defibrillator. The medication record reviewed on 09/06/2024 revealed the patient was taking glimepiride, Jardiance, and metformin, which were added on 06/27/2024. The plan of care dated 06/27/2024-09/24/2024 lacked problems, interventions, and goals for hyperglycemia, hypoglycemia, falls, cardioverter-defibrillator, wounds, and risk for skin breakdown. During a joint clinical record review and interview on 09/05/2024, the Administrator/Registered Nurse confirmed there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the assessments.”

“It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed revealed the agency did not ensure that counseling services, including spiritual counseling, were provided based on an assessment of the patient’s and family’s spiritual needs. Clinical Record 5: The patient’s date of election was 03/11/2024. The initial plan of care dated 03/11/2024-06/08/2024 ordered the chaplain to assess and evaluate 03/11/2024-03/15/2024. The record lacked evidence the chaplain made a visit from 03/11/2024 through 03/15/2024. The record lacked evidence that the order was discontinued. Clinical Record 7: The patient’s date of election was 04/18/2024. The initial plan of care dated 04/18/2024-07/17/2024 ordered the chaplain to assess and evaluate 04/18/2024-04/22/2024. A missed visit dated 04/19/2024 documented, “Unable to contact patient for initial assessment. Will try again later.” The records lacked any further contact with the patient or caregiver. The record lacked evidence that the order was discontinued. During a joint clinical record review and an interview on 09/06/2024, the Director of Nursing confirmed that there was no documented evidence that spiritual counseling services were provided during the times identified.”

“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 an 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 2 of 14 (14%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure that the hospice aide care plan provided specific instructions to the aide. Clinical Record 1: The patient’s date of election was 04/18/2024. The primary hospice diagnosis was chronic kidney disease, unspecified. The hospice aide care plan dated 04/18/2024, reviewed on 09/05/2024, assigned the hospice aide the tasks, “Hygiene: Bath: Tub; Hygiene: Bath: Partial; Hygiene: Bath: Shower; Hygiene: Bath: Bed; Hygiene: Bath: Shower Chair; Hygiene: Bath: Complete; Hygiene: Bath.” The care plan did not provide clear instructions to the hospice aide regarding the type of bath. Clinical Record 2: The patient’s date of election was 07/01/2023. The primary hospice diagnosis was heart failure, unspecified. The hospice aide care plan dated 07/01/2023, reviewed on 09/05/2024, assigned the hospice aide the tasks “Hygiene: Bath: Shower Chair; Hygiene: Bath: Complete; and Hygiene: Bath: Shower.” The care plan did not provide clear instructions to the hospice aide regarding the type of bath. During a joint review of the record and an interview on 09/05/2024, the Administrator/Registered Nurse agreed the instructions on the hospice aide care plan were not specific.”

“It is required that a hospice aide provide services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records with hospice aide services reviewed revealed the agency did not ensure that a hospice aide provide services included in the plan of care. Clinical Record 3: The patient’s date of election was 06/27/2024. The date of the aide plan of care was 06/27/2024 included to document bowel movements, report to RN if no BM in 3 days, give SSE as directed by RN; give SSE as directed by RN; bed bath; complete bath; shower; pt to be non-weight bearing; bath; partial bath; do patient laundry; dinner; clean living area of the patient; blood pressure; report patient pain to nurse; assist with positioning, repositioning, alignment; change adult diapers; water temperature check; snack; oral care; foot care; ambulate only with assistance; transfer belt; assist with meal preparation; shave: safety razor; may trim or file any long or uneven finger nails; standard precautions; ROM exercises; pulse; assist patient to open medication container; document bowel movements; assess pain; independent ambulation; denture care; shampoo; clean up kitchen after meal preparation; emergency call system; assist with meal preparation, set-up, feeding; report to RN if no BM; weight; assist with meal planning; assist to commode; bath: shower chair; remind patient to take medications; change patient linen; temperature; lunch; breakfast; incontinent care; fall precautions; assist with transfers, ambulation, exercise program; respirations; clean bathroom after patient care; nail care; universal precautions; assist with transfers; recognize and report any changes in the patient’s skin condition; record intake and output; meal planning/preparation; shopping/errands; shave; fluid intake; skin care; assist patient with dressing; assist to BSC/toilet; shave electric; assist with medication administration; up in chair/wheelchair; report abnormal vital signs to nurse; perineal care; encourage to wear glasses/hearing aids; transfer to bed/chair with assistance; encourage patient to wear dentures; oxygen precautions; teach/reinforce home safety interventions (lighted stairs, clear walkways, no throw rugs, personal alert system, etc.); and patient to dangle. The aide follow up visit note dated 07/03/2024 documented, “Applied cream to legs, applied Nystatin cream on feet and wound care was provided to shin wounds and big toe and applied compression sock on patient.” The aide’s plan of care did not include interventions to apply Nystatin cream on the feet and to complete wound care to shin wounds and the big toe. During a joint review of the record and an interview on 09/06/2024, the Administrator/Registered Nurse confirmed that the hospice aide provided services not included in the plan of care.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1, and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Upon reviewing the volunteer program, the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from January 2024 to March 2024. The documentation lacked evidence of the amount that, at a minimum, equals five percent (5%) of the total patient care hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions During a joint review of the volunteer program records and interview on 09/06/2024, the Administrator/Registered Nurse confirmed that the agency did not document the direct care staff hours, the volunteer percentage, and the cost savings from January 2024 through March 2024, and the average percentage for April 2024 through August 2024 did not equal five percent (5%). Upon reviewing the volunteer program, the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from January 2024 to March 2024. The documentation lacked evidence of the amount that, at a minimum, equals five percent (5%) of the total patient care hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. In 3 of 13 (23%) personnel records reviewed revealed that the agency did not ensure employees were assessed for skills and competencies. Personnel Record 2: The Patient Care Coordinator’s date of hire was 08/25/2022. The record lacked evidence of skills and competency. Personnel Record 9: The Registered Nurse’s date of hire was 11/13/2023. The record lacked skills and competency. Personnel Record 13: The Licensed Practical Nurse’s date of hire was 07/12/2023. The record lacked evidence of skills and competency. During a joint record review and interview on 09/06/2024, the Administrator/Registered Nurse confirmed that the records did not include evidence that the employees were assessed for skills and competencies. The Administrator/Registered Nurse stated that nursing staff have an initial competency complete before seeing patients on their own.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 11: The revocation date was 10/05/2023. The discharge summary electronically signed on 10/09/2023 lacked documentation that the discharge summary was forwarded to the patient’s attending physician. Clinical Record 12: The revocation date was 07/11/2024. The discharge summary electronically signed on 07/12/2024 lacked documentation that the discharge summary was forwarded to the patient’s attending physician. During a joint record review and interview on 09/06/2024, the Administrator/Registered Nurse confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records for discharged patients reviewed revealed that the agency did not ensure that the discharge summary included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Clinical Record 11: The date of the revocation was 10/05/2023. The Discharge Summary lacked a summary that included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Clinical Record 12: The date of the revocation was 07/11/2024. The Discharge Summary lacked a summary that included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. During a joint record review and interview on 09/06/2024, the Administrator/Registered Nurse confirmed that the record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician.”