Hospice of Midland Inc.

“It is required that all hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure that the Registered Nurse prepared the written home health aide care plan with clear and patient-specific directions {HCDT.15. I/L625}; Failed to ensure that aides followed the aide plan of care {HCDT.16. I/L626}; and Failed to ensure that all aides reported changes in the patient’s nursing needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities {HCDT.18. I/L628}. 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 418.76, Hospice Aide and Homemaker Services. 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, interview, and observation. In 2 of 19(11%) home visits and clinical records reviewed revealed that the agency did not ensure that the drug profiles were updated and current. Agency policy titled, “Medication Profile” Policy No. 2 - 004 revised 03/21/2024 read in part, A drug regimen review will be done at the time of initial and comprehensive assessment and when updates to the comprehensive assessment are performed. During subsequent home visits, the medication profile will be used as a care planning and teaching guide. Home Visit 1: During a home visit (Home Visit 1) on 12/10/2024 with the registered nurse (RN) (Personnel Record 1) during the RN. The clinical record (Clinical Record 1) and plan of care dated 10/27/2024 indicated that the patient was prescribed Lisinopril 40 mg 1 tab once a day beginning 08/06/2024. The patient fills a 28-day mediset. A bottle of Lisinopril in the patient’s drawer that the patient stated was a current prescription bottle and dated 10/18/2024 read, Lisinopril 10 mg 1 tablet daily. The patient also reported that he breaks the tablets in half and takes 5 mg two times a day instead of 10 mg once a day. Blood pressure during the site visit was 130/60. The RN (Personnel Record 1) confirmed that medications have not been reconciled to match what is prescribed per the medication labels and patient reports. Home Visit 2: The patient was admitted on 10/11/2024 with a diagnosis of malignant neoplasm of the prostate. During the home visit (Home Visit 2) with the Chaplain (Personnel Record 2) on 12/10/2024 a review of the patient’s medications includes Systane eyedrops. The patient reported that he has dry eyes and has used Systane daily for “half a dozen months.” Systane eye drops were not included on the patient medication profile. The COO (Personnel Record 8) stated in an interview on 12/10/2024, that she would expect medication reconciliation to occur every visit and voiced understanding that the nurse confirmed that a reconciliation had not been completed for some time since the prescription was over 30 days old.”

“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 and interview. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that the plan of care identified all of the planned interventions based on the assessment. Clinical Record 8: The patient’s election of benefits was 11/23/2024 with a diagnosis of metastatic prostate cancer. The initial SN assessment on 11/23/2024, described the patient having frequent UTIs and requiring a Foley catheter, 16 FR with a leg bag last inserted 11/04/2024. The SN assessment did not include a balloon size. The plan of care dated 11/23/2024 - 02/20/2024 did not include goals or interventions for the care and management of the Foley catheter. Orders were added on 12/03/2024 that read, “May have foley catheter.” Goals and interventions were added on 12/03/2024 to teach assess for UTI symptoms, for the family to voice understanding related to the catheter, and for the catheter to remain patent. The clinical record did not contain any orders for the size of the catheter, balloon size, or management of catheter changes. After a joint review of the clinical record on 12/11/2024, the COO (Personnel Record 8) confirmed that the plan of care did not include sufficient orders for the care of the patient’s foley catheter.”

“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 and interview. In 2 of 11 (18%) clinical records reviewed with a home health aide involved in the care revealed that the agency did not ensure that that a home health aide care plan was written with clear and patient-specific directions. Clinical Record 14: The patient’s election of benefit was 10/28/2024 with a diagnosis of malignant neoplasm of the colon. The plan of care dated 11/11/2024 included orders for an HHA 1 wk1, 2 wk. 12 beginning 10/29/2024. The clinical record contained no evidence of an aide care plan 10/28/2024- 11/14/2024. On 11/15/2024 there was an aide care plan initiated that stated, “Problem ADL’s/IADL’s=HHA”. There was no documented evidence that the RN developed a specific care plan. Clinical Record 18: The patient’s election of benefit was 10/06/2024 with a diagnosis of malignant neoplasm of the liver. The skilled nurse assessment and plan of care dated 10/06/2024 revealed that the patient had a peritoneal drain in place. The care plan included orders for an HHA 3 times per week. The aide plan of care did not include the peritoneal drain or provide the aide any direction related to the site of the drain or dressing. There was no documented evidence that the RN developed a specific care plan In an interview on 12/11/2024, the COO (Personnel Record 8) reviewed the clinical record and confirmed the finding and lack of clarity in the aide care plan.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed with a home health aide revealed that the agency did not ensure that aides followed the aide plan of care. Clinical Record 14: The patient’s election of benefit was 10/28/2024 with a diagnosis of malignant neoplasm of the colon. Aide services were ordered one time a week for 1 week, two times a week for 12 weeks (1 w 1, 2 wk 12). There was no aide care plan created to define tasks for the aide. The aide visited the patient on 11/02/2024 and documented “Upon arrival patient was lying in bed with her daughter by her side but couldn’t get a shower today because hot water is out. The patient was left comfortably lying in bed. The patient was visited by the aide on 11/08/2024. The aide noted in the clinical record, “Upon arrival, the patient was lying in the bed sleeping. The patient got a warm bath, a clean diaper, a hair wash, clean clothes, and bed change. The patient was left comfortably sitting at the dining room table. There was no aide care plan assigning the tasks completed on 11/08/2024. On 11/12/2024, the aide visited the patient and documented in part, “Patient got a warm bed bath, a clean diaper, a hair wash, clean clothes, and a bed change. The patient was left comfortably lying in her bed. On 11/19/2024 the aide documented a visit that read in part, “Patient got a warm bath, a clean diaper, a hair wash, clean clothes and bed changed. On 11/23/2024, the aide documented a visit that read, “Upon arrival, the patient was complaining about pain. The patient received total personal care, and lotion to all extremities. The patient was left down in bed with caregiver at side. Aide visited patient on 11/26/2024 and documented “Patient got a warm shower, a clean diaper, a hair wash, clean clothes and a bed changed. Patient was left lying comfortably on her bed.” On 12/03/2024 aide visit note read, “Patient got a warm shower, a clean diaper, a hair wash, clean clothes and a bed changed. Patient was left lying comfortably on her bed.” on 12/06/2024 the aide visited the patient and documented, “Note: Pt. still in get up shower pt. after shower caregiver she was going to eat breakfast took precautions safety.” After dual chart review, COO (Personnel Record 8) confirmed on 12/09/2024 that the home health aide did not have a plan of care and provided services without a plan of care.”

“It is required that the hospice aides must report changes in the patient’s nursing needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed revealed that the agency did not ensure that all aides reported changes in the patient’s nursing needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. Clinical Record 14: The patient’s election of benefit was 10/28/2024 with a diagnosis of malignant neoplasm of the colon. The SN assessment revealed that the patient required assistance with ADL’s and a home health aide was ordered as aide one time a week for 1 week, two times a week for 12 weeks (1 w 1, 2 wk 12) on the plan of care. There was no documented evidence of an aide plan of care with assigned tasks. The aide visited the patient on 11/01/2024, 11/05/2024, 11/08/2024, 11/12/2024, 11/19/2024, 11/23/2024, 11/26/2024, 12/03/2024, and 12/06/2024. There was no aide care plan, task list, or direction for any aide visits. There was no documentation that an RN was notified to request specific patient information and task list. On 11/23/2024, the aide documented that the patient was complaining about pain. There was no documentation to indicate that the RN was notified of patient complaints of pain. In an interview and joint chart review with COO (Personnel Record 8) on 12/10/2024, the COO confirmed there was not a completed aide care plan in the clinical record and no aide documentation that a nurse was notified.”