Housecall Providers Hospice

“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 intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure the individualized plan of care was updated to include interventions to manage pain and symptoms. Clinical Record 4: The patient elected the hospice benefit on 11/16/2023 with the diagnosis of malignant neoplasm of pancreas. The plan of care (POC) was dated 11/16/2023 and did not include a goal for nausea. A nursing assessment dated 12/19/2023 noted “says nausea is bothering her but hasn’t used any PRN Haldol”. A nursing assessment dated 12/29/2023 stated “Feeling nauseous and although we talked about her using a PRN Haldol she hasn’t done so.” A nursing assessment dated 1/2/2024 stated “No nausea since Friday”. A nursing assessment dated 1/9/2024 stated, “Not having much nausea, used a PRN (as needed) dose on Sunday.” During the Home Visit on 2/27/2024, the patient verbalized to the registered nurse she was still having issues with nausea and requested the RN assist with filling the Haldol syringes as she had been using the medication “more frequently”. Clinical record review indicated the nausea problem, goals, or interventions had not been added to the care plan. Clinical Record 17: The patient elected the hospice benefit on 3/21/2023 for the diagnosis of malignant neoplasm of the colon. The initial plan of care (POC) dated 3/21/2023 did not include intervention for nausea. The patient was moved to general inpatient level of care on 4/7/2023 for “intractable nausea/vomiting”. There have been no updates to the POC since admission. A nursing note on 4/8/2023 documented the “patient states nausea is so bad he wants to just die.” The patient remained in general inpatient level of care until 4/10/2023 when he expired. During an interview and joint record review with the Hospice Director on 2/28/2024, it was confirmed the plans of care did not contain interventions to manage the symptoms described in the assessments.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed, the hospice did not ensure the plan of care (POC) was updated as frequently as the patient’s condition required. Clinical Record 2: The patient elected the hospice benefit on 2/9/2024 with a diagnosis of congestive heart failure. The initial plan of care dated 2/9/2024 included a cardiovascular goal and interventions. A nursing note dated 2/20/2024 stated in part “patient had decreased BP (blood pressure), passing out. Losartan DC (discontinued) on 2/20/2024. The registered nurse (RN) obtained VS (vital signs) log from facility.” During the Home Visit observation with the RN (Personnel Record 4) on 2/27/2024, the registered nurse spoke with the patient about her blood pressure changes and syncopal episodes. There was no documented evidence that the care plan had been updated since admission. Clinical Record 10: The patient elected the hospice benefit on 12/14/2023 with a diagnosis of bile duct carcinoma. The initial plan of care (POC) dated 12/14/2023 lists a goal “patient will have acceptable pain level”. Nursing assessment dated 12/20/2023 noted ‘Pain was good yesterday but worse today. Constant in abdomen.” Nursing assessment dated 1/25/2024 noted “Recent increase in Fentanyl patch from 200 to 225 mcg. Describes pain as 8/10. Takes 6 doses in the last 24 hours of her Hydromorphone instead of the prescribed 2 tablets. “ Nursing assessment dated 2/8/2024 noted “Fentanyl increased to 300 mcg for better pain control”. There was no documented evidence that the care plan had been updated for the pain goal/interventions since admission. Clinical Record 12: The patient elected the hospice benefit on 12/12/2023 with a diagnosis of malignant neoplasm of sigmoid colon. The initial plan of care (POC) dated 12/12/2023 lists a goal “patient will have acceptable pain level”. The initial nursing assessment dated 12/12/2023 noted the patient is on a CADD pump. Nursing assessment dated 2/4/2024 noted pain 3/10. A nursing assessment dated 2/6/2024 noted “Patient states, “ I just want to be knocked out” Patient has increased anxiety. “. There was no documented evidence that the care plan had been updated for the pain goal/interventions since admission. Clinical Record 15: The patient elected the hospice benefit on 11/5/2023 with a diagnosis of malignant neoplasm of oral pharynx. The initial plan of care (POC) dated 11/5/2023 lists a goal “Patient/CG will verbalize understanding of pain management regimen” A nursing assessment dated 12/27/2023 noted the patient was “Not wanting to use new medications for pain, wanting to keep using Oxy. Became tearful. Offered to have Dr call and speak with patient. Very freaked out about the prospect of using morphine or possibly methadone.” There was no documented evidence that updates had been made to initial plan of care. Clinical Record 19: The patient elected the hospice benefit on 5/31/2023 with a diagnosis of malignant neuroendocrine tumor. The initial plan of care (POC) dated 5/31/2023 lists a goal “patient will have acceptable pain level”. A nursing assessment dated 6/16/2023 noted “Pain 4/10 with new Fentanyl dose and 1-2 PRN Hydromorphone.” A nursing assessment dated 7/13/2023 noted “Patient in constant pain. Now unable to swallow.” There was no documented evidence that updates had been made to initial plan of care. During an interview and joint record review with the Hospice Director on 2/28/2024, it was confirmed the plans of care had not been updated according to the comprehensive assessments.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 3 (100%) clinical records reviewed in which a supervisory visit was required per agency policy it was not completed. Nursing Services Policy states in part “Version 4 Ref 502 Dated 5/4/2023. i. ii. A RN makes routine visits at least every 14 days and documents at least every 30 days that the LPN is routinely providing nursing services in accordance with the patient’s plan of care.” Clinical Record 5: The patient elected the hospice benefit on 11/29/2022 with a diagnosis of Parkinson’s disease. The patient had Licensed Practical Nurse (LPN) visits on 1/24/2024, refused 2/2/2024 and 2/21/2024 and no evidence of supervisory visits by a registered nurse (RN). Clinical Record 6: The patient elected the hospice benefit on 8/13/2023 with a diagnosis of cerebrovascular disease. The patient had LPN visits on 8/18/2023, 12/1/2023 and 12/20/2023 and no evidence of supervisory visits by a RN. Clinical Record 12: The patient elected the hospice benefit on 12/12/2023 with a diagnosis of malignant neoplasm of sigmoid colon. The patient had LPN visits on 12/18/2023 and 1/5/2024 and no evidence of supervisory visits by a RN. During an interview and joint record review with the Hospice Director on 2/28/2024, it was confirmed that the LPN supervisory visits had not been completed per current agency policy.”

“It is required that 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 9 of 13 (69%) clinical records reviewed in which aide services were accepted revealed the agency did not ensure the hospice registered nurse provided the aide with specific instructions. Clinical Record 1: The patient elected the hospice benefit on 12/1/2023 for the diagnosis of cerebrovascular disease. The hospice aide care plan dated 12/6/2023 included the relevant tasks of bed bath and shampoo. The Initial nursing assessment dated 12/1/2023 listed the patient on continuous oxygen at 2 liters per minute. The aide care plan did not provide the aide with specific instructions for the oxygen during tasks. Clinical Record 2: The patient elected the hospice benefit on 2/9/2024 for the diagnosis of congestive heart failure. The hospice aide care plan dated 2/14/2024 included the relevant tasks of shampooing, showering and oxygen precautions. The initial nursing assessment dated 2/9/2024 listed the patient on continuous oxygen at 3-4 liters per minute. The aide care plan did not provide the aide with specific instructions for the oxygen during tasks. Clinical Record 5: The patient elected the hospice benefit on 11/29/2022 for the diagnosis of Parkinson’s disease. The hospice aide care plan dated 11/29/2022 included the relevant tasks of bed bath, skincare, perineal care, and assisting with repositioning. A nursing assessment dated 12/27/2023 noted a “non-healing stage II to coccyx to be with bordered form dressing.” A second nursing assessment and physician’s order dated 2/8/2024 noted “thoracic spine wound, cleanse with wound cleaner and apply Vaseline gauze.” The aide care plan care did not include care for the wounds during bathing nor what to do if the dressings became dislodged, soiled, or wet. Clinical Record 6: The patient elected the hospice benefit on 8/13/2023 for the diagnosis of cerebrovascular disease. The hospice aide care plan dated 9/25/2023 included the relevant tasks of bed bath and shower. The aide care plan assignment did not provide the aide with specific instructions or criteria to determine the type of bath that should be performed. Clinical Record 7: The patient elected the hospice benefit on 9/25/2023 for the diagnosis of malignant neoplasm of the rectum. The hospice aide care plan dated 12/8/2023 included the relevant tasks of bed bath and skin care. The initial nursing assessment dated 9/25/2023 listed the patient as having a colostomy. A nursing assessment dated 2/21/2024 noted a “wound to scrotum treated with emulsion gauze.” The aide care plan care did not include care for the wound during bathing nor what to do if the dressing became dislodged, soiled, or wet. The aide care plan did not include specific instructions or notification to the aide regarding the colostomy. Clinical Record 9: The patient elected the hospice benefit on 2/14/2024 for the diagnosis of chronic obstructive pulmonary disease. The hospice aide care plan dated 2/12/2024 included the relevant tasks of oxygen precautions, shower-chair bath, and assistance with dressing. The initial nursing assessment dated 2/14/2024 listed the patient on continuous oxygen at 2 liters per minute. The aide care plan did not provide the aide with specific instructions for the oxygen during tasks. Clinical Record 12: The patient elected the hospice benefit on 12/12/2023 for the diagnosis of malignant neoplasm of sigmoid colon. The hospice aide care plan dated 1/2/2024 included the relevant tasks of shampoo and foot care. The initial nursing assessment dated 12/12/2023 included the patient had a colostomy, foley, and CADD pump. A nursing assessment dated 2/23/2024 noted the patient had a “foam dressing to coccyx”. The aide care plan care did not include care for the wounds during bathing nor what to do if the dressings became dislodged, soiled, or wet. The aide care plan did not notify the aide of the colostomy, foley, or CADD pump nor provide specific instructions for these during tasks. Clinical Record 14: The patient elected the hospice benefit on 8/21/2023 for the diagnosis of chronic obstructive pulmonary disease. The hospice aide care plan dated 12/20/2023 and updated 1/6/2024 included the relevant tasks of oxygen precautions, shower chair and assistance with dressing. The initial nursing assessment dated 8/21/2023 listed the patient on continuous oxygen at 2-4 liters per minute. The aide care plan did not provide the aide with specific instructions for the oxygen during tasks. Clinical Record 18: The patient elected the hospice benefit on 11/2/2023 for the diagnosis of respiratory failure. The hospice aide care plan dated 11/3/2023 included the relevant tasks of complete bath, and shampoo. The initial nursing assessment dated 11/2/2023 noted ‘left heel wound covered with foam dressing.” The aide care plan care did not include care for the wounds during bathing nor what to do if the dressings became dislodged, soiled, or wet. During an interview and joint record review with the Hospice Director on 2/28/2024, it was confirmed the aide care plans did not include specific instructions.”

“It is required that a hospice aide provides services Ordered by the Interdisciplinary Group Included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed in which aide services were accepted revealed the agency did not ensure the hospice aide provided services as ordered in the plan of care. Clinical Record 2: The patient elected the hospice benefit on 2/9/2024 with a diagnosis of congestive heart failure. The hospice aide care plan included orders for a shower. On 2/15/2024 Aide documented “got verbal orders to give a bed bath instead of a shower.” On 2/22/2024 the aide documented that they provided a bath instead of a shower. On 2/16/2024 the nursing supervision visit noted the aide was “following plan of care”. A nursing note on 2/23/2024 indicates that “she (patient) is too weak to get up and walk and agrees to a bed bath vs shower for now due to weakness and unpredictable dizziness.” Review of the clinical record on 2/29/2024 indicated the hospice aide care plan still listed shower instead of bed bath. Clinical Record 16: The patient elected the hospice benefit on 4/21/2023 with a diagnosis of pneumonitis due to inhalation of food and vomit. A hospice aide visit frequency order dated 4/21/2023 listed aide visits at 1 x weekly for 13 weeks. Hospice aide visit note dated 4/25/2023 stated “Initial visit. Staff declined services and all care stated he wasn’t aware of the visit and that he needed to confirm before letting me in. He also said that the patient was given a shower prior to the visit RNCM notified.” No further visits were documented, and the aide frequency order was not discontinued. Clinical Record 19: The patient elected the hospice benefit on 5/31/2023 with a diagnosis of a malignant neuroendocrine tumor. The hospice aide care plan included the relevant task of a shower chair. Aide visit dated 7/7/2023 noted “Patient preferred bed bath due to pain and she was feeling tired. RNCM notified.” Aide visit dated 7/14/2023 noted “Bed bath RNCM notified” Aide visit dated 7/18/2023 noted “Bed bath RNCM notified.” During an interview and joint record review with the Hospice Director on 2/28/2024, it was confirmed the aide had not followed the services included in the plan of care.”