Professional Hospice

“Based on record review and interview, the agency failed to maintain a system of communication and integration, in accordance with its policies and procedures, to provide and ensure the ongoing sharing of information between all disciplines providing care and services in all settings in that patient care coordination was not documented in the clinical records of the coordination that occurred at the interdisciplinary group/team meetings in the clinical records for 9 (#3, #4, #5, #6, #7, #10, #11, #12, #13) of 12 discharged patient records. The failure placed the clients at risk that non-current client information would be shared resulting in a negative outcome and/or poor symptom control. Review of the Agency’s policy titled “Interdisciplinary Group Roles and Responsibilities,” labeled PC.40, and last reviewed on 10/1/2021. The policy read in part; “Purpose To identify the roles and responsibilities of the Interdisciplinary Group/Team (IDG/IDT)...Procedure...IV. IDG/IDT meetings will be held during the course of patient care to monitor and evaluate the patient’s interdisciplinary POC (Plan of Care) progress, at least every 15 days, or more frequently if warranted by the patient’s condition...VIII. Formal communication regarding the patients POC is documented at the IDG/IDT meeting ensuring care and services are provided in accordance with the POC. A. Informal verbal and written communication demonstrating coordination of care among all staff members and others providing care is also documented in the medical record...” Review of the Agency’s policy titled “Coordination of Care,” labeled PC.110, and last reviewed 10/21/2021, read in part; “Purpose To ensure coordination of all care provided for patients receiving hospice services and/or services from other providers. Policy I. The Hospice will provide for and ensure the ongoing sharing of information between disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement, by the Hospice, or by other providers...Procedure...VII. All communications and coordination of care is documented in the clinical record.” Patient #3:Record review of Patient #3’s client record revealed a Plan of Care dated 11/21/2024 to 2/18/2025. The Plan of Care listed Heart Failure (heart muscle unable to pump enough blood to meet the body’s needs for blood and oxygen) as the terminal diagnosis. Patient #3’s record contained a physician order, dated 12/17/2024, to discontinue hospice due to client transferring to another hospice agency. The agency provided documentation that the agency conducted interdisciplinary team meetings on 12/4/2024 and 12/18/2024. Patient #3’s client record did not contain the documentation of the coordination that occurred at the interdisciplinary group/team meetings that occurred on 12/4/2024 and 12/18/2024. Patient #4:Record review of Patient #4’s client record revealed a Plan of Care dated 8/28/2024 to 11/25/2024. The Plan of Care listed Hypertensive Heart Disease with Heart Failure (condition of chronic high blood pressure that damages the heart and the heart being unable to pump enough blood or oxygen for the body’s needs) the terminal diagnosis. Patient #4’s record contained a document titled “Discharge-Live” dated 10/15/2024. The document indicated that Patient #4 was transferred to another hospice agency on 10/15/2024. The agency provided documentation on paper that the agency conducted interdisciplinary group/team meetings on 10/9/2024 and 10/23/2024. Patient #4’s client record did not contain the documentation of the coordination that occurred at the interdisciplinary group/team meetings that occurred on 10/9/2024 and 10/23/2024. Patient #5:Record review of Patient #5’s client record revealed a Plan of Care dated 3/6/2024 to 6/3/2024. The Plan of Care listed Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung (Lung Cancer) as the terminal diagnosis. Patient #5’s record contained a document titled “Discharge-Death” dated 4/13/2024. The document indicated that Patient #5 died on 4/13/2024. The agency provided documentation of interdisciplinary group/team meetings conducted on 3/13/2024, 3/27/2024, 4/10/2024, and 4/24/2024. Patient #5’s client record did not contain the documentation of the coordination that occurred at the interdisciplinary group/team meetings that occurred on 3/13/2024, 3/27/2024, and 4/10/2024, and 4/24/2024. Patient #6:Record review of Patient #6’s client record revealed a Plan of Care dated 3/9/2024 to 6/6/2024. The Plan of Care listed Malignant Neoplasm of the Uterus, Part Unspecified (cancer of the Uterus) as the terminal diagnosis. Patient #6’s record contained a document titled “Discharge-Death” dated 4/12/2024. The document indicated that Patient #6 died on 4/12/2024. The agency provided paper documentation of interdisciplinary group/team meetings conducted on 3/13/2024, 3/27/2024, and 4/10/2024, and 4/24/2024. Patient #6’s client record did not contain the documentation of the coordination that occurred at the interdisciplinary group/team meetings on 3/13/2024, 3/27/2024, and 4/10/2024, and 4/24/2024. Patient #7:Record review of Patient #7’s client record revealed a Plan of Care dated 10/3/2024 to 12/31/2024. The Plan of Care listed Alzheimer’s Disease (brain disorder that destroys memory, thinking skills, and the ability to carry out the simple tasks) as the terminal diagnosis. Patient #7’s record contained a document titled “Discharge-Death” that was dated 10/28/2024. The document indicated that Patient #7 died on 10/28/2024. The agency provided documentation that the agency conducted interdisciplinary group/team meetings on 10/9/2024, 10/23/2024, and 11/6/2024. Patient #7’s client record did not contain documentation of the coordination that occurred at the interdisciplinary group/team meetings on 10/9/2024, 10/23/20204, and 11/6/2024. Patient #10Record review of Patient #10’s client record revealed a Plan of Care dated 9/27/2024. The Plan of Care listed Malignant Neoplasm of Endometrium (cancer of the lining of the Uterus) as the terminal diagnosis. Patient #10’s record contained a document titled “Discharge- Death” dated 10/1/2024. The document indicated that Patient #10 died on 10/1/2024. The agency provided documentation that the agency conducted interdisciplinary group/team meetings on 10/9/2024. Patient #10’s record did not contain documentation of the coordination that occurred at the interdisciplinary group/team meeting on 10/9/2024. Patient #11:Record review of Patient #11’s client record revealed a Plan of Care dated 11/21/2024 to 2/18/2024. The Plan of Care listed Malignant Neoplasm of Lower Lobe, Right Bronchus or lung (Lung Cancer) as the terminal diagnosis. Patient #11’s record contained a document titled “Discharge- Death” dated 11/26/2024. The documented indicated that Patient #11 died on 11/26/2024. The agency provided documentation that an interdisciplinary group/team meeting was conducted on 12/4/2024. Patient #11’s client record did not contain documentation of the coordination that occurred at the interdisciplinary group/team meeting on 12/4/2024. Patient #12:Record review of Patient #12’s client record revealed a Plan of Care dated 8/24/2024 to 11/21/2024. The Plan of Care listed Other Cirrhosis of Liver (permanent scarring that damages the liver interfering in functioning leading to liver failure) as the terminal diagnosis. Patient #12’s record contained a document titled “Discharge- Death” dated 10/15/2024. The document indicated that Patient #12 died on 10/15/2024. The agency provided documentation of interdisciplinary group/team meetings that occurred on 8/28/2024, 10/9 2024, and 10/23/2024. Patient #12’s record did not contain documentation of the coordination that occurred on 8/28/2024, 10/9/20204, and 10/23/2024. Patient #13:Record review of Patient #13’s revealed a Plan of Care dated 12/27/2023 to 1/8/2024. The Plan of Care listed Myelodysplastic Syndrome with Chromosomal Abnormality (type of blood cancer) as the terminal diagnosis. Patient #13’s record contained an “Election of the Medicare/Medicaid Hospice Benefit” with an election date 12/27/2023, the day hospice services were to start. Patient #13’s record contained a document titled “Discharge- Death” dated 1/8/2024. The document indicated that Patient #13 died on 1/8/2024. The agency provided documentation of interdisciplinary group/team meetings. An interdisciplinary group/team meeting document was dated 1/3/2023 but the document indicated that Patient #13 was an admitted on 12/27/(no year). Patient #13 was admitted to the agency on 12/27/2023. The agency provided documentation of interdisciplinary group/team meeting on 1/17/2024. Patient #13’s record did not contain documentation of the coordination that occurred at the interdisciplinary group/team meetings conducted on 1/3/2024 and 1/17/2024. During an interview on 1/31/2025 at 10:41 a.m. with the Administrator, Alternate Administrator/Supervising Nurse, the Alternate Supervising Nurse, and the Business Manager, the surveyor discussed the clinical records did not contain documentation of the coordination that occurred at the Interdisciplinary Group/Team meetings. The surveyor asked what the agency’s procedure was for documenting the coordination into the clinical records. The Supervising Nurse informed the surveyor that the Supervising Nurse was the one responsible to document the coordination into the record. The Alternate Supervising Nurse informed the surveyor that the agency originally did both, on paper and the electronic medical record. All were done on paper. The surveyor asked why the Interdisciplinary Group/Team meeting coordination was not documented in the clinical records. The Administrator stated, “I think it was something that involved the signatures to capture some of the information.” The surveyor asked how it could affect the agency’s patients. The Administrator stated, “It would put the them at risk.” The Alternate Administrator provided the surveyor with a binder that contained documents titled “IDT Meeting Minutes.” The binder was the agency’s documentation of the interdisciplinary group/team meetings.”

“Based on record review and interview, the agency failed to provide a licensed person directly or under contract to actively participate in the coordination of all aspects of the patient’s hospice care, in accordance with current professional standards and practice, including participation in ongoing interdisciplinary comprehensive assessments, development and evaluation of the plan of care, and contribution of counseling and education to the client and family, in that, a plan of care was not developed for 1 (#2) of 2 active patient records reviewed. The failure placed the patient at risk that inconsistent and inadequate care would be provided and needs would be missed resulting in poor symptom management. Patient #2:Record review of Patient #2’s clinical record for the 7th hospice benefit period dated 12/4/2024 to 2/1/2025 revealed that a Plan of Care had not been developed for 12/4/2024 to 2/1/2025. Patient #2’s record contained an Initial Plan of Care dated 10/11/2023 to 1/8/2024. The Plan of Care listed Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris (build up plaque in heart arteries which reduces the blood flow to the heart with chest pain). During an interview on 1/31/2025 at 10:41 a.m. with the Administrator, Alternate Administrator/Supervising Nurse, Alternate Supervising Nurse, and the Business Manager, the surveyor discussed Patient #2 did not have a Plan of Care for the benefit period of 12/4/2024 to 2/1/2025. The surveyor asked who was responsible for generation of the Plan of Care. The Alternate Administrator/Supervising Nurse stated, “The case manager was responsible for the Plan of Care.” The Alternate Administrator/Supervising Nurse informed the surveyor that Registered Nurse C was Patient #2’s case manager. The surveyor asked whether it had been noticed that a Plan of Care had not been generated. The attendees shook their heads to indicate no. The surveyor asked how could this affect the agency’s patients. The Administrator stated, “It would put them at risk.” The surveyor was unable to interview Registered Nurse C. Registered Nurse C resigned without notice from the agency on 1/31/2025. Review of the agency’s policy titled “Plan of Care Process,” labeled PC.30, and last reviewed on 10/20/2022, read in part; “Purpose To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient’s and family’s specific needs. Policy...II. The Hospice will develop an individualized written POC for each patient...” Review of the agency’s policy titled “Interdisciplinary Group Roles and Responsibilities,” labeled PC.40, and last reviewed 10/1/2021, read in part; “Purpose To identify the roles and responsibilities of the Interdisciplinary Group/Teams (IDG/IDT). Policy I. The Hospice will designate an IDG/IDT, who in consultation with the patient’s Attending Physician will work together to provide for the physical, medical, psychosocial, emotional, and spiritual needs of the terminally ill patient and/or family members as delineated in a patient specific Plan of Care (POC)...Procedure I. The IDG/IDT, in collaboration with the Attending Physician (if any), will prepare a written POC for each patient and family, which specifies the care and services necessary to meet the patient and/or family’s specific needs...””

“Based on record review and interview, the agency failed to include physician orders in the patient records for wound care; continuous care; indwelling urinary catheters (hollow tube inserted into the bladder to drain and collect urine); and/or medications for 8 (#2, #3, #4, #5, #7, #11, #12, and #13) of 14 patient records reviewed. The failure placed the patients at risk of omission of care/inappropriate care, at risk for infection, and worsening of symptoms. Wound CarePatient #2:Record review of Patient #2’s clinical record for the 7th hospice benefit period dated 12/4/2024 to 2/1/2025 revealed that a Plan of Care had not been developed for the timeframe of 12/4/2024 to 2/1/2025. Patient #2’s record contained an Initial Plan of Care dated 10/11/2023 to 1/8/2024. The Plan of Care listed Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris (build up plaque in heart arteries which reduces the blood flow to the heart with chest pain). Registered Nurse C conducted a skilled nurse visit on 12/16/2024. Registered Nurse C documented that Patient #2 had a wound to the back of the head. Registered Nurse C documented cleaning the wound with Normal Saline, triple antibiotic was applied, and the wound covered with a non-adherent dressing. Patient #2’s record did not contain a physician order for wound care to Patient #2’s head. Patient #5:Record review of Patient #5’s revealed a Plan of Care dated 3/6/2024 to 6/3/2024. The Plan of Care listed Malignant Neoplasm of Unspecified part of Unspecified Bronchus or Lung (Lung Cancer) as the terminal diagnosis. Registered Nurse C conducted a skilled nurse visit on 4/11/2024. Registered Nurse C documented that Patient #5 had a Stage 2 pressure wound (Damage to the skin caused by constant pressure on the area for a long time) to the right hip. Registered Nurse C documented cleaning the wound with Normal Saline and applying triple antibiotic ointment. Patient #5’s record did not contain a physician order for wound care to Patient #5’s right hip. Patient #7:Record review of Patient #7’s patient record revealed a Plan of Care dated 10/3/2024 to 12/31/2024. The Plan of Care listed Alzheimer’s Disease (brain disorder that destroys memory, thinking skills, and the ability to perform simple tasks) as the terminal diagnosis. Registered Nurse C conducted a skilled nurse visit on 10/24/2024. Registered Nurse C documented that Patient #7 had a Stage 2 Pressure wound to the left buttock. Registered Nurse C documented cleaning the wound with antiseptic cleaner and applying triple antibiotic ointment. Patient #7’s patient record did not include a physician order for wound care to Patient #7’s left buttock. Patient #12:Record review of Patient #12’s patient record revealed a Plan of Care dated 8/24/2024 to 11/21/2024. The Plan of Care listed Cirrhosis of the Liver (chronic disease where liver tissue is replaced by scar tissue preventing the liver from working properly and liver failure) as the terminal diagnosis. Registered Nurse C conducted a skilled nurse visit on 9/11/2024. Registered Nurse C documented that Patient #12 had a Stage 2 pressure wound to the coccyx (lower back). Registered Nurse C documenting cleaning the wound with antiseptic cleaner and applying triple antibiotic ointment. Registered Nurse C conducting a skilled nurse visit on 9/16/2024. Registered Nurse C documented cleaning the coccyx wound the wound with antiseptic cleaner and applied honey-impregnated gauze. Patient #12’s patient record did not include physician orders for wound care to Patient #12’s coccyx. Indwelling Urinary Catheter Patient #3:Record review of Patient #3’s patient record revealed a Plan of Care dated 11/21/2024 to 2/18/2025. The Plan of Care listed Heart Failure (heart doesn’t pump enough blood for the body’s needs) as the terminal diagnosis. Registered Nurse C conducted a skilled nursing visit on 11/25/2024. Registered Nurse C documented that an indwelling catheter was inserted due to urinary retention. Patient #3’s patient record did not contain an order for Registered Nurse C to insert an indwelling urinary catheter into Patient #3. MedicationsPatient #3:Record review of Patient #3’s patient record revealed a Plan of Care dated 11/21/2024 to 2/18/2025. The Plan of Care listed Heart Failure (heart doesn’t pump enough blood for the body’s needs) as the terminal diagnosis. Registered Nurse C conducted a skilled nurse visit on 12/2/2024. Registered Nurse C documented that Albuterol (used to treat shortness of breath) and Fleets enema (used to treat constipation) was ordered. Registered Nurse C documented that Patient #3 had oxygen at 2-4 liters per minute by nasal cannula (thin, flexible tube fitting into the nostrils, connected to an oxygen source which supplies oxygen to the patient) as needed. Registered Nurse C conducted a skilled nurse visit on 12/4/2024. Registered Nurse C documented new orders for Ultracet (used to treat pain) and Milk of Magnesia (used to treat constipation). Registered Nurse C documented that Patient #3 had oxygen at 2-4 liters per minute by nasal cannula as needed. Patient #3’s patient record did not include physician orders for Oxygen, Albuterol, Ultracet, Fleets enema, and Milk of Magnesia. Patient #4:Record review of Patient #4’s patient record revealed a Plan of Care dated 8/28/2024 to 11/25/2024. The Plan of Care listed Hypertensive Heart Disease with Heart Failure (chronic high blood pressure that damages the heart and causes the heart to fail) as the terminal diagnosis. Registered Nurse C conducted a skilled nurse visit on 8/29/2024. Registered Nurse C documented that Patient #4 was started on Azithromycin (antibiotic used to treat infection). Patient #4’s patient record did not contain a physician order for Patient #4 to take Azithromycin. Patient #11:Record review of Patient #4’s patient record revealed a Plan of Care dated 11/21/2024 to 2/18/2025. The Plan of Care listed Malignant Neoplasm of Lower Lobe, Right Bronchus or Lung (Lung Cancer) as the terminal diagnosis. The Supervising Nurse conducted a skilled nurse visit on 11/24/2024. The Supervising Nurse documented that Patient #11 was not responding to pain medication. The Supervising Nurse documented that continuous care was initiated. Registered Nurse C conducted a skilled nurse visit on 11/25/2024. Registered Nurse C documented that Patient #11 was on Oxygen at 2.5 liter per minute. Patient #11’s patient record did not include an order for continuous care and Oxygen. Patient #12:Record review of Patient #12’s patient record revealed a Plan of Care dated 8/24/2024 to 11/21/2024. The Plan of Care listed Cirrhosis of the Liver (chronic disease where liver tissue is replaced by scar tissue preventing the liver from working properly and liver failure) as the terminal diagnosis. Registered Nurse C conducted skilled nurse visits on 8/27/2024, 9/11/2024, and 9/30/2024. Registered Nurse C documented at each visit that Patient #12 was on Oxygen continuously at 2.5 liters per minute. Registered Nurse C conducted a skilled nurse visit on 9/16/2024. Registered Nurse C documented that Patient #12 was on oxygen at 3.5 liters per minute as needed. Patient #12’s patient record did not include a physician order for Patient #12 to have oxygen. Patient #13:Record review of Patient #13’s patient record revealed a Plan of Care dated 12/27/2023 to 1/8/2024. The Plan of Care listed Myelodysplastic Syndrome with Chromosomal Abnormality (a type of blood cancer) as the terminal diagnosis. Registered Nurse D (no longer employed at the agency) conducted a skilled nursing visit on 12/29/2023. Registered Nurse D documented that Patient #13 was on continuous Oxygen at 2 liter per minute. Patient #13’s patient record did not include a physician order for Patient #13 to use Oxygen. During an interview on 1/31/2025 at 10:41 a.m. with the Administrator, Alternate Administrator/Supervising Nurse, Alternate Supervising Nurse, and the Business Manager, the surveyor discussed that the patient records did not include physician orders for wound care, continuous care, oxygen/medications, and indwelling urinary catheters. The surveyor asked the process staff was to follow when they had received a physician order. The Supervising Nurse informed the surveyor that the order would be transcribed and sent to the physician to sign. The surveyor asked what the time-frame for documentation of the physician order would be in the patient record. The Alternate Supervising Nurse informed the surveyor that it would be done immediately when the order was received. The agency policy was reviewed. The policy read that physician orders would be documented within 24 hours. The attendees agreed that was what the agency’s policy read. The surveyor asked who would be responsible to put orders in the patient record. The Alternate Supervising Nurse stated, “The nurse that received the order.” The Supervising Nurse informed the surveyor that the Supervising Nurse had obtained the orders continuous care and Oxygen for Patient #11. The Supervising Nurse informed the surveyor that the Supervising Nurse should have been the one to have written the orders. The Supervising Nurse informed the survey that the Supervising Nurse thought the orders had been written. The surveyor asked how often the records were reviewed by quality assurance. The Administrator stated, “They are looked at continuously and as we do IDG (interdisciplinary group meeting). Whatever was missing, we take care of that. We bring in an auditor to look at the records.” The Administrator informed the surveyor that an outside auditor reviewed the patient records quarterly and the Administrator was surprised that this was not caught. The surveyor asked how this could affect the agency’s patients. The Administrator stated, “I think we put the patient at risk.” Registered Nurse C resigned without notice on 1/31/2025 and was not available for interview. Policy reviewed with attendees at record review:Review of the agency’s policy titled “Timelines,” labeled IM.40, last reviewed 10/1/2022 read in part; “Purpose To establish timely parameters for all medical record information. Policy The Hospice will ensure timely provision of care to meet the patient’s needs in compliance with all federal and state laws and regulations. Procedure 1...G. Supplemental verbal orders may be obtained before care is provided and are written within 24 hours of receiving the orders. Orders will be signed by the physician and/or non-physician practitioner prior to billing...” Review of the agency’s policy titled “Medical Record Content,” labeled IM.30, last reviewed 11/30/2022 read in part; “Purpose To ensure each medical record contains complete, correct information which identifies the patient, describes problems, and need of the patient, justifies patient care, and accurately describes care provided, outcomes, significant events and continuity/coordination of care. Policy I. The Hospice will initiate and maintain an individual and accurate medical record containing past and current information for each patient accepted for care. The medical record will be in compliance with all federal and state laws and regulations. The record may be in a paper, electronic, or combination format...Procedure I. Each medical record will contain, but not be limited to , the following...H. Documentation of care provided will include...7. Physicians’ orders...””