Gracious Care 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. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 4 (25%) home visits performed revealed the agency did not ensure the drug profile contained the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Clinical Record 14: The patient elected the hospice benefit on 2/5/2024 for the diagnosis of squamous cell carcinoma. During Home Visit 1 on 6/27/2024 to observe Staff 5 (SW), the hospice medication profile was compared to the medications in the patient’s adult foster home and reviewed with the caregiver. It was found that the Immodium dosing schedule had been changed on 6/14/2024 from 1 mg twice daily (ordered on 2/5/2024) to 2 mg once daily (ordered on 6/14/2024). The hospice medication profile did not discontinue the 1 mg twice daily and left both dosing schedules on the medication profile. During an interview and joint record review with the Administrator, Co-CEO, and Director of Patient Care Services on 6/27/2024, it was confirmed the medication profile had not been reconciled and the “nurse must have forgotten to discontinue to old dosage of the medication.””

“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; but no less frequently than every 15 calendar days. 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 the individualized plan of care was updated as frequently as the patient’s condition required. Clinical Record 15: The patient elected the hospice benefit on 4/24/2024 for the diagnosis of malignant neoplasm of the liver. On 5/21/2024 communication/progress notes were entered that noted: “9:20 AM PCG (primary caregiver) reporting patient hurting bad in left shoulder. Pain 8 on a 1-10 scale. Dr contacted. 9:22 AM Dr ordered Oxycodone with STAT delivery. 10:30 AM No relief from Morphine and Tylenol.” A nursing visit on 5/21/2024 at 1:20 PM noted: “arrived for routine visit. Patient made 4 calls to agency this morning due to pain. Pain 8 on scale of 1-10.” On 5/21/2024 at 9:36 PM an on-call communication/progress noted “Severe pain to left shoulder. Patient angry and screaming d/t pain. Medications given prior to call. Call hospice again in 30 minutes if no relief.” The plan of care dated 4/24/2024 included the following: “Pain. Problem: Patient has chronic pain at times > ...........shoulders. Goal: Pain will remain in a comfortable level during care daily. Intervention: Monitor/assess the effectiveness of current and new medication/treatment. Tylenol.” This plan of care was not modified or updated as the medications changed from Tylenol to Morphine and Ativan. There was no evidence in the plan of care being updated to reflect the education by the nurse when the family was described as “hesitant to give medications for fear it would cause death.” During an interview and joint record review with the Administrator, Co-CEO, and Director of Patient Care Services on 6/26/2024, it was confirmed that the patient had a “significant change of condition”, and the care plan did not reflect those changes.”

“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 5 of 13 (38%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific instructions for the hospice aide. Clinical Record 3: The patient elected the hospice benefit on 7/6/2023 for the diagnosis of Alzheimer’s disease. The initial nursing assessment dated 7/6/2023 noted patient had a “left forearm laceration with pressure dressing applied in the emergency department. “ The hospice aide care plan dated 7/7/2023 included the relevant tasks of “bathing via a shower chair and visualize skin condition and report to RN.” The aide care plan did not notify the aide of the wound nor provide specific instructions for care of the dressing (as needed) during tasks. Clinical Record 7: The patient elected the hospice benefit on 6/4/2024 for the diagnosis of congestive heart failure. A nursing comprehensive assessment dated 6/8/2024 noted “wound care to lower extremities, cover with Xerofoam.” The hospice aide care plan dated 6/4/2024 included the relevant task of “bathing via a shower chair.” The aide care plan did not notify the aide of the wound nor provide specific instructions for care of the dressing during tasks. Clinical Record 10: The patient elected the hospice benefit on 4/4/2024 for the diagnosis of chronic obstructive pulmonary disease. On a hospice aide visit dated 5/3/2024, the aide documented reporting a wound to the left ankle to the registered nurse. The registered nurse made a “visit to cover the wound with a dressing”. This wound was not added to the hospice aide care plan dated 4/4/2024 nor were specific instructions provided for care of the dressing during tasks. Clinical Record 17: The patient elected the hospice benefit on 4/19/2024 for the diagnosis of malignant neoplasm of the duodenum. The hospice aide care plan dated 4/19/2024 included the relevant tasks of “incontinent care, change briefs and bathing via a bed bath.” The clinical record contained a physician order dated 4/30/2024 and a nursing visit in which a Foley catheter was started. The aide care plan was not updated to reflect the Foley nor specific instructions provided for the Foley care. Clinical Record 19: The patient elected the hospice benefit on 3/7/2024 for the diagnosis of malignant neoplasm of connective and soft tissue. The initial nursing assessment dated 3/7/2024 noted the patient had bilateral nephrostomy tubes. The hospice aide care plan dated 3/7/2024 included the relevant tasks of “bathing via bed bath and empty collection bag.” It did not provide any further detail for the aide on the nephrostomy tubes or “collection bags”. During an interview and joint record review with the Administrator, Co-CEO, and Director of Patient Care Services on 6/26/2024, it was confirmed adding wounds to the hospice aide care plans was “new to them”. The foley and nephrostomy tubes care had been missed and the nurses would need to “continue to receive education.””

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the aide provided services included in the plan of care. Clinical Record 5: The patient elected the hospice benefit on 6/17/2024 for the diagnosis of malignant neoplasm of the lower respiratory tract. The hospice aide care plan dated 6/17/2024 included the relevant task of providing a bed bath. Hospice aide visit dated 6/21/2024 noted, “Provided companionship, shower, and personal care.” During an interview and joint record review with the Administrator, Co-CEO, and Director of Patient Care Services (DPCS) on 6/26/2024, it was confirmed the aide provided a shower instead of a bed bath as ordered in the plan of care. The DPCS advised, “The aides have been educated not to perform tasks until the plans of care have been updated.””

“It is required that a patient clinical record containing past and current findings was maintained for each hospice patient. Each patient’s record includes, at a minimum: Responses to medications, symptom management, treatments, and services. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 19 (16%) clinical records reviewed revealed the agency did not ensure that responses to medication, symptom management, treatments and services were documented. Document 1: Agency Policy PC.P10 Pain and Symptom Management stated in the relevant part: “ 2. Patient pain and other symptoms are thoroughly assessed by RN Case Manager or designee. 4. Pain is re-assessed any time a patient states his/her pain level has changed. This information is documented in the patient’s clinical record.” Document 2: Agency Policy PC.010 On Call stated in the relevant part: “10. Problems that require an emergency visit from a hospice nurse include, but not limited to: b. New, unusual or severe pain. m. duplicate calls regarding the same problem.” Document 3: Agency Policy AD HS57 HIPAA Compliant Texting (Tiger Connect) stated in the relevant part: “Clinical information is transferred from the text to the patient’s clinical record when appropriate” Clinical Record 10: The patient elected the hospice benefit on 4/4/2024 for the diagnosis of chronic obstructive pulmonary disease. A hospice aide visit dated 6/21/2024 noted “Patient was having pain to lower legs and ankles, notified RNCM xxxxx of this.” There was no documented visit from the RN or a phone call to indicate the report of pain had been followed up. The clinical information exchanged between the RN and the patient to address the patient’s pain (via the he agency’s HIPAA-compliant texting system) had not been transferred to patient’s clinical record. Clinical Record 15: The patient elected the hospice benefit on 4/24/2024 for the diagnosis of malignant neoplasm of the liver. On 5/21/2024 communication/progress notes were entered that noted: “9:20 AM PCG (primary caregiver) reporting patient hurting bad in left shoulder. Pain 8 on 1-10 scale. Dr contacted. 9:22 AM Dr ordered Oxycodone with STAT delivery. 10:30 AM No relief from Morphine and Tylenol.” A nursing visit on 5/21/2024 at 1:20 PM noted: “arrived for routine visit. Patient made 4 calls to agency this morning due to pain. Pain 8 on scale of 1-10.” On 5/21/2024 at 9:36 PM an on-call communication/progress noted “Severe pain to left shoulder. Patient angry and screaming d/t pain. Medications given prior to call. Call hospice again in 30 minutes if no relief.” The family did not return a call to the hospice agency with 30 minutes. The nurse visited during the day, but the agency did not follow their on-call policy which stated in part duplicate calls regarding the same problem warranted a nursing visit. Clinical Record 18: The patient elected the hospice benefit on 4/27/2023 for the diagnosis of chronic obstructive pulmonary disease. A hospice aide visit dated 5/4/2023 noted “RN xxxx contacted about patient having some pain that resulted in me not being able to do bed bath.” There was not a documented visit from the RN, a progress note, or a phone call to indicate the report of pain had been followed up. The next scheduled visit was on 5/5/2023. The clinical information exchanged between the RN and the patient to address the patient’s pain (via the agency’s HIPAA-compliant texting system) had not been transferred to patient’s clinical record. During an interview and joint record review with the Administrator, Co-CEO, and Director of Patient Care Services on 6/26/2024, it was confirmed Clinical Records 10 and 18 did not contain documentation of follow-up on the hospice aide reports. It was stated that “information was communicated via Tiger Connect, “ the Agency’s HIPAA-compliant texting system. It was agreed this is not in line with Agency policy as stated in Document 3. This was also not in compliance with Document 1 which requires a registered nurse assess pain and symptoms. During the interview regarding Clinical Record 15, it was stated the family member was “hesitant to give pain medications”. The Site Visitor asked the Administrator for clarification on Agency Policy regarding On Call during an interview on 6/26/2024. The administrator stated an LPN (licensed practical nurse) triaged calls and an RN (registered nurse) was available to make visits. A visit was expected to be made “for duplicate calls for pain and symptom management or a death within two hours”. The Administrator and Director of Patient Care Services agreed that the Agency Policies were not followed regarding sending a nurse out when duplicate calls came in regarding the same issue or assessing pain and symptoms.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 2 of 9 (22%) clinical records reviewed in clinical records reviewed with recertification, revealed the agency did not ensure the recertification of the terminal illness was completed by the physician no later than two calendar days after the first day of the benefit period and no more than 15 days before the next benefit period. Clinical Record 3: The patient elected the hospice benefit on 7/6/2023 for the diagnosis of Alzheimer’s disease. Clinical record review revealed the third benefit period started on 1/2/2024 and the recertification of terminal illness was signed by the hospice medical director on 1/5/2024, 3 days after the start of the benefit period and 1 day outstanding. There was not a verbal order present. Clinical Record 13: The patient elected the hospice benefit on 3/7/2023 for the diagnosis of malignant neoplasm of the prostate. Clinical record review revealed the 3rd benefit period started on 9/3/2023 and the recertification of terminal illness was signed by the hospice medical director on 8/15/2023, 18 days before the start of the benefit period and 3 days outstanding. There was not a verbal order present. During an interview and joint record review with the Administrator, Co-CEO, and Director of Patient Care Services on 6/26/2024, it was confirmed the recertifications were signed outside the time frame and there was no explanation provided.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review. In 1 of 2 (50%) clinical records reviewed in which a patient was discharged revealed the agency did not ensure the receiving facility received a copy of the discharge summary. Clinical Record 15: The patient elected the hospice benefit on 4/24/2024 for the diagnosis of malignant neoplasm of the liver. The patient elected to revoke their hospice benefit for aggressive treatment on 5/22/2024 and was transferred to a hospital which is a Medicare/Medicaid certified facility. The clinical record did not contain evidence that the discharge summary had been faxed to the hospital. During an interview and joint record review with the Administrator, Co-CEO, and Director of Patient Care Services on 6/27/2024, the Co-CEO advised she had “called the hospital and talked to them about the status of the patient but had not faxed anything from the clinical record to them.””

“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 the patient’s current plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which the patient was live discharged revealed the agency did not ensure the discharge summary included at least the patient’s current plan of care. Clinical Record 15: The patient elected the hospice benefit on 4/24/2024 for the diagnosis of malignant neoplasm of the liver. The patient elected to revoke their hospice benefit for aggressive treatment on 5/22/2024. A nursing visit note dated 5/22/2024 noted: “Received call from ***** RN (registered nurse) supervisor requesting RN go to patient’s SO (significant other) to have her sign the revocation form. Patient had serious fall with head lacerations and confusion and taken to hospital for sutures and evaluation.” The nursing visit note did not include a discharge summary with the patient’s current plan of care, hospice diagnosis or any further information. During an interview and joint record review with the Administrator, Co-CEO, and Director of Patient Care Services on 6/27/2024, it was confirmed the nursing note did not meet the requirements as described in the discharge summary regulation.”