Hope 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; Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; and Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in hospice populations are anticipated, and as appropriate, preventive measures are implemented to manage the side effects. 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 and interview. In 1 of 3 (33%) clinical records in which GIP (general in-patient) care was provided, the medication profile was not complete for all medications to treat the patient and consequently the full review for potential interactions was not completed. Document 5: (State) 17 Medication List and Monitoring stated in part, “The Hospice will maintain a current, accurate Medication Profile of all prescription and over the counter medications taken by the patient. The Registered Nurse will monitor medications for potential adverse effects and drug reactions including ineffective and effective drug therapy, significant side effects, significant drug interactions, significant drug and food interactions duplicate drug therapy and drug therapy associated with laboratory monitoring.” Clinical Record 7: The patient was admitted to hospice on 12/30/2023 with a failed outpatient treatment of symptoms. The initial comprehensive assessment documented that an intravenous catheter (IV) was started in the ER (emergency room) and then the patient would be admitted to GIP bed for symptom control of dyspnea and pain. Medications ordered were lorazepam 1 mg IV every 30 minutes for anxiety, morphine 1 mg inject 1-2 mg every hour prn (as needed) for dyspnea and, morphine 2 mg administered IV every 10 minutes prn dyspnea. The medication profile did not include saline that would have been needed before and after administering the prn medications and consequently all medications were not reviewed for all potential interactions. During the interview with the Director of Quality and Compliance and the Director of Clinical Services, it was stated that the saline used to flush the peripheral catheter was not documented on the medication profile.”

“It is required that each patient’s individualized written plan of care: Reflects patient and family goals; and 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, interview and observation. In 6 of 27 (22%) clinical records review, the agency did not ensure that the plan of care documented planned interventions based on problems identified in the initial and updated comprehensive assessments. Document 5: (State).6 Plan of Care Process stated in part, “A revised POC (the plan of care) will include information from the patient’s updated comprehensive assessment and will note the patient’s progress toward outcomes and goals specified in the plan of care.” “The POC (plan of care) must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments.” Clinical Record 1: The Hospice Benefit of Election was signed on 12/19/2023. During the nursing comprehensive visit documented on 12/31/2023, oral suction was started for increased secretions and difficulty managing secretions. The updated plan of care intervention was to suction the patient but lacked the detail for frequency of suctioning or type of suction that was ordered by the physician. The ordered suction was as needed with a Yonker intermittent suction cannula. Clinical Record 7: The Hospice Benefit of Election was signed on 12/30/2023 for a patient with a primary diagnosis of congestive heart failure. The patient was admitted to GIP (general in-patient) level of care, with IV medications of morphine and lorazepam to be delivered every 1-3 hours. The interventions were for GIP but lacked detail of the kind of infusion (i.e. peripheral), the size of the peripheral catheter, the frequency of change of the infusion site, or the dressing change with frequency. Clinical Record 16: The Hospice Benefit of Election was signed on 12/14/2022 with Alzheimer’s and Breast Cancer. The initial comprehensive assessment (12/14/2022) documented a fistula with uncontrolled diarrhea and pain. The updated comprehensive assessments documented continued concern with diarrhea and the protection of the skin. Orders were obtained for medications to assist with the diarrhea and barrier cream to protect the skin. No interventions were written to address the diarrhea problem identified on admission and continued with no interventions documented specific to diarrhea and skin protection through review date of 09/11/2024. Clinical Record 17: The Hospice Benefit of Election was signed on 12/21/2023 with a primary diagnosis of Pulmonary Fibrosis. The updated nursing comprehensive assessment completed on 08/15/2024 documented that a Foley catheter (16FR/10cc) was placed. As of the date of review (09/11/2024) the updated plans of care did not include goals or interventions specific to the Foley catheter. Clinical Record 23: The Hospice Benefit of Election was signed on 06/08/2024 with a primary diagnosis of senile dementia. The updated nursing comprehensive assessment dated 07/27/2024 documented that the patient was living at home and that he had now moved from the facility back to his home. The plan of care effective from 06/08/2024 to current, continued to document the interventions: “Facility remains responsible for 24-hour care needs, call with changes.” The plan was not updated as of the observed home visit (Home Visit 3) with the registered nurse (Personnel Record 3) at the patient’s home on 09/10/2024. Clinical Record 25: The Hospice Benefit of Election was signed on 04/06/2023 with a primary diagnosis of Alzheimer’s Disease. The initial nursing comprehensive assessment (04/06/2023) documented that the patient required a Hoyer Lift for transfers and that the patient was at risk for skin breakdown. The face-to-face dated 02/28/2024 documented that Prevalon Boots were to be worn to prevent pressure areas from the patient crossing his legs. The observed home visit (Home Visit 6) on 09/11/2024 revealed a sign above the patient’s bed that directed all staff to be sure the patient had “Prevalon boots” on. The registered nurse (Personnel Record 6) observed during the home visit stated that the patient did at times remove the boots, but he crossed his legs and had a history of previous pressure areas that they were trying to prevent. The problem for skin integrity was updated on 04/27/2023 and 07/01/2024 but did not include the intervention for Prevalon Boots. During an interview the Director of Quality and Compliance stated that updates of care plans is a current PIP that the agency continues to work on.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as safe handling of soiled items in the patient’s care environment; Other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview and observation. In 1 of 6 (17%) observed visits the agency did not ensure that the clinician followed all recommended manufacturer requirements for cleaning of equipment. Document 2: Sani-Cloth Label reads: “Contact Time: Use second germicidal cloth to thoroughly wet surface. Allow to remain wet for three (3) minutes, let air dry.” Home Visit 3: During the observed home visit (Home Visit 3) on 9/10/2024 with the registered nurse (Personnel Record 3), the nurse completed the physical assessment using: pulse ox, blood pressure cuff, thermometer, and stethoscope. The equipment used was all wiped with a Sani-Cloth and immediately returned to the bag with no allowed wet/dry time as per manufacturer recommendation. During an interview with the administrative team who read the package label and agreed that education would be provided related to dry time.”

“Hospice aides are assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group. Written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of this section. It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. 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, observation, and interview. In 3 of 25 (12%) clinical records reviewed in which a hospice aide was accepted, the agency did not ensure that the registered nurse prepared a hospice aide plan of care that included clear and specific instructions for all care that the patient required. Clinical Record 5: The initial nursing comprehensive assessment completed on 02/13/2024 documented that the patient had a Foley catheter for a neurogenic bladder. The aide plan of care dated 02/13/2024 did not include a task for catheter care during the assigned task of a bed bath. Clinical Record 17: The patient was admitted to care on 12/21/2023 and the updated nursing comprehensive assessment dated 08/15/2024 stated the patient had a foley catheter with a large drainage bag. The aide plan of care did not include specific instruction for the aide for foley catheter care during the bathing task as of review 09/11/2024. Clinical Record 25: The patient was admitted to care on 04/06/2023 with a primary diagnosis of Alzheimer’s disease. The observed home visit (Home Visit 6) with the registered nurse (RN)(Personnel Record 6) on 09/11/2024 revealed a sign above the patient’s bed that directed all staff to be sure the patient had “Prevalon boots” on. The nurse doing the visit stated the boots were to decrease the risk of pressure areas from the patient always crossing his legs. The face-to-face on 02/08/2024 documented that the patient now requires Prevalon boots to decrease the risk of pressure areas. The aide plans of care dated 04/28/2024, 07/01/2024 and 08/10/2024 did not document a task for the Prevalon boots to be placed after the ordered bathing task. The aide plan was developed on and updated on but still did not include the task for the boots. During the interview, the Director of Quality and Compliance stated that there is a current PIP on this and has noted improvements but is still something that they are working on.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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 and interview. In 1 of 5 (20%) clinical records reviewed, in which volunteer services were documented as requested, revealed the agency did not ensure the clinical record contained clinical notes regarding volunteer services provided or declined. Clinical Record 25: The IDT (interdisciplinary) meeting dated 06/08/2023 included a social worker note that the patient would benefit from a volunteer as the family does not visit much. The record had no further documentation for a referral for a volunteer or any follow-up for the volunteer need as of 09/13/2024. Upon interview the social worker who wrote the note stated that she had reached the wife, and the wife did not feel the patient would benefit from a volunteer. The clinical record did not include a clinical note of this conversation as of the review 09/13/2024.”