Hospice of San Angelo

“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. 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%) clinical records reviewed revealed that the agency did not ensure that the patient’s drug profile contained all current prescription and over the counter drugs. Agency Policy: Medication Administration (Operational Procedure: 130-94, Established: December 2008; Revised: May 2012; April 2017, reviewed: September 2015) included in part that “Hospice licensed Nursing personnel will ...document only ordered medications that are a part of the Plan of Care...The Assessment Process includes a drug history and a comparison between the physician’s orders and the current medications the patient is taking. Hospice personnel report discrepancies or contradictions to the physician for resolution.” Clinical Record 3/Home Visit 2: During the home visit (Home Visit 2) with the Licensed Vocational Nurse (LVN) on 01/09/2024, a medication regimen review was completed. The patient and the patient’s daughter had a hand-written list of medications that the patient was taking that included Zoloft 25mg: 1/2 a tab by mouth in the evening. The daughter also stated that she used Thick-It in any liquids for the patient, such as water, coffee, and soup. The daughter and patient both reported that she coughs with thin liquids. The patient’s medication profile did not include the Zoloft or Thick-It. A joint record review and interview with the Administrator on 1/11/2024 confirmed the Zoloft and Thick-It were not on the medication profile for Record 3. Clinical Record 7/Home Visit 1: During the home visit (Home Visit 1) observation with the registered nurse (RN) (Personnel Record 8) on 01/9/2024, a medication regiment review was completed. The patient stated during the visit that she takes 2 Aspirin for pain when needed. She stated to the RN that she prefers to take the Aspirin instead of Tylenol as she feels the Aspirin more effectively manages her pain and takes Benadryl as needed for allergy symptoms. The patient’s medication profile stated, “Tylenol 650mg suppository to be administered rectally every 6 hours as needed for elevated temperature or discomfort dated 10/9/2023. The Aspirin and Benadryl was not listed on the patient’s medication profile. The RN (Personnel Record 8) confirmed during the home visit that the two over-the-counter medications the patient reported taking were not on the list of the patient’s current medications.”

“It is required that the hospice provides infection control education to employees, contracted providers, patients, family members, and other caregivers that is individualized to the needs of each patient. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure that infection control education was provided to the patient/family/caregivers. Agency Policy: Patient/Caregiver Education (Operational Procedure: 130-97; Established: December 2008; Reviewed: September 2015) included in part that “Patients will receive education. The assessed needs of the patient or caregiver will determine the scope of teaching. Education is the responsibility of each hospice clinician and will focus on, as appropriate ...Maintaining the patient, family or caregiver’s health status... Documentation of patient, family or caregiver education consists of ... Describing patient teaching (if using preprinted written materials, document the name of the handout), describing the patient’s response to the teaching including the level of understanding, the ability to repeat or demonstrate the teaching, describing any additional learning needs not currently met, describing the planned teaching for subsequent visits...” Clinical Record 17: The patient elected the hospice benefit on 2/13/2023 and was on the General Inpatient Level of Care due to uncontrolled symptoms related to COVID-19 and Sepsis. The registered nurse (RN) visit note dated 2/13/2023, stated “Admission forms reviewed and completed...(daughter) agreed to be the PCG. Understanding of all hospice admission forms and the hospice Medicare benefits verbalized ...Hospice admission packet reviewed and left with pt/family. Medications and hospice 24-hour on call service reviewed. “ The Social Worker visit note dated 2/13/2023, stated in part that “...present to ...emergency room ...on 2/13/2023 ...It was there that he was tested positive for COVID-19 and continues to have COVID symptoms. Staff and family are to were full PPE prior to entering pt’s room...” The RN visit note dated 2/14/2023 stated, “...Reinforced teaching with family regarding continued need for general inpatient care and transition to a lower level of care once symptoms are adequately managed ...” The RN visit note dated 2/15/2023 stated, “...Family updated with visit findings. No other needs noted at this time. Advised to call 24-hour line with any needs, concerns, or condition changes at any time, verbalized understanding and agrees.” There was no documented evidence that infection control information was reviewed with the patient’s family. Clinical Record 18: The patient elected the hospice benefit on 5/27/2023 with a diagnosis of Severe Protein-Calorie Malnutrition. The Licensed Vocational Nurse (LVN) documented on 12/10/2023 that the patient had a fever over 101 the previous night, coarse breath sounds, and coughed up thick yellowish secretions after Mucinex and an Albuterol treatment. The LVN obtained an order on the same day for Omnicef 300mg by mouth twice a day for seven days for a suspected respiratory tract infection.” There was no documented evidence of teaching on infection control on LVN visit notes dated 12/11/2023 and 12/13/2023 and the RN visit note dated 12/15/2023. During an interview on 1/11/2024 with the Administrator, she confirmed that the clinical record did not contain documentation that the patient/family/caregivers received education on infection control.”

“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 registered nurse (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 17 (12%) clinical records reviewed in which Hospice Aide services were accepted the agency did not ensure that the Hospice Aide was provided clear instructions for the patient’s wound. Clinical Record 1: The patient elected the hospice benefit on 10/9/2023 with a diagnosis of breast cancer. The patient’s Plan of Care (POC) for the benefit period effective dates of 10/9/2023 to 1/6/2024 included Hospice Aide visits twice a week. The Hospice Aide plan of care dated 10/9/2023 included an intervention to shower the patient. During the initial RN visit on 10/9/2023, a 3cm open red lesion was present in the right upper quadrant of the right breast. Redness and swelling are present throughout most of the rest of the breast. The lesion was covered with gauze. A physician order dated 10/9/2023 stated to “initiate hospice standing orders protocol for symptom management, bowel protocol for constipation, and skin/wound protocol for skin breakdown and/or minor wound care, per hospice physician.” The Agency Standing Orders dated 4/25/2023 “included care orders for a skin tear. The directions read for the nurse to clean the wound using either wound cleanser, mild soap, water, or saline to flush out the wound, pat the surrounding area dry to prevent any subsequent damage...apply a nonadherent dressing, and secure with appropriate adhesive. Also included were instructions for a stage 1 pressure ulcer: wash the area gently with wound cleanser, mild soap, and water, or saline, and apply protectant to the skin as needed.” A physician’s order dated 12/11/2023, stated to care for the right breast cancer site, cleanse with wound cleanser, pat dry with gauze, apply crushed Flagyl, cover with non-adherent pad and gauze, and secure with tape 2 x a week or as needed if the dressing became saturated or dislodged.” The Hospice Aide plan of care dated 10/9/2023 included an intervention to shower the patient but did not include any instructions to the Aide on what to do if the dressing became wet or soiled. Clinical Record 12/Home Visit 3: The patient elected the hospice benefit on 3/6/2023 with a diagnosis of Other specified eating disorder. The patient’s Plans of Care for 11/1/2023 to 12/30/2023 and 12/31/2023 to 2/28/2024 included orders for the Hospice aide visits from two to five times a week. The nurse documented on 11/5/2023 that a visit was made after the patient returned from the Emergency Room after having a fall. It was stated in part that the nurse “removed the dressing obscuring the wound ... 13 sutures present...at the discretion of (hospice Medical Director) of when to remove sutures. I re-wrapped leg ...” A physician’s order dated 11/6/2023 included instructions for the patient’s left shin wound. The order read to cleanse the area with wound cleanser, pat dry, apply TAO or Bacitracin to the site, apply nonadherent dressing and an ABD pad, and secure with roll gauze and tape. Change dressing daily and if soiled or dislodged. The nurse documented on 01/01/2023, “Wound to left leg has slough present and measurements is 4cmx 1.5cm.” As of 1/1/2024, the nurse documented that “...Wound to left leg has slough present and measurements is 4cmx 1.5cm.” The Hospice Aide plan of care dated 4/17/2023 included an intervention to shower the patient. There was no documented evidence that the aide plan of care had been updated since the original aide plan of care dated 4/17/2023 and no specific instructions for the Aide on what to do if the patient’s dressing became wet or soiled. During an interview with the Administrator 1/11/2024, she confirmed that the patient’s Hospice Aide Visit Assignment/Care Plan did not direct the Hospice Aide on what to do should the patient’s wound dressing become wet and/or soiled.”

“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 and interview. In 1 of 17 (6%) clinical records reviewed in which Hospice Aide services were accepted revealed that the agency did not ensure that Hospice Aide visits were provided per the Plan of Care. Clinical Record 19: The patient elected the hospice benefit on 6/2/2022. Orders for Hospice Aide visits for the benefit period 11/29/2022 to 1/27/2023 included Interdisciplinary Group Meeting (IDG) dated 12/14/2023 stating that Hospice Aide services were declined. A review of the clinical record identified hospice aide visit notes dated 12/16/2022, 12/18/2022, 12/20/2022 and 12/27/2022. There was no documented evidence of a physician order for these visits. During the IDG Meeting dated 12/28/2022, Hospice Aide frequency orders included for weekly Hospice Aide visits. The week of 1/1/2023, there were 2 Aide visits documented on 1/3/2023 and 1/5/2023. There was no documented evidence of a physician order for the additional Aide visit. During the IDG Meeting dated 1/11/2023, the frequency of Hospice Aide visits was increased to twice weekly. During the week of 1/15/2023, the Hospice Aide documented visits on 1/16/2023, 1/18/2023, and 1/20/2023. There was no documented evidence of a physician order for the additional Aide visit. During an interview with the Administrator on 1/11/2024 she confirmed that the Hospice Aide visits do not match the Plan of Care frequencies documented in IDT.”

“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. This standard was not met as evidenced by clinical record review and interview. In 3 of 17 (18%) clinical records reviewed in which Hospice Aide services were accepted revealed that the agency did not ensure that he Hospice Aide reported changes in the patient or care plan needs to the registered nurse (RN). Clinical Record 9: The patient elected the hospice benefit on 5/1/2023. A physician order dated 5/7/2023 effective until 11/18/2023, for the Hospice Aide to visit the patient five times a week. The Hospice Aide care plan dated 10/17/2023 by the RN included instructions for the Aide to shower the patient. The nurse included the instructions in part: “ Wash patient’s back, trunk, and extremities each visit with soap/water on Monday, Wednesday, and Friday.” The patient refused the showers on Tuesday, 10/31/2023 and Thursday, 11/2/2023. There was no documented evidence that the aide reported to the RN the patient refusing the shower. Clinical Record 11: The patient elected the hospice benefit on 7/4/2023. The patient’s Plans of Care for the benefit period effective 10/2/2023 to 12/30/2023 and 12/31/2023 to 2/28/2024 included orders for the Hospice Aide to see the patient in varying frequencies from three to five times a week. The Hospice Aide, care plan by the RN dated 11/7/2023 included the task for a shower and read, “Wash patient back, trunk, extremities each visit with soap/water every Monday, Tuesday, Thursday.” On the following hospice aide visit notes dated, 11/13/2023, 11/15/2023, 11/17/2023, 11/21/2023, 12/1/2023, 12/5/2023, 12/6/2023, 12/11/2023, 12/13/2023, 12/15/2023, 12/20/2023, 12/27/2023, 12/29/2023, and 1/2/2024, the shower was documented as “pt/caregiver refused”, however, there was no documented evidence that the aide reported to the RN the patient refusing the shower. Clinical Record 19: The patient elected the hospice benefit on 6/2/2022. The Hospice Aide plan of care by the RN dated 9/1/2022 included an intervention for the patient to be showered. On 1/23/2023, the Aide documented that she “Gave pt a bed bath due to him being weak.” There was no documentation that the hospice RN was notified. During an interview and joint record review with the Administrator on 1/11/2024, it was confirmed that the Hospice Aide did not document that the nurse was contacted with patient changes or changes from the Hospice Aide plan of care.”