Sanford Hospice

“Based on record review, interview, and policy review, the provider failed to ensure their policy was followed for one of one closed record sampled patient (18) who revoked her Medicare hospice benefit. The provider did not have documentation to support: *A Medicare hospice revocation form was signed by the patient. *Interdisciplinary discharge planning occurred before the patient revoked her Medicare hospice benefit. Findings include: 1. Review of patient 18’s electronic medical record (EMR) revealed: *Her initial hospice benefit period was from 9/14/23 through 10/25/23. *Her terminal diagnosis was malignant ovarian cancer and her other medical diagnoses included end-stage renal disease with dependence on renal dialysis, congestive heart failure, and diabetes. *A 10/25/23 Encounter Note completed by registered nurse (RN) D: “Patient disclosed she is no longer interested in hospice comfort cares and plans to continue dialysis indefinitely as long as she is able. Patient signed hospice revocation form.” Continued review of patient 18s EMR revealed: *The patients 9/14/23 Hospice Admission Plan of Care (POC) indicated skilled nurse visits were scheduled once weekly with an additional one to ten visits as needed for symptom management. Social worker visits were scheduled once monthly with an additional one to four visits as needed to provide emotional and bereavement support to the patient and her family. *POC interventions included the following: -“Collaboration with facility/agency staff, discuss/review Plan of Care, provide Certification of Terminal Illness, Plan of Care and future updates to facility/agency. Instruct how to order/obtain hospice covered meds [medications], instruct on the role of Hospice at the facility/agency, and discuss schedule of facility/agency Interdisciplinary Group (IDG) and provide invite to Hospice IDG.” -“Patient receiving dialysis 3 days a week at [name of dialysis unit].” -“Evaluate patient code status, preferences for hospitalization and other life-sustaining treatments (e.g. dialysis, artificial nutrition).” *RN Ds nurse visit Encounter Notes for patient 18: -10/13/23: The patient discontinued her blood pressure medications upon hospice admission and continued to receive dialysis. That increased her “;risk of coding [cardiac arrest] due to often having hypertensive urgency (systolic [blood pressure reading] above 180).” -“Patient 18 disclosed she wasn’t ready for Hospice. She said she only did this because her daughter talked to her husband about it and they thought it would be best. Patient plans to revisit the topic with her daughter this weekend. However, patient may not have acceptance of terminal condition. Will FU [follow-up] Wednesday [10/18/23].” -To social worker (SW) E: “;See actions/narrative of [10/13/23] encounter. Patient may not have acceptance of terminal condition. Patient is considering discontinuing hospice cares.” --There were no SW Encounter Notes in response to the 10/13/23 RN communication to SW E referred to above. -10/18/23: [Patients] “;Long term plan is to continue dialysis as long as she is physically able to go.” --There was no documentation to support that RN D followed up with the patient regarding her plan to discuss hospice discontinuation with her daughter as referred to in her 10/13/23 Encounter Note. *Patient 18s 10/19/23 Hospice POC Update: -“;Other IDT [Interdisciplinary Team] discussion: Patient not accepting of terminal diagnosis and wishes to continue dialysis treatment long term.” “;Will schedule care conference for next week with SW, CM [case manager], and family to discuss discharge from hospice if patient wants to continue dialysis.” -“;Dr. recommendations: discharging patient from hospice due to continuing to seek dialysis.” --There was no documentation to support a discharge planning care conference occurred after the 10/19/23 IDG meeting. -10/25/23: “Patient disclosed she is no longer interested in hospice comfort cares and plans to continue dialysis indefinitely as long as she is able. Patient signed hospice revocation form.” 2. Interviews on 8/7/24 at 9:00 a.m. and 10:00 a.m. with administrator A regarding patient 18s hospice revocation revealed: *The patient was not accepting of her terminal diagnosis. She wanted to continue dialysis despite non-compliance issues related to dialysis that possibly negated the benefit of continuing those treatments. *There was no documentation leading up to the hospice revocation to support: -Follow-up by SW E after she was notified on 10/13/23 by RN D the patient was contemplating discontinuing hospice care. -The discharge planning care conference recommended by the IDG on 10/19/23 occurred promptly after that meeting occurred. -Hospice collaborated with the dialysis unit or provided the patient and her family with education regarding the risks and benefits of continuing dialysis versus discontinuing dialysis. -The interventions referred to in the patients Admission POC were revised or updated to reflect patient 18s individualized discharge planning needs. *A copy of patient 18’s signed hospice revocation form was requested from administrator A on 8/7/24 at 10:00 a.m. Administrator A confirmed at the exit conference on 8/8/24 at 12:40 p.m. that a signed hospice revocation form for patient 18 was not found. 3. Review of the 2/1/24 reviewed/revised Discharge or Transfer, Hospice policy revealed: *Policy: “;2. Patients/families who wish to terminate hospice may initiate a revocation. A Revocation of Hospice form must be signed and dated by the patient.” *Discharge Planning and Discharge: -“;Discharge planning and instruction begins upon admission.” -“;The staff will continually assess the patient/family for discharge during all subsequent visits.””