VNA Hospice, Western Pa

“Based on a review of agency policy, clinical records (CRs), and staff (EMP) interview, the agency failed to protect and promote the exercise of patient rights. Specifically, the agency failed to ensure an alert and oriented patient signed the election of hospice benefit form, and was informed they were receiving hospice services for one (1) of two (2) patients observed residing in a skilled nursing facility (CR1). Findings include: Review of agency policy on September 27, 2024, at 11:30 a.m., “Policy Title: Patient/Client Rights and Responsibilities ... Policy Statement: ... Patient/Client Rights 1. You have the right to be informed of and exercise your rights as a patient. The patient’s family/legal guardian may exercise the patient’s rights when the patient has been judged incompetent. ... 9. You will be fully informed of the medical condition that relates to the care provided. To the extent possible, you will participate in making informed decisions regarding your care, including the development and revision of your plan of care. ... 19. You have the right to participate in, be informed about, and consent or refuse care in advance of and during treatment.” Review of CR1 on September 24, 2024, at 1 p.m. showed an initial hospice plan of care from 8/28/2024 to 11/25/2024. The patient’s admitting diagnoses were cachexia (weight loss) and failure to thrive. The registered nurse (RN) completed the initial assessment on 8/28/2024. The RN’s initial assessment showed the patient was alert and oriented. Per the RN’s narrative of patient’s sequela, “94 [year] old with fall in June causing hematoma to left flank area. Pt [patient] with fx [fracture] of ribs and L1-3 nondisplaced fx. Pt has HX [history] TIA, AFIB, DM type 2 [diabetes]. Pt no longer ... at apartment ... complex and was moved to SNF at [...]. Pt has had poor appetite with loss of 25 lbs since June. She is sleeping long periods and no longer able to get oob [out of bed]. Due to hypotension. Family requested comfort care at facility and md [physician] ordered hospice care.” The social worker (SW) saw the patient on 8/28/2024. Per the SW visit note, the family did not want the patient to know that he/she was on hospice, “Summary Narrative: LCSW [social worker] met with patient’s daughter [...] and her husband [...] at VNA Butler Office at [daughter’s] request, to review benefit, sign consents, complete MSW [social worker] initial assessment. [Daughter] stated due to cognitive decline and concerned about causing emotions.., she has used the phrase ‘VNA’ but not ‘Hospice’ with patient to describe the increase of services. Stated she feels this way because ‘hospice has a bad connotation in society.’ LCSW explored wishes, [Daughter] denied history of specific events causing poor feelings related to hospice. LCSW provided education team will honor patient/ family wishes to “not dwell” and/or avoid use of hospice in front of patient so as not to cause distress.” The SW assessment showed the patient was alert an oriented, “Alert, appeared oriented to self, person. Situation. She appeared thin, with slightly sunken cheeks, pale skin. Accepted social visit. ... She spoke of acceptance of her decline. She is able to engage daily with family through their visits, as well as through phone calls and watches her granddaughter’s softball games on Gamechanger live event feeds.” Review of the physician’s initial certification of terminal illness narrative from August 30, 2024, did not show patient was mentally incapacitated but had experienced a physical decline in June 2024 after suffering a fall, “Active Physician Certification of Terminal Illness Statement Patient is a 94 [year] old woman with a history of afib on Eliquis, history of TIA, diabetes on insulin, who is a resident of [SNF]. In June 2024, patient was admitted to the hospital due to a fall sustaining multiple fractures. Patient was then transferred to [SNF] for rehabilitation and then LTC [long term care]. Patient has lost a significant amount of weight in the last few months from 154 lbs to 132 lbs. Patient has poor appetite and states that she is not hungry; despite all interventions, the patient continues to lose weight and has increased weakness and sleeping long periods. Her family would like to keep her at the facility with comfort care only and would like to avoid rehospitalizations. I certify patient for Hospice Care. Start Effective Date: 08/30/2024.” Review of CR1’s election of hospice benefit document showed it was signed by the patient’s “Daughter / POA [power of attorney]” on 8/28/2024. The reason given for the patient not signing her own election of hospice benefit was, “Due to cognitive decline.” Review of a history and physical (H&P) from a 6/11/2024 hospital admission related to the recent fall showed the patient was alert and oriented “Neuro A0X3 [alert and oriented to person, place, and time]” and had been living independently prior to the hospitalization. The H&P showed patient was able to make her needs known and answer questions from medical providers. Review of “Provider Progress Note[s]” from 8/2, 8/8, and 8/9/2024 showed the patient was evaluated by a nurse practitioner. The notes showed the patient was able to answer questions appropriately. There was nothing to show that the patient was not able to direct her own care, and the nurse practitioner noted, “Appropriate mood and affect.” A home visit was conducted with CR1 and EMP1 (associate director) on September 25, 2024, at 9:30 a.m. Observation and interview with CR1 during the visit found the patient was pleasant, able to converse, alert and oriented, and able to verbalize the current year, “24.” EMP1 read the Medicare “Consent for Home Visit” form to CR1. CR1 verbalized understanding and signed the consent form for surveyor to observe care provided to her by the hospice. The home visit did not show that the patient was confused or mentally incapacitated-- she was mentally and physically able to review, sign, and understand her own Consent for Home Visit form and the purpose of the visit. Interview with EMP1 and EMP2 on September 27, 2024, at 11 a.m. confirmed above findings.”

“Based on review of agency policy, clinical records (CR), observation during home visit, and patient and staff (EMP) interviews, the agency failed to ensure the clinical record contained an election statement in accordance with §418.24 for one (1) of two (2) patients observed residing in a skilled nursing facility (CR1) who did not sign their own election statement. Based on review of agency policy, clinical records (CR), observation during home visit, and patient and staff (EMP) interviews, the agency failed to ensure the clinical record contained an election statement in accordance with §418.24 for one (1) of two (2) patients observed residing in a skilled nursing facility (CR1) who did not sign their own election statement. Findings include: Review of agency policy on September 27, 2024, at 11:30 a.m., “Policy Title: Patient/Client Rights and Responsibilities ... Policy Statement: ... Patient/Client Rights 1. You have the right to be informed of and exercise your rights as a patient. The patient’s family/legal guardian may exercise the patient’s rights when the patient has been judged incompetent.” §418.24 Election of hospice care. (a) Filing an election statement. (1) General. An individual who meets the eligibility requirement of §418.20 may file an election statement with a particular hospice. If the individual is physically or mentally incapacitated, his or her representative (as defined in §418.3) may file the election statement. Review of CR1 on September 24, 2024, at 1 p.m. showed an initial hospice plan of care from 8/28/2024 to 11/25/2024. The patient’s admitting diagnoses were cachexia (weight loss) and failure to thrive. The registered nurse (RN) completed the initial assessment on 8/28/2024. The RN’s initial assessment showed the patient was alert and oriented. Per the RN’s narrative of patient’s sequela, “94 [year] old with fall in June causing hematoma to left flank area. Pt [patient] with fx [fracture] of ribs and L1-3 nondisplaced fx. Pt has HX [history] TIA, AFIB, DM type 2 [diabetes]. Pt no longer ... at apartment ... complex and was moved to SNF at [...]. Pt has had poor appetite with loss of 25 lbs since June. She is sleeping long periods and no longer able to get oob [out of bed]. Due to hypotension. Family requested comfort care at facility and md [physician] ordered hospice care.” The social worker (SW) saw the patient on 8/28/2024. Per the SW visit note, the family did not want the patient to know that he/she was on hospice, “Summary Narrative: LCSW [social worker] met with patient’s daughter [...] and her husband [...] at VNA Butler Office at [daughter’s] request, to review benefit, sign consents, complete MSW [social worker] initial assessment. [Daughter] stated due to cognitive decline and concerned about causing emotions.., she has used the phrase ‘VNA’ but not ‘Hospice’ with patient to describe the increase of services. Stated she feels this way because ‘hospice has a bad connotation in society.’ LCSW explored wishes, [Daughter] denied history of specific events causing poor feelings related to hospice. LCSW provided education team will honor patient/ family wishes to “not dwell” and/or avoid use of hospice in front of patient so as not to cause distress.” The SW assessment showed the patient was alert an oriented, “Alert, appeared oriented to self, person. Situation. She appeared thin, with slightly sunken cheeks, pale skin. Accepted social visit. ... She spoke of acceptance of her decline. She is able to engage daily with family through their visits, as well as through phone calls and watches her granddaughter’s softball games on Gamechanger live event feeds.” Review of the physician’s initial certification of terminal illness narrative from August 30, 2024, did not show patient was mentally incapacitated but had experienced a physical decline in June 2024 after suffering a fall, “Active Physician Certification of Terminal Illness Statement Patient is a 94 [year] old woman with a history of afib on Eliquis, history of TIA, diabetes on insulin, who is a resident of [SNF]. In June 2024, patient was admitted to the hospital due to a fall sustaining multiple fractures. Patient was then transferred to [SNF] for rehabilitation and then LTC [long term care]. Patient has lost a significant amount of weight in the last few months from 154 lbs to 132 lbs. Patient has poor appetite and states that she is not hungry; despite all interventions, the patient continues to lose weight and has increased weakness and sleeping long periods. Her family would like to keep her at the facility with comfort care only and would like to avoid rehospitalizations. I certify patient for Hospice Care. Start Effective Date: 08/30/2024.” Review of CR1’s election of hospice benefit document showed it was signed by the patient’s “Daughter / POA [power of attorney]” on 8/28/2024. The reason given for the patient not signing her own election of hospice benefit was, “Due to cognitive decline.” Review of a history and physical (H&P) from a 6/11/2024 hospital admission related to the recent fall showed that patient was alert and oriented “Neuro A0X3 [alert and oriented to person, place, and time]” and had been living independently prior to the hospitalization. The H&P showed patient was able to make her needs known and answer questions from medical providers. Review of “Provider Progress Note[s]” from 8/2, 8/8, and 8/9/2024 showed the patient was evaluated by a nurse practitioner. The notes showed the patient was able to answer questions appropriately. There was nothing to show that the patient was not able to direct her own care, and the nurse practitioner noted, “Appropriate mood and affect.” A home visit was conducted with CR1 and EMP1 (associate director) on September 25, 2024, at 9:30 a.m. Observation and interview with CR1 during the visit found the patient was pleasant, able to converse, alert and oriented, and able to verbalize the current year, “24.” EMP1 read the Medicare “Consent for Home Visit” form to CR1. CR1 verbalized understanding and signed the consent form for surveyor to observe care provided to her by the hospice. The home visit did not show that the patient was confused or mentally incapacitated-- she was mentally and physically able to review, sign, and understand her own Consent for Home Visit form and the purpose of the visit. Interview with EMP1 and EMP2 on September 27, 2024, at 11 a.m. confirmed above findings.”

“Based on review of clinical records (CR), observations during home visits at skilled nursing facility (SNF), and staff (EMP) interview, the agency failed to provide the SNF the most recent hospice plan of care for two (2) of two (2) clinical records (CR1, & CR2) residing in a SNF. Findings include: Review of CR1 on September 24, 2024, at 1 p.m. showed an initial hospice plan of care from 8/28/2024 to 11/25/2024. The patient’s most recent plan of care was updated on 9/11/2024 to include changes to nursing, home health aide, and spiritual counseling visit frequencies. Review of CR1 during a home visit on September 25, 2024, at 10 a.m. with EMP1 (associate director) at CR1’s residence (SNF), showed it did not contain the most recent plan of care from 9/11/2024. Review of CR2 on September 24, 2024, at 1:35 p.m. showed a recertified hospice plan of care from 8/1/2024 to 9/29/2024. The patient’s most recent plan of care was updated on 8/24, 8/28, and 9/11/2024, and included changes to the patient’s activity level, “Musculoskeletal/Activities Interventions rock and go chair ordered due to patient leaning in her w/c [wheelchair] and recliner Start Effective Date: 08/29/2024.” Review of CR2 during a home visit on September 25, 2024, at 10:05 a.m. with EMP1 (associate director) at CR2’s residence (SNF), showed it did not contain the most recent plan of care from 9/11/2024 (last plan of care in CR2 was from 7/31/2024). Interview with EMP1 (associate director) during the home visits on September 24, 2024, at 10 a.m. confirmed above findings.”