Cypress Basin Hospice Inc.

“It is required that each patient’s individualized written plan of care reflects patient and family goals, 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 5 of 19 (26%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 4: The patient’s date of the election was 05/13/2024. The primary hospice diagnosis was malignant neoplasm of the upper lobe left bronchus or lung. The RN comprehensive assessment dated 05/13/2024 documented that the patient had bowel and bladder incontinence and a seizure disorder. The medication profile reviewed on 08/14/2024 documented Levetiracetam 500mg tablets, take three tablets by mouth twice daily. The POC dated 05/13/2024-08/10/2024 did not include problems, interventions, and goals for risk for skin breakdown, incontinence, and seizures. Clinical Record 13: The patient’s date of the election was 06/05/2024. The primary hospice diagnosis was alcoholic cirrhosis of the liver with ascites with comorbidities of esophageal varices, portal hypertension, and chronic diastolic (congestive) heart failure. The RN comprehensive assessment dated 06/05/2024 documented that the patient fatigued easily, had abnormal breath sounds, shortness of breath upon exertion, oxygen saturation of 89% on room air with exertion, acute and chronic abdominal pain managed with narcotic analgesics, over-the-counter pain relievers, and rest/relaxation, and ascites. The POC dated 06/05/2024-09/02/2024 did not include problems, interventions, and goals for risk for skin breakdown, incontinence, impaired mobility, impaired cognition, and insomnia. The POC did contain problems and interventions for “congestive heart failure,” “heart failure,” “hospice care,” and “pain management,” but did not have goals. Clinical Record 17: The patient’s date of election was 10/27/2023. The primary hospice diagnosis was cerebral infarction due to unspecified occlusion or stenosis of the left anterior cerebral artery. The initial nursing assessment on 10/27/2023 documented that the patient had shortness of breath upon exertion, used oxygen at 2 LPM via nasal cannula intermittently, had a Braden Scale (Pressure Ulcer Risk Assessment) score of 12 (high risk), had physical immobility, had bowel incontinence, and had a Foley catheter. The POC dated 10/27/2023-01/24/2024 and resolved care plans dated 01/27/2024 lacked problems, interventions, and goals for impaired respiratory function, oxygen use, the risk for impaired skin integrity, and altered urinary function. Clinical Record 18: The patient’s date of election was 11/10/2023. The primary hospice diagnosis was unspecified severe protein-calorie malnutrition with comorbidities of COPD and Alzheimer’s disease. The initial nursing assessment on 11/10/2023 documented that the patient had shortness of breath upon exertion, used oxygen at 2 LPM via nasal cannula intermittently, and had bladder incontinence. The Skilled Nursing Visit Note dated 01/25/2024 documented that the patient had been started on Macrobid. The Registered Nurse Hospice Comprehensive Assessment dated 02/27/2024 documented that the patient had shortness of breath upon exertion, used oxygen at 2 LPM via nasal cannula intermittently, and had bladder and bowel incontinence. The Skilled Nursing Visit Note dated 03/23/2024 documented that the patient had “bumped (the) head on the door and has a laceration,” and wound care was initiated. The POCs dated 11/10/2023-02/07/2024 and 02/08/2024-05/07/2024, the Interdisciplinary Group Meetings dated 02/01/2024 and 03/28/2024, and resolved care plans dated 04/14/2024 lacked problems, interventions, and goals for impaired respiratory function, oxygen use, infection, the risk for impaired skin integrity, and wound management. Clinical Record 19: The patient’s date of election was 01/11/2024. The primary hospice diagnosis was end-stage renal disease with comorbidities of heart failure, a history of transient ischemic attacks, chronic kidney disease stage 5, dysphagia, type 2 diabetes mellitus, osteoarthritis, and a history of colon cancer. The initial nursing assessment on 01/11/2024 documented that the patient had shortness of breath upon exertion, used oxygen at 2 LPM via nasal cannula intermittently, was diabetic, used oral hypoglycemic and insulin, and used a blood glucose monitor before meals and bedtime. The Registered Nurse Hospice Comprehensive Assessment dated 01/19/2024 documented that the patient had vomiting episodes. The Skilled Nursing Visit Note dated 01/20/2024 documented that the patient had “open blisters that were bleeding to both feet,” and wound care was initiated. The POC dated 01/11/2024-04/09/2024, the Interdisciplinary Group Meeting dated 01/28/2024, and resolved care plans dated 01/27/2024 lacked problems, interventions, and goals for hypoglycemia, hyperglycemia, oral hypoglycemic use, insulin dependence, glucometer management, nausea and vomiting, impaired respiratory function, oxygen use, the risk for impaired skin integrity, and wound management. During a joint review of the record and an interview on 08/14/2024, the Alternate Administrator/Clinical Director confirmed that there was no documented evidence that the POC included problems, goals, and interventions for the problems identified in the assessments.”

“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 3 of 11 (27%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure the aide plan of care included clear and specific instructions for task. Clinical Record 4: The patient’s date of election was 05/13/2024. The primary hospice diagnosis was malignant neoplasm of the upper left bronchus or lung. The hospice aide care plan dated 05/13/2024 assigned the hospice aide tasks, “Hygiene: Bath: Shower; Hygiene: Bath: Complete; and Hygiene: Bath: Shower Chair.” The care plan did not provide clear instructions to the hospice aide regarding the type of bath. Clinical Record 17: The patient’s date of election was 10/27/2023. The primary hospice diagnosis was cerebral infarction due to unspecified occlusion or stenosis of the left anterior cerebral artery. The hospice aide care plan dated 10/30/2023 assigned the hospice aide tasks, “Hygiene: Bath: Shower; Hygiene: Bath; Hygiene: Bath: Complete; and Hygiene: Bath: Shower Chair.” The care plan did not provide clear instructions to the hospice aide regarding the type of bath. Clinical Record 18: The patient’s date of election was 11/10/2023. The primary hospice diagnosis was unspecified severe protein-calorie malnutrition. The hospice aide care plan dated 11/11/2023 assigned the hospice aide tasks “Hygiene: Bath; Hygiene: Bath: Shower Chair; Hygiene: Bath: Complete; and Hygiene: Bath: Shower.” The care plan did not provide clear instructions to the hospice aide regarding the type of bath. During a joint clinical review of the record and an interview on 08/13/2024, the Alternate Administrator/Clinical Director agreed the instructions on the hospice aide care plan were not specific.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. Clinical Record 16: The patient’s care was transferred to another Hospice provider on 04/05/2024. The record lacked evidence that the discharge summary was forwarded to the receiving hospice. During a joint record review and interview on 08/14/2024, the Alternate Administrator/Clinical Director confirmed that the record lacked evidence that the discharge summary was sent to the receiving Medicare/Medicaid-certified facility.”

“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 and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 15: The discharge summary dated 01/14/2024 lacked documentation that the discharge summary was forwarded to the patient’s attending physician. During a joint record review and interview on 08/14/2024, the Alternate Administrator/Clinical Director confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary included at least the following a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Clinical Record 16: The date of the transfer was 04/05/2024. The summary stated, “During patient’s time on hospice patient symptoms managed well. Patient transferred to another facility to be with another doctor. The record lacked evidence of a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. During a joint record review and interview on 08/13/2024, the Alternate Administrator/Clinical Director confirmed that the record lacked evidence of a completed discharge summary of the patient’s hospice stay, including treatments, symptoms, and pain management.”