Hospice Plus

“Upon patient record review, 4 of 27 records (Patient #8,#9,#12,#13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #8: Upon patient visit, Lorazepam was listed on the medication profile at the ALF but was not included on the hospice medication profile. Corrected on site. In addition, Acetaminophen rectal suppository and Bisacodyl were on the Hospice medication profile but not the facility MAR. Corrected on site Patient #9: Upon patient visit, Ascorbic Acid was listed on the medication profile at the SNF but was not included on the hospice medication profile. Corrected on site. In addition, Acetaminophen suppository was on the Hospice medication profile but not the facility MAR. Corrected on site. Patient #12: Upon patient visit, medications in the home included Tums and Esomeprazole. The caregiver indicated that the patient was taking both of these medications. There was not evidence that they were on the hospice medication profile. In addition, upon patient record review the medication profile contained Coricidin chest congestion cough 10mg-200mg cap as needed per instructions. Corrected on site. Patient #13: Upon patient visit, the medication profile included Docusate Sodium, Gabapentin, Mirtazapine, Oxygen and Zonisamide. A medication reconciliation and comparison could not be completed as the bottles from these medications could not be found. There was a monthly pill planner in the home and on most days, the compartments from 9/1/24 to current still contained the medications for that particular day.”

“Upon patient record review, 4 of 27 records (Patient #11,#13,#17,#20) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #11: The patient was admitted on 1/20/24 and the record indicated that the bereavement assessment was completed on 2/8/24. Patient #13: The record indicated that the patient’s wife lived with him and was the primary caregiver. There was not evidence of an initial bereavement assessment on the wife (only the son and God-daughter). Patient #17: The patient was admitted on 2/9/24 and the record indicated that the bereavement assessment was completed on 2/20/24. Patient #20: The record indicated that the patient lived with her spouse. There was not evidence that a bereavement risk assessment was completed on the spouse (Only completed on the daughter).”

“Upon patient record review, 2 of 27 records (Patient #5,#14) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #5,#14: The initial visit frequency for both the social worker and the spiritual care counselor was 1 prn with no indication of a scheduled frequency.”

“Upon patient record review, 5 of 27 records (Patient #7,#8,#9,#12,#13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #7: The certification of terminal illness indicated that the patient had/used an in and out urinary catheter. Nurse documentation indicated he had urinary retention and used it. There was not evidence of an order for catheter usage including how frequently and under what conditions to use the catheter. Corrected on site. Patient #8: Lorazepam was listed on the medication profile at the ALF. There was not evidence of an order for Lorazepam on the hospice record. Corrected on site. Patient #9: Ascorbic Acid was listed on the medication profile at the SNF. There was not evidence of an order for Ascorbic Acid on the hospice record. Corrected on site. Patient #12: The record contained an order for Coricidin chest congestion cough 10mg-200mg cap as needed per instructions. Corrected on site. In addition, medications in the home included Tums and Esomeprazole. The caregiver indicated that the patient was taking both of these medications. There was not evidence of an order. Corrected on site Patient #13: During an observed home visit, the nurse and patient were discussing that the nurse advised the patient to take Imodium for his complaint of diarrhea. There was not evidence of an order”

“Upon client record review, 4 of 27 records (Patient #1,#8,#13, #15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The initial plan of care indicated for a volunteer evaluation. There was not evidence that this was performed. Patient #8: The visit frequency for the spiritual care counselor for the benefit period starting 6/18/24 was 1m1, 2m2, 1m1. The record indicated only 1 visit during the month of July. Patient #13: The nurse recommended Imodium on 8/30/24 due to the patients complaints of diarrhea, yet the record indicated that the patient remained on docusate sodium, 1 capsule BID. There was instruction provided with no order. Patient #15: The visit frequency for the social worker was 1m1, 2m2, 1m1 effective 6/24/24. The record indicated visits were conducted on 6/26/24, 7/10/24, 8/13/24 and 9/5/24.”

“Upon patient record review, 2 of 27 records (Patient #8,#12) did not have evidence that Social work services are based on the patient’s psychosocial assessment and the patient/family’s needs and acceptance of these services. Patient #8: The initial bereavement risk assessment which the RN conducted on the daughter dated 5/3/34 (admission), indicated that she was a high risk with a score of 10. Factors leading to this included but were not limited to a dependent relationship, family conflict, multiple loses and unresolved issues with the patient. There was not evidence of any follow-up regarding this assessment. Patient #12: The initial bereavement risk assessment which the RN conducted on the son was indicated as high risk with a score of 11. There was not evidence of any follow-up regarding this assessment.”

“Upon personnel record review, 1 of 16 records (Personnel #14) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. The supervising nurse must assess an aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include all required content. Personnel #14: There was not evidence that the following tasks were return demonstrated on a patient or pseudo-patient at the annual on-site visit: • Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. (42 CFR 418.76(b)(3)(i)) • Reading and recording temperature, pulse, and respiration (42 CFR 418.76(b)(3)(iii)) • Safe transfer techniques and ambulation. (42 CFR 418.76(b)(3)(ix)) • Normal range of motion and positioning (42 CFR 418.76(b)(3)(x)) • Appropriate and safe techniques in personal hygiene and grooming that include-(42 CFR 418.76(b)(3)(xi)) • Bed bath • Sponge, tub, and shower bath • Shampoo, sink, tub, and bed • Nail and skin care • Oral hygiene • Toileting and elimination”

“Upon patient client record review, 4 of 27 records (Patient #1,#2,#7,#15) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1: The patient was admitted 7/19/24 and was a Full Code at that time. On 8/25/24, the patient signed an OOHDNR for a no code. All IDG plans of care from admission listed the patient as a NO code. Patient #2: The legal admission document which had a question, “Does the patient have an Advance Directive or not” was not completed. Neither checkbox was filled, both were left blank. Patient #7: The patient was admitted on 3/21/24 and was a Full Code. The OOHDNR was obtained on 7/10/24. The IDG plan of care updates listed the patient as a DNR from admission. Patient #15: The patient was admitted 6/24/24 and was a Full Code at that time. On 8/25/24, the patient signed an OOHDNR for a no code. All IDG plans of care from admission listed the patient as a NO code.”

“Upon client record review, 1 of 27 records (Patient #14) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #14: The record indicated an order dated 8/13/24, wound care to MASD sacral area. Clean with wound cleanser. Apply collagen sheet. Cover with bordered gauze. Wound care to be provided by facility nurse or hospice nurse. There was not evidence that specifically identify which provider (nursing facility or hospice) is responsible for performing the wound care. Corrected on site.”

“Upon patient record review, 2 of 8 (Patients #2,#8) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 2: The medical record contained documentation of a phone call to triage 9/1/23 identifying patient was having increased agitation and the facility stated medications ordered a week ago had not been delivered and were not available for administration. Triage recommended visit to be made but there was no evidence of a visit completed. Patient 8: The medical record contained a PRN nursing visit 1/3/23 for reported combativeness. An order for Benedryl topical gel was previously ordered to a local pharmacy 1/2/23. The local pharmacy did not have the medication available. The agency did not utilize an immediate delivery option in response to PRN visit for combativeness, instead a nurse documented that follow up would be made with the pharmacy the next day. Additional nurse documentation 1/4/24 identified the pharmacy still did not have medication and was expecting delivery that night. There was no further documentation to verify medication was received.”

“Upon patient record review, 1 of 8 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 2: The medical record contained documentation of a phone call to triage 9/1/23 identifying patient was having increased agitation and the facility stated medications ordered a week ago had not been delivered and were not available for administration. Ativan and Tramadol ordered 8/23/23 was the medication referenced. The agency did not utilize an immediate delivery option in response to report increase in agitation, instead a nurse documented medications to be delivered in the morning. There was no evidence of a nursing visit completed per triage recommendation.”