Interim Healthcare of the Upstate Hospice

“It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. CONTINUED PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. Agency policy “Interdisciplinary Group (IDG) Plan of Care” stated in part, “The plan of care includes, but is not limited to the following: (a) interventions to manage pain and symptoms, (b) identified patient/family physical, psychosocial, functional, educational, and bereavement needs, (e) measurable outcomes anticipated as a result of implementing and coordinating the plan of care.” In 1 of 7 (14%) clinical records reviewed, the hospice did not ensure the plan of care (POC) identified planned interventions based on problems identified in the updated comprehensive assessment. Clinical Record 3: The patient elected hospice care on 02/11/2024 with a diagnosis of Alzheimer’s Disease. For the recertification period dated 02/11/2024 through 04/10/2024, the Certification of Terminal Illness dated 02/01/2024 documented that the patient had “pill dysphagia.” In the IDG meetings held on 02/01/2024 and 02/15/2024, the Registered Nurse (RN) update stated, “pt has dysphagia.” The plan of care dated 02/11/2024 through 04/10/2024 did not include documentation of a problem, goals, or interventions related to the patient’s dysphagia. During a joint record review and interview on 02/22/2024, the Director of Clinical Services confirmed that the plan of care was not updated to reflect the problems, interventions, and goals for the patient’s dysphagia. Agency policy “Interdisciplinary Group (IDG) Plan of Care states in part, “The plan of care includes, but is not limited to the following: (a) interventions to manage pain and symptoms, (b) identified patient/family physical, psychosocial, functional, educational, and bereavement needs, (e) measurable outcomes anticipated as a result of implementing and coordinating the plan of care.””

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by a review of clinical records and interviews with the Hospice Clinical Quality Supervisor and the Director of Hospice, which revealed the hospice: Failed to ensure that the Registered Nurse (RN) provided coordination of patient care, continuous assessment of the patient and family’s needs, and implementation of the interdisciplinary plan of care [HCPC.19.I/L540]; Failed to ensure an individualized written plan of care was prepared for each patient based on the comprehensive assessment [HCPC.21.I/L545]; Failed to ensure that the patient’s care and services followed the plan of care established by the hospice interdisciplinary group [HCPC.19.I/L543]; and Failed to ensure all drugs and treatments necessary to meet the patient’s needs were included in the plan of care [HCPC.21.I/L549]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided; signed copies of the notice of patient rights and the hospice election statement; responses to medications, symptom management, treatments, and services; outcome measure data elements per regulation; physician certification and recertification of terminal illness as required; any advance directives; copies of inpatient discharge summary, as applicable; and physician orders. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews with the Hospice Clinical Quality Supervisor and the Director of Hospice which revealed the hospice: Failed to ensure the clinical record contained a plan of care with correct clinical information [HSIM.3.I/L672]; Failed to ensure that the patient’s clinical record and information was safeguarded against loss or unauthorized use [HSIM.5.I/L680]; Failed to ensure that the clinical record included documentation of physician’s orders for care and services provided [HSIM.3.I/L678]; and Failed to ensure that the patient’s attending physician received a copy of the hospice discharge summary [HCDT.39.I/L683]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.104: Clinical Records. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“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 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, interview, and observation. Agency policy “Drugs and Biologics-Administration, Use, and Disposal” (revised 06/08/2021) stated in part, “Each patient’s drugs, biologics, over-the-counter-drugs, herbal remedies, and alternative treatments are identified on the medication profile as part of the Interdisciplinary Group (IDG) plan of care.” In 5 of 6 (83%) home visits observed, the hospice did not ensure the comprehensive assessment included a drug profile that contained the patient’s current medications. Home Visit 1/Clinical Record 2: The patient elected hospice care on 10/09/2023. Medication reconciliation was performed during the home visit on 01/09/2024, comparing the agency’s medication profile to the patient’s current medication regimen. The medication profile dated 01/09/2024 documented, “Bisacodyl 10 mg suppository, give one (1) suppository daily as needed (PRN) ordered 10/18/2023; Lorazepam 0.5 mg, give one (1) tablet every four (4) hours PRN for anxiety, ordered 10/18/2023; Haldol 2 mg per ml, give 0.5 mg every four (4) hours as PRN agitation.” The patient reported they had never taken the medications Bisacodyl, Lorazepam, or Haldol. The Director of Hospice, present at the home visit, called the pharmacy and confirmed the patient had never received the medications Bisacodyl, Lorazepam, or Haldol. The Director of Hospice confirmed the pharmacy did not have an active physician order for Bisacodyl, Lorazepam, or Haldol. Home Visit 2/Clinical Record 9: The patient elected hospice care on 10/06/2023. Medication reconciliation was performed during the home visit on 01/10/2024, comparing the agency’s medication profile to the patient’s current medication regimen. The patient’s caregiver reported the patient was taking Docusate 5 mg, taking two (2) tablets daily; Mirtazapine 15 mg, one (1) tablet at bedtime; Senna 8.6 mg tablet, taking one (1) tablet in the morning. The agency’s medication profile and the hospice plan of care dated 01/04/2024 through 04/02/2024 did not document Docusate, Mirtazapine, or Senna. The patient’s medication history record indicated Docusate was discontinued on 12/22/2023, Mirtazapine was discontinued on 10/16/2023, and Senna was discontinued on 12/22/2023. The agency’s Hospice Clinical Quality Specialist was present for the home visit and confirmed the hospice medication profile did not match the patient’s current medication regimen. Home Visit 3/Clinical Record 11: The patient elected hospice care on 11/29/2023. Medication reconciliation was performed during the home visit on 01/10/2024, comparing the agency’s medication profile to the patient’s current medication regimen. The patient’s caregiver reported the patient takes Ibuprofen 200 mg and two (2) tablets as needed for pain and fever. The caregiver reported the patient last took Ibuprofen “a few weeks ago.” The medication profile and the hospice plan of care dated 11/29/2023 through 01/27/2024 did not document Ibuprofen. The medication profile and plan of care documented “Lamotrigine 25 mg, take one (1) tablet two (2) times daily” and “Baclofen 10 mg, take one (1) tablet four (4) times daily.” The caregiver reported that the patient did not take Lamotrigine and did not think the patient had ever taken the medication. The caregiver reported the patient was taking Baclofen 10 mg three (3) times a day. The agency’s Hospice Clinical Quality Specialist was present for the home visit and confirmed the hospice medication profile did not match the patient’s current medication regimen. Home Visit 4/Clinical Record 7: The patient elected hospice care on 10/31/2023. Medication reconciliation was performed during the home visit on 01/10/2024, comparing the agency’s medication profile to the patient’s current medication regimen. The medication profile and the plan of care dated 10/31/2023 through 01/28/2024 documented, “Acetic Acid 2%, instill three (3) drops, four (4) times daily.” The caregiver reported the patient was using Acetic Acid 2% and instilled three (3) drops two (2) times daily. The agency’s Hospice Clinical Quality Specialist was present for the home visit and confirmed the hospice medication profile did not match the patient’s current medication regimen. Home Visit 5/Clinical Record 10: The patient elected hospice care on 07/31/2023 and resided in a skilled nursing facility (SNF). Medication reconciliation was performed during the home visit on 01/10/2024, comparing the agency’s medication profile to the patient’s current medication regimen. The agency’s medication profile and the plan of care dated 10/29/2023 through 01/26/2024 documented, “Meclizine 12.5 mg, take one (1) tablet every six (6) hours as needed for nausea and vomiting.” The patient’s SNF medication list/administration record dated 01/10/2023 documented, “Meclizine 12.5 mg, take one (1) tablet every four (4) hours as needed for nausea and vomiting.” The agency’s Hospice Clinical Quality Specialist was present for the home visit and confirmed the hospice medication profile did not match the patient’s current medication regimen.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, interview and observation. Agency policy “Coordination of Care and Services” (revised 12/02/2008) stated in part, “The (Hospice name) Interdisciplinary Group (IDG) retains responsibility for directing, coordinating, and supervising care and services provided to the patient/family...The IDG ensures that the frequency, type, and scope of care and services provided are based on the initial and comprehensive assessments of each patient/family’s needs...The Hospice Administrator, the Hospice Medical Director, and the Hospice DHCS are responsible for the effective direction, coordination, and supervision of hospice care in all settings and by all disciplines.” Agency policy “Interdisciplinary Group (IDG) Plan of Care” (revised 12/02/2008) stated in part, “All IDG members providing care, regardless of the setting, have access to the current IDG plan of care, and any revisions are documented.” In 3 of 23 (13%) clinical records reviewed, the hospice did not ensure the Registered Nurse (RN) provided care coordination to implement the interdisciplinary care plan. Clinical Record 8/Home Visit 6: The patient elected hospice care on 05/02/2023 and resided in an assisted living facility (ALF). During the home visit with the Hospice Aide (HA) {Personnel Record 6] on 01/10/20224, the ALF Executive Director (ED) stated during an interview that the staff providing care to the patient do not have access to the hospice plan of care because “They don’t need that information.” The ALF ED stated that only the ED and the ED assistant, who do not provide direct patient care, have access to the hospice plan of care “in the portal.” The ED reported that the “state” regulation was to ensure the ALF plan of care matched the hospice plan of care, and “it does” the ED stated. The ALF ED provided the ALF POC dated 12/2023, which did not match the hospice POC dated 12/28/2023 through 02/25/2024. The hospice POC ordered the disciplines of Social Worker (SW), Chaplain (CH), and Registered Nurse (RN). The RN, CH, and SW all actively seeing the patient, were not documented on the ALF plan of care. The ALF ED stated, “Why do my staff need to know if the hospice Social Worker sees this patient?” The ALF POC did not include documentation of interventions related to hospice. In addition, the ALF POC documented, “shower two (2) times a week on Monday and Thursday.” During the home visit on Wednesday, 01/10/2024, the Hospice Aide was observed and provided the patient with a bed bath per the hospice plan of care. During the joint home visit and interview, the Hospice Clinical Quality Supervisor [Personnel Record 13] confirmed there was a lack of care coordination between the ALF and the hospice. The Hospice Clinical Quality Supervisor confirmed the hospice plan of care did not match the Assisted Living Facility (ALF) plan of care. Clinical Record 14: A patient elected hospice care on 08/23/2023 with the diagnosis of chronic systolic heart failure. The patient had a suprapubic catheter. The POC dated 08/23/2023 through 10/21/2023 ordered the “hospice RN to change suprapubic catheter every thirty (30) days and as needed (PRN). On 09/19/2023, the Registered Nurse (RN) documented that the patient refused to have the catheter changed. On 09/22/2023, there was no documentation from the RN addressing the need to change the catheter. The RN visit note dated 09/26/2023 documented the RN changed the suprapubic catheter. The patient was diagnosed with a urinary tract infection (UTI) on 10/11/2023 and treated with Doxycycline 100 mg, take one (1) tablet two (2) times a day for seven (7) days. During a joint record review and interview on 01/11/2024, the Director of Hospice confirmed the catheter was not replaced every thirty (30) days as ordered. The Director of Hospice stated, “I do not believe the Urinary Tract Infection was related to the catheter not being replaced on time.” Clinical Record 18: The patient elected hospice care on 09/25/2023. The initial comprehensive assessment completed by the RN documented, “hospice nurse perform wound care to stage two (2) on Sacrum. Utilizing clean technique/cleanse with wipes. Apply Calsime [sic] /barrier cream. Cover with tegaderm. Change every week and as needed (PRN). Instruct caregiver in wound care.” The RN documented that wound care was provided on 09/25/2023. During the week of 10/01/2023 through 10/07/2023, the RN visit note dated 10/03/2023 documented in part, “New small dime-sized sacral sore.” The RN did not document that wound care was performed on 10/03/2023. The week of 10/08/2023 through 10/14/2023, the RN visit note dated 10/13/2023 documented “small dime sized sacral sore. Cream appropriate.” During a joint record review and interview on 01/11/2024, the Director of Hospice confirmed the wound care was not documented as performed per the physician’s order on 09/25/2023. The Director of Hospice stated, “I believe the RN completed the wound care, but it didn’t get documented.””

“It is required that the hospice designates a registered nurse member of the IDG to: ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; [and] the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the hospice did not ensure the patient’s care and services followed the plan of care established by the hospice interdisciplinary group (IDG). Clinical Record 18: The patient elected hospice care on 09/25/2023. The initial comprehensive assessment completed by the RN documented, “hospice nurse perform wound care to stage two (2) on Sacrum. Utilizing clean technique/cleanse with wipes. Apply Calsime [sic] /barrier cream. Cover with tegaderm. Change every week and as needed (PRN). Instruct caregiver in wound care.” The RN documented that wound care was provided on 09/25/2023. During the week of 10/01/2023 through 10/07/2023, the RN visit note dated 10/03/2023 documented in part, “New small dime-sized sacral sore.” The RN did not document that wound care was performed on 10/03/2023. The week of 10/08/2023 through 10/14/2023, the RN visit note dated 10/13/2023 documented “small dime sized sacral sore. Cream appropriate.” During a joint record review and interview on 01/11/2024, the Director of Hospice confirmed the wound care was not documented as performed per the physician’s order dated 09/25/2023. The Director of Hospice stated, “I believe the RN completed the wound care, but it didn’t get documented.””

“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: 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, document review, and interview. Agency policy “Interdisciplinary Group (IDG) Plan of Care” (revised 12/02/2008) stated in part, “The plan of care includes, but is not limited to the following: (a) interventions to manage pain and symptoms, (b) identified patient/family physical, psychosocial. Functional, educational, and bereavement needs, (e) measurable outcomes anticipated as a result of implementing and coordinating the plan of care.” In 2 of 23 (9%) clinical records reviewed, the hospice did not ensure the plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 3: The patient elected hospice care on 07/25/2022. The patient’s Certificate Terminal Illness (CTI) dated 11/15/2023 documented, “During this certification period, the patient was treated for pneumonia. This is suspected to be aspiration-related given his significant dysphagia.” The Registered Nurse (RN) assessments dated 11/22/2023, 12/06/2023, and 12/28/2023 documented “gastrointestinal... abnormal symptoms and dysphagia.” In the interdisciplinary group (IDG) meeting dated 11/29/2023, the physician’s narrative confirmed dysphagia and documented, “The patient was treated for pneumonia. This is suspected to be aspiration-related given his significant dysphagia.” The plan of care dated 11/17/2023 through 01/15/2024 did not include documentation of problems, goals, or interventions related to the patient’s dysphagia. During a joint record review and interview on 01/09/2024, the Director of Hospice confirmed the patient was treated for pneumonia, which was suspected to be a result of dysphagia, but the plan of care did not contain problems, goals, or interventions related to dysphagia. Clinical Record 13: The patient elected hospice care on 06/14/2023. The patient was identified with a urinary tract infection (UTI) on 10/16/2023 and treated with antibiotics for ten (10) days. The IDG meeting dated 10/25/2023 did not include documentation that the IDG discussed the patient’s change of condition and infection. The plan of care dated 09/25/2023 through 12/10/2023 did not document problems, goals, or interventions related to the infection. During a joint record review and interview on 01/11/2024, the Director of Hospice confirmed the patient was treated for a UTI, but the plan of care did not contain any problems, goals, or interventions related to the UTI.”

“It is required that each patient’s individualized written plan of care includes all drugs and treatments necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, observation, document review, and interview. Agency policy “Interdisciplinary Group (IDG) Plan of Care” (revised 12/02/2008) stated in part, “The plan of care includes, but is not limited to the following: (d) drugs and treatment, medical supplies, and medical appliances necessary to meet the needs of the patient.” In 3 of 23 (13%) clinical records reviewed and home visits observed, the hospice did not ensure all drugs and treatments necessary to meet the patient’s needs were included in the plan of care (POC). Clinical Record 9/Home Visit 2: The patient elected hospice care on 10/06/2023. Medication reconciliation was performed during the home visit on 01/10/2024, comparing the agency’s medication profile to the patient’s current medication regimen. The patient’s caregiver reported the patient was taking Docusate 5 mg, two (2) tablets daily; Mirtazapine 15 mg, one (1) tablet at bedtime; Senna 8.6 mg tablet, one (1) tablet in the morning. The patient’s medication history record indicated Docusate was discontinued on 12/22/2023, Mirtazapine was discontinued on 10/16/2023, and Senna was discontinued on 12/22/2023. The hospice plan of care dated 01/04/2024 through 04/02/2024 did not document Docusate, Mirtazapine, or Senna. During a joint record review, interview, and observation on 01/10/2024, the Clinical Quality Specialist confirmed the written plan of care did not contain the medications needed for the palliation of the patient. Clinical Record 11/Home Visit 3: The patient elected hospice care on 11/29/2023. Medication reconciliation was performed during the home visit on 01/10/2024, comparing the agency’s medication profile to the patient’s current medication regimen. The patient’s caregiver reported the patient takes Ibuprofen 200 mg, two (2) tablets as needed for pain and fever. The caregiver reported the patient last took Ibuprofen “a few weeks ago.” The hospice plan of care dated 11/29/2023 through 02/26/2024 did not document Ibuprofen. During a joint record review, interview, and observation on 01/10/2024, the Clinical Quality Specialist confirmed the written plan of care did not contain all the medications needed for the palliation of the patient. Clinical Record 6: The patient elected hospice care on 12/11/2023. The initial comprehensive assessment completed by the RN documented, “Patient replaces coude catheter himself monthly as needed.” The RN visit note dated 12/18/2023 documented that the patient changed their coude catheter on 12/16/2023 following their admission to the agency. The plan of care (POC) dated 12/11/2023 through 03/09/2024 ordered “Hospice nurse to insert, maintain, indwelling catheter 18 French Coude. Change every month as needed.” The POC documented the goal, “Hospice nurse for reinforcement of indwelling catheter care.” A clinical record review revealed the plan of care did not document the catheter care to be performed, who was to perform the catheter care, and how often the catheter care was to be performed. During a joint record review and interview on 01/09/2024, the Director of Hospice confirmed that the record did not include the catheter care.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions, such as: hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; safe handling of soiled items in the patient’s care environment; [and] other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview and observation. The Centers for Disease Control and Prevention (CDC) “Hand Hygiene Guidance” for healthcare providers sated in part, “Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient...Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices...Before moving from work on a soiled body site to a clean body site on the same patient...After touching a patient or the patient’s immediate environment...After contact with blood, body fluids, or contaminated surfaces...Immediately after glove removal.” In 2 of 6 (33%) home visits observed, the hospice did not ensure accepted standards of practice to prevent the transmission of infections and communicable diseases, included hand hygiene as indicated. Home Visit 1/Clinical Record 2: During the home visit with the Registered Nurse (RN) [Personnel Record 1] on 01/09/2024, the RN performed hand hygiene and donned gloves. The RN completed the physical assessment of the patient and upon completion of the assessment, the RN cleaned the blood pressure cuff, thermometer, and stethoscope wearing the same gloves, and then pre-filled morphine syringes wearing the same gloves used to assess the patient and clean the equipment. The RN did not change gloves or perform hand hygiene following the patient assessment, cleaning of used equipment, and prefilling of the syringes. During an interview, and observation, the Hospice Director, present for the home visit, confirmed the RN did not change soiled gloves at any time during the home visit. In addition, the Hospice Director confirmed the RN should have removed the gloves after cleaning dirty equipment before pre-filling morphine syringes. Home Visit 5/Clinical Record 10): The patient elected hospice care on 07/31/2023 and resided at a Skilled Nursing Facility (SNF). During the home visit with the RN [Personnel Record 5] on 01/10/2024, the RN performed hand hygiene and performed a physical assessment of the patient. The RN cleaned the blood pressure cuff, thermometer, and stethoscope without gloves, and without sanitizing their hands. During a joint observation, the Clinical Quality Specialist, present for the visit, confirmed the RN cleaned the used equipment with ungloved hands. During a joint document review and interview on 01/11/2024, the Hospice Director confirmed that the RN cleaned equipment with ungloved hands. The Hospice Director stated, “Our policy doesn’t say they must use gloves to clean the equipment.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Interdisciplinary Group (IDG) Plan of Care” (revised 12/02/2008) stated in part, “All care necessary to manage the terminal illness and related conditions are provided in accordance with the IDG plan of care.” In 3 of 17 (18%) clinical records reviewed where hospice aide services were accepted, the hospice did not ensure the Hospice Aide (HA) provided all services ordered by the Interdisciplinary Group (IDG). Clinical Record 1: The patient elected hospice care on 06/17/2022. Effective 12/17/2023, HA services were ordered two (2) times a week for 12/17/2023 through 12/23/2023. There was documented evidence of a missed visit communication note dated 12/26/2023 for the missed HA visit on 12/23/2023. A clinical record review revealed no evidence of a second missed visit note documented for the week of 12/17/2023. Clinical Record 6: The patient elected hospice care on 12/11/2023. On 12/19/2023, the updated physician plan of care ordered HA services one (1) time weekly for 12/24/2023 through 12/30/2023. The HA documented a missed visit on 12/29/2023. The missed visit did not include documentation of the reason for the missed visit. Clinical Record 8: The patient elected hospice care on 05/02/2023. The plan of care dated 10/29/2023 through 12/27/2023 ordered HA services two (2) times weekly. For the weeks of 12/03/2023 through 12/09/2023, 12/10/2023 through 12/16/2023, and 12/17/2023 through 12/23/2023, there was no documented evidence that the patient received HA services. A clinical record review revealed one (1) HA documented missed visit note dated 12/15/2023. The missed visit note did not document the date of the missed visit. During a joint record review and interview on 01/10/2024, the Director of Hospice confirmed the hospice aide did not provide services as ordered by the interdisciplinary group (IDG) plan of care.”

“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, document review, and interview. Agency policy “Interdisciplinary Group (IDG) Plan of Care” (revised 12/02/2008) stated in part, “All care necessary to manage the terminal illness and related conditions are provided in accordance with the IDG plan of care.” In 2 of 17 (12%) clinical records reviewed where Hospice Aide services were accepted, the hospice did not ensure the Hospice Aide (HA) provided all services included in the plan of care (POC). Clinical Record 15: The patient elected hospice care on 11/14/2023. The plan of care dated 11/14/2023 through 02/11/2024 ordered HA services two (2) times a week. The Hospice Aide care plan assigned the HA the tasks “transfer client from chair to bed, transfer client from bed to chair.” The HA visit notes dated 12/19/2023 and 12/20/2023 documented that the assigned tasks “transfer the client from the chair to bed and transfer client from bed to the chair” were not performed. There was no evidence the HA care plan was changed or that the HA updated the Registered Nurse (RN) about tasks not performed. Clinical Record 18: The patient elected hospice care on 09/25/2023. The plan of care dated 09/25/2023 through 12/23/2023 ordered HA services two (2) times a week. The Hospice Aide care plan assigned the HA the tasks “transfer client from chair to bed, transfer client from bed to chair.” The HA visit notes dated 10/04/2023 and 10/06/2023 documented that the assigned tasks “transfer the client from the chair to bed and transfer client from bed to the chair” were not performed. There was no evidence the HA care plan was changed or that the HA updated the RN about tasks not performed. During a joint record review and interview on 01/10/2024, the Director of Hospice 01/10/2024 confirmed the hospice aide did not perform all tasks as ordered in the plan of care.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Coordination of Care and Services” (revised 12/02/2008) stated in part, “The IDG is responsible for the ongoing, effective sharing of information among all disciplines providing care and services to the patient/family in all settings, regardless of how the services are provided, directly and under contract.” In 5 of 17 (29%) clinical records reviewed in which hospice aid services were accepted, the agency did not ensure the Hospice Aide reported changes related to the plan of care to the Registered Nurse. Clinical Record 1: The patient elected hospice care on 06/17/2022. Effective 12/17/2023, HA services were ordered two (2) times a week for 12/17/2023 through 12/23/2023. There was documented evidence of a missed visit communication note dated 12/26/2023 for the missed HA visit on 12/23/2023. A clinical record review revealed no evidence of a second missed visit note documented for the week of 12/17/2023. A clinical record review revealed no evidence that the HA updated the Registered Nurse (RN) of the missed visit. Clinical Record 6: The patient elected hospice care on 12/11/2023. On 12/19/2023, the updated physician plan of care ordered HA services one (1) time weekly for 12/24/2023 through 12/30/2023. The missed hospice aide visit dated 12/29/2023 did not document the reason for the missed visit. A clinical record review revealed no evidence that the HA updated the Registered Nurse (RN) of the missed visit. Clinical Record 8: The patient elected hospice care on 05/02/2023. The plan of care dated 10/29/2023 through 12/27/2023 ordered HA services two (2) times weekly. For the weeks of 12/03/2023 through 12/09/2023, 12/10/2023 through 12/16/2023, and 12/17/2023 through 12/23/2023, there was no documented evidence that the patient received HA services. A clinical record review revealed one (1) HA documented missed visit note dated 12/15/2023. The missed visit note did not document the date of the HA missed visit. A clinical record review revealed no evidence the HA updated the RN of the missed visits. Clinical Record 15: The patient elected hospice care on 11/14/2023. The plan of care dated 11/14/2023 through 02/11/2024 ordered HA services two (2) times a week. The Hospice Aide care plan assigned the HA the tasks “transfer client from chair to bed, transfer client from bed to chair.” The HA visit notes dated 12/19/2023 and 12/20/2023 documented that the assigned tasks “transfer the client from the chair to bed and transfer client from bed to the chair” were not performed. A clinical record review revealed no evidence that the HA updated the RN about tasks not performed. Clinical Record 18: The patient elected hospice care on 09/25/2023. The plan of care dated 09/25/2023 through 12/23/2023 ordered HA services two (2) times a week. The Hospice Aide care plan assigned the HA the tasks “transfer client from chair to bed, transfer client from bed to chair.” The HA visit notes dated 10/04/2023 and 10/06/2023 documented that the assigned tasks “transfer the client from the chair to bed and transfer client from bed to the chair” were not performed. A clinical record review revealed no evidence that the HA updated the RN about tasks not performed. During a joint record review and interview on 01/10/2024, the Director of Hospice 01/10/2024 confirmed that the Hospice Aide did not update the RN about assigned visits and tasks not performed.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 23 (13%) clinical records reviewed, the hospice did not ensure the clinical record contained a plan of care with correct clinical information. Clinical Record 7: The patient elected hospice care on 10/31/2023. The plan of care dated 10/31/2023 through 01/28/2024 included documentation of two (2) orders for discipline and treatment that stated in part, “change level of care to respite.” There was no documented evidence that the patient received respite care. During a joint record review and interview on 01/9/2024, the Director of Hospice confirmed the finding and stated the patient did not have a change in the level of care. The Director of Hospice stated I believe this was “entered in error.” Clinical Record 10/Home Visit 5: The patient elected hospice care on 07/31/2023 with the diagnosis of Unspecified Severe Protein Calore Malnutrition. The patient resided in a skilled nursing facility (SNF). The plans of care dated 07/31/2023 through 10/28/2023 and 10/29/2023 through 01/27/2024 ordered, “Patient caregiver will verbalize/demonstrate how to use oxygen safely in the home.” The initial comprehensive assessment completed by the Registered Nurse (RN) dated 07/31/2023 documented the patient was alert to name and birthdate only and refused oxygen.” The patient did not have oxygen during the home visit with the RN [Personnel Record 5] on 01/10/2024. The caregiver stated, “No, we have never had oxygen here. We don’t need oxygen.” The Hospice Clinical Quality Specialist present at the home visit stated, “I believe that was an error in the plan of care.” Clinical Record 11/Home Visit 3: The patient elected hospice care on 11/29/2023. The plan of care dated 11/29/2023 through 01/27/2024 included documentation in the section labeled “DME and Supplies”: “Infusion/blood draw, ostomy supplies, Pleurex supplies, respiratory, and urology/catheter supplies.” The plan of care and comprehensive assessment did not include documentation of identified problems indicating the need or use of “Infusion/blood draw, ostomy supplies, Pleurex supplies, respiratory, and urology/catheter supplies.” During a joint record review and interview on 01/11/2024, the Director of Hospice confirmed the comprehensive assessments did not identify any need for Infusion/blood draw, ostomy supplies, Pleurex supplies, Respiratory, and urology/catheter supplies. The Director of Hospice stated, “I believe the nurses are clicking all supplies available because when we initially had training on the Electronic Medical Record (EMR), that is what they were instructed to do.””

“It is required that a patient’s clinical record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy “Entries into the Patient/Family Record” (revised 08/16/2023) stated in part, “Verbal orders are provided to the attending physician, or the Medical Director for signature in a timely manner, in accordance with state law and regulation. All physician’s orders are to be filed into the patient/family record (b) within two (2) weeks of the date the order was written.” In 1 of 23 (4%) clinical records reviewed, the hospice did not ensure the clinical record contained all physician orders. Clinical Record 4: The patient elected hospice care on 09/22/2023 and resided in a private residence. The initial comprehensive assessment completed by the Registered Nurse (RN) dated 09/22/2023 documented the presence of a colostomy: “colostomy pink and moist. Bowel movements daily. Color within normal limits.” The plan of care dated 09/22/2023 through 12/20/2023 documented “colostomy supplies.” The RN assessed the colostomy during the visits dated 09/22/2023, 10/17/2023, 10/20/2023, 10/23/2023, 10/26/2023, 11/03/2023 11/13/2023, 11/17/2023, 11/21/2023, 12/4/2023 ,11/30/2023, and 12/11/2023. During a joint record review and interview on 01/09/2024, the Director of Hospice confirmed the record did not contain a documented physician’s order for the colostomy or colostomy care.”

“It is required that the clinical patient record, its content, and the information it contains is safeguarded against loss or unauthorized use. The hospice addresses leaving and protecting patient record information in the home. The hospice complies with state and federal privacy laws and regulations, including the Health Insurance and Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy “Breach and Risk Investigation” (revised 08/16/2013) stated in part, “defines the process associated with the investigation of any report of a possible breach; the scope of the risk investigation to establish if a breach as defined by law or regulation has occurred; and the timing and types of notification of the patient required by law or regulation...The unauthorized access, acquisition, use, or disclosure of any PHI by or to an individual...Unsecured Protected health information is PHI that is not secured through the use of a technology or methodology specified by the Secretary of HHS as making it unusable, unreadable, or indecipherable.” In 1 of 6 (17%) home visits observed, the hospice agency did not ensure that the patient’s clinical record and information were safeguarded against loss or unauthorized use. Home Visit 6/Clinical Record 8: The patient elected hospice care on 05/02/2023 and resided at an assisted living facility (ALF). During the home visit on 01/10/2024, five (5) or more hospice agency binders were observed in the public common area upon entrance to the main facility foyer. The binders contained patient information. One (1) of the binders belonged to the hospice agency being surveyed. The binder included one (1) hospice aide charting sheet dated 08/23/2023 and 08/25/2023 for the patient observed during the home visit. The hospice agency’s binder included documentation for four (4) other patients receiving care from the hospice agency. The Clinical Quality Supervisor at the home visit confirmed the hospice records were in an unsecured location and stated, “These records shouldn’t be here.” The hospice agency’s compliance officer was notified on 01/10/2024 and confirmed that the hospice agency would follow its policy concerning a suspected breach of healthcare information. On 01/11/2024, it was confirmed that the hospice RN assigned to the patients residing in the ALF moved their records to a secure location. Before the survey exit on 01/12/2024, the Director of Hospice reported that the hospice RN assigned to the patients residing in the ALF called the hospice agency’s leadership to report that the ALF moved the records back to the unsecured public location. The Director of Hospice reported the additional information to the compliance officer on 01/12/2024.”

“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. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review of a patient who revoked the hospice benefit, the hospice did not ensure the patient’s attending physician received a copy of the hospice discharge summary. Clinical Record 20: The patient elected hospice care on 07/25/2023 and revoked the election of hospice care on 08/24/2023. The discharge summary was completed on 08/24/2023, automatically generated, and sent to the hospice agency’s Nurse Practitioner, who would no longer care for the patient. The Registered Nurse (RN) discharge note dated 08/24/2023 documented, “The patient is seeing the Oncologist on 08/25/2023 to receive additional radiation treatments.” A clinical record review revealed no evidence that the discharge summary was sent to the patient’s attending physician. During a joint record review and interview on 01/11/2024, the Director of Hospice confirmed the hospice did not send the patient’s attending physician a copy of the hospice discharge summary. The Director of Hospice stated, “We should have sent the discharge summary to the Oncologist.””