Three Oaks Hospice

“It is required that during the initial assessment visit and in advance of providing care the hospice provides the patient—or his or her representative—with verbal and written notice of the patient’s rights and responsibilities. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the hospice did not ensure that the patient or their representative received verbal and written notice of the patient’s rights and responsibilities before providing care. Clinical Record 18: The patient elected the hospice benefit on 09/29/2023 for the diagnosis of Alzheimer’s disease. A review of the clinical record revealed the consents, including the patient’s rights and responsibilities, were docusigned by the patient’s legal representative on 12/21/2023. There was no evidence that the patient or their representative was provided verbal or written notice of the patient’s rights and responsibilities during the initial assessment visit and in advance of providing care. During an interview and joint record review on 02/14/2024, the Regional Vice President of Quality confirmed that the admission date and date on the consent did not match. The Regional Vice President of Quality said they would need to “discharge and re-admit the patient correctly.””

“It is required that a revised plan of care includes: information from the patient’s updated comprehensive assessment and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 19 (5%) clinical records reviewed, the hospice did not ensure the plan of care (POC) was updated as the patient’s condition required. Clinical Record 4/Home Visit 4: The patient elected the hospice benefit on 06/28/2023 for the diagnosis of senile degeneration of the brain. During the home visit with the Hospice Aide (Aide) [Personnel Record 8], the daughter stated, “Hospice staff told me my mother didn’t have many days left, and we’re making funeral arrangements now. She’s barely taking sips of water and not eating.” A review of the clinical record revealed visit notes documented by the Spiritual Counselor on 02/12/2024: “Patient appears to decline in trajectory toward death” and the Social Worker on 02/12/2024, “SW assist with end of life and respite for caregiver burnout.” On 02/14/2024, the Skilled Nurse (SN) documented, “SN Family accepting of pending outcomes. Minimal water intake.” The plan of care was not updated or revised to include the new assessment findings documented by the SN and the findings documented by the Spiritual Counselor and Social Worker. The POC was unchanged since the patient’s hospice benefit election on 06/28/2023. During an interview and joint record review on 02/15/2024, the Regional Vice President of Quality and the Director of Patient Care Services confirmed that the POC had not been updated for this patient, and the visit notes by the interdisciplinary group appeared to show “she was imminently dying.””

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. Agency policy #IC.3 “Hand Hygiene” (dated 9/1/2022) stated in part, “ To ensure patient care staff practice proper hand hygiene techniques in the prevention and spread of infection per CDC guidelines... All hospice staff providing patient care will perform hand hygiene in accordance with CDC guidelines...1. Washing hands with soap and water. 2. Alcohol based hand sanitizer.” The Centers for Disease Control and Prevention (CDC) “Hand Hygiene Guidance” stated in part, “Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient... Before moving from work on a soiled body site to a clean body site on the same patient...After touching a patient or the patient’s immediate environment...” In 1 of 4 (25%) home visits observed, the hospice did not ensure that staff performed hand hygiene when indicated to prevent the transmission of infections and communicable diseases per the agency’s policy. Home Visit 4/Clinical Record 4: During the home visit with the Hospice Aide (Aide) [Personnel Record 8] on 02/14/2024, the Aide entered the home and prepared the items for the patient’s bed bath (basin, water, washcloths), then began preparing clothes. The Aide used scissors to cut the side of a shirt per the daughter’s request to make it “easier to put on the patient.” The Aide then set the items on the bedside table and began removing the blankets from the patient. The patient started to moan, and the Aide stepped away from the bed so the daughter could administer the pain medication. Once the daughter gave the pain medication, the Aide stepped back to the patient and began uncovering and undressing the patient. The Aide did not perform hand hygiene before or after patient care. During an interview and joint record review on 02/14/2024, the Regional Vice President of Quality confirmed that agency policy regarding hand hygiene and sanitizing was not followed.”

“It is required that 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 6 of 15 (46%) clinical records reviewed in which aide services were accepted, the hospice did not ensure the Registered Nurse (RN) provided the Hospice Aide (HA) with specific instructions. Clinical Record 2: The patient elected the hospice benefit on 01/31/2024 with the diagnosis of Alzheimer’s disease. The HA care plan dated 01/31/2024 assigned the HA the tasks: complete bed bath, partial bed bath and shower each visit. The HA care plan did not provide the HA specific instructions or criteria to determine the type of bath that should be performed. Clinical Record 5: The patient elected the hospice benefit on 01/26/2024 for the diagnosis of malignant neoplasm of bladder. The HA care plan dated 01/26/2024 assigned the HA the relevant tasks of showering two times weekly and bed bath. The HA visits dated 01/31/2024 and 02/02/2024 have both shower and bed bath checked as completed. The HA care plan did not provide the HA specific instructions or criteria to determine the type of bath that should be performed. Clinical Record 10: The patient elected the hospice benefit on 07/10/2023 for the diagnosis of multiple sclerosis. The HA care plan dated 07/10/2023 assigned the HA the tasks: bed bath and dressing the patient. The nursing assessment dated 09/01/2023 documented in part “Stage IV wound to right buttocks covered with a folded 4x4 and foam dressing.” The HA care plan did not notify the HA of the exact location of the wound, nor were specific instructions added to include care of the wound during bathing or what to do if the dressing became soiled or wet. Clinical Record 12: The patient elected the hospice benefit on 11/25/2023 for the diagnosis of congestive heart failure. The HA care plan dated 11/25/2023 assigned the HA the tasks of showering, skin care, and clothing assistance. The nursing assessment dated 12/17/2023 documented “wounds to lower extremities, covered with foam dressings and kerlix.” The HA care plan did not notify the HA of the exact location of the wound. Clinical Record 13: The patient elected the hospice benefit on 01/11/2024 for the diagnosis of malignant neoplasm of rectosigmoid junction. The HA care plan dated 02/12/2024 assigned the HA the tasks of showering, skin care, and perineal care. The nursing assessment dated 01/12/2024 documented, “Patient denies any issues with urinary catheter.” The HA care plan did not notify the aide of the presence of the catheter nor provide instructions for care of the catheter during other assigned tasks. Clinical Record 15: The patient elected the hospice benefit on 12/23/2022 for the diagnosis of protein-calorie malnutrition. The HA care plan dated 04/03/2023 assigned the HA the tasks: showering x 2 daily, applying lotion, and shampoo. The RN updated the HA care plan on 04/06/2023 to apply “medihoney and hydrocolloid to left buttock wound.” The HA care plan did not include specific instructions regarding wound care during bathing nor what to do if the dressing became soiled or wet. During an interview and joint record review on 02/14/2024, the Regional Vice President of Quality (RVPQ) confirmed that the RN did not provide specific instruction to the Hospice Aide for Clinical Records 10, 12, and 15 regarding what the HA should do with the patient’s wound during care and if the dressing became soiled or wet. The RVPQ confirmed that Clinical Record 2 did not provide specific instructions for the type of bath, and Clinical Record 13 did not provide the HA with instructions regarding the urinary catheter.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 1 of 15 (7%) clinical records reviewed in which Hospice Aide (HA) services were accepted, the hospice did not ensure that the Hospice Aide provided services ordered by the Interdisciplinary Group. Clinical Record 9: The patient elected the hospice benefit on 08/08/2022 for the diagnosis of chronic diastolic heart failure. The HA care plan dated 01/28/2024 ordered HA services three times per week. No visits were documented for the week of 01/28/2024 through 02/02/2024. During an interview and joint record review with the Regional Vice President of Quality on 2/14/2024, it was confirmed that Clinical Record 9, the HA, did not provide services as ordered.”

“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 3 of 15 (20%) clinical records reviewed in which Hospice Aide (HA) services were accepted, the hospice did not ensure that the Hospice Aide provided services included in the plan of care. Clinical Record 1: The patient elected the hospice benefit on 03/29/2023 for the diagnosis of inclusion body myositis. Hospice Aide services were ordered three times a week. The HA care plan assigned the HA the relevant task of shaving the patient one time a week. The HA visit notes dated 01/29/2024, 01/31/2024, and 02/01/2024 documented that the patient fell during the week, and a “shave” was provided for each visit. In addition, the HA visit notes dated 02/07/2024 and 02/09/2024 documented that a shave was provided for each visit. Clinical Record 2: The patient elected the hospice benefit on 01/31/2024 for the diagnosis of Alzheimer’s disease. The HA care plan dated 01/31/2024 assigned the HA the relevant task: “document if no BM (bowel movement).” The HA visit notes dated 02/05/2024 and 02/07/2024 marked this task as completed without documentation of the bowel movement status. Clinical Record 5: The patient elected the hospice benefit on 01/26/2024 for the diagnosis of malignant neoplasm of bladder. The HA care plan dated 01/26/2024 assigned the HA the relevant tasks of showering two times weekly and bed bath. The HA visit note dated 01/29/2024 was blank. No assigned tasks were marked as completed, only acknowledged. During an interview and joint record review with the Regional Vice President of Quality on 2/14/2024, it was confirmed that in Clinical Records 1, 2, and 5, the HA did not document services were provided as ordered per the plan of care.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are: noted in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 3 (67%) clinical records reviewed of patients receiving volunteer visits, the hospice did not ensure that a plan of care was established for volunteer services. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 03/29/2023 for the diagnosis of inclusion body myositis. During the home visit on 02/13/2024, the patient was asked about the hospice services received. The patient reported that they enjoyed the volunteer, although they “hadn’t seen him in a few months.” A clinical record review revealed volunteer visit notes dated 08/11/2023, 08/18/2023, 08/25/2023, 08/28/2023, 09/01/2023, and 09/08/2023. There was no evidence that a plan of care was developed for the patient’s volunteer services. During an interview, the Volunteer Coordinator (VC) stated the volunteer “was a student and a new volunteer would be assigned.” Clinical Record 17: The patient elected the hospice benefit on 05/10/2023 for the diagnosis of malignant melanoma. A note from the Volunteer Coordinator dated 05/15/2023 documented that the “patient would like emotional support in the afternoons for when he is home alone.” Volunteer visits were documented on 05/15/2023, 05/19/2023 and 06/23/2023. There was no evidence that a plan of care was developed for the patient’s volunteer services. During an interview and a joint record review on 2/15/2024, the Regional Vice President of Quality and the Volunteer Coordinator confirmed that volunteer care plans had not been added to the clinical records 1 and 17.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement and that recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed of patients with recertification of the terminal illness, the hospice did not ensure the recertification of the terminal illness was completed in the required time frame. Clinical Record 6: The patient elected the hospice benefit on 06/15/2022 for the diagnosis of chronic obstructive pulmonary disease. A clinical record review revealed the ninth (9) benefit period started on 12/07/2023. The physician signed the recertification of the terminal illness on 11/22/2023, sixteen (16) days before the next benefit period began. During an interview and joint record review on 02/14/2024, the Regional Vice President of Quality confirmed that the recertification of terminal illness was signed before the 15-day timeframe.”

“It is required that a patient’s clinical record contains correct clinical information, including physician’s orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure the physician orders contained all required elements. Clinical Record 12: The patient elected the hospice benefit on 11/25/2023 for the diagnosis of congestive heart failure. On 12/17/2023 the physician ordered “Clean wounds with normal saline and betadine mix, pat dry, apply calcium alginate.....Hospice SN to complete wound care 2x weekly, (name of wound care center) wound care to complete 1x weekly. “ The physician’s order was incomplete and did not include documentation of the location of the wounds. Clinical Record 15: The patient elected the hospice benefit on 12/23/2022 for the diagnosis of protein-calorie malnutrition. On 04/03/2023, the physician ordered, “Apply medihoney to wound bed daily and prn.” The physician’s order was incomplete and did not include documentation of the location of the wound and instructions or indications for the “PRN” (as needed) visit. During an interview and joint record review on 02/14/2024, the Regional Vice President of Quality confirmed that the orders should have contained the location of the wounds and the reason for the PRN visit.”