Bristol Hospice - Dallas

“It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This Condition was not met as evidenced by clinical record review, document review, and interview with the Executive Director, which revealed issues with the completion of a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services in the following areas: Failure to assess the patient’s pain as part of a comprehensive assessment [HCPC 12.I/L524]; Failure of the hospice Interdisciplinary Group to ensure the comprehensive assessment included a drug profile that contained the patient’s current prescription drugs [HCPC.15.I/L530]; and Failure of the hospice Interdisciplinary Group to ensure the patient’s comprehensive assessment was completed as frequently as the patient’s condition required to reassess the patient’s response to care. [HCPC.17.I/L533]. The cumulative effect of these systemic problems has resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation 42 CFR 418.54 Initial and Comprehensive assessment of the patient. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the patient’s pain be assessed as part of a comprehensive assessment. The documented evaluation of the patient’s pain includes characteristics of the pain, including location, frequency, and intensity, how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping), and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-018, “Pain Assessment” (revised May 2020), stated in part, “All patients will receive a pain assessment. When pain is identified, a more comprehensive pain assessment will be completed when warranted by the patient’s condition. Pain assessments will be appropriate and documented to facilitate regular reassessment and follow-up by clinicians...When a patient or clinician identifies pain, the following in-depth pain assessment information will be obtained when possible, (A) pain intensity, (B) pain location and frequency, (C) pain quality, (D) pain onset, duration, variations, and patterns, (E) alleviating and aggravating factors, (F) present pain management regimen and effectiveness.” In 1 of 19 (5%) clinical records reviewed, the hospice did not ensure that the patient’s pain was assessed as part of the comprehensive assessment. Clinical Record 9: The patient elected hospice care on 4/8/2023. The registered nurse (RN) assessment dated 10/9/2023 documented the patient verbalized a pain level of eight (8) with a pain level goal of five (5). The pain was documented as “abdominal.” The physician ordered the medication Fentanyl 25 mcg, apply one (1) patch every three (3) days. The RN made a PRN (as needed/pro re nata) visit on 10/9/2023 to administer an intramuscular (IM) injection of Promethazine 25 mg. The RN assessment note documented, “Medication injected safely. The patient tolerated the procedure.” The RN visit note did not document a pain assessment. During a joint record review and interview on 12/13/2023, the Executive Director stated, “I think the physician ordered Promethazine because the patient reported the pain was abdominal in location.” The RN visit note dated 10/12/2023 documented the patient’s abdominal pain level of eight (8). The pain was documented as aching and aggravated by activity; “duration” and “frequency” were blank. The RN visit note dated 10/16/2023 documented, “The patient continues to (complain of) C/O pain level of eight (8), the location was back, the description was aching, aggravated by was general activity.” The pain assessment “duration” and “frequency” were blank. The SN visit note dated 10/20/2023 documented, “Routine visit administered Promethazine injection per MD order to right gluteal. The patient tolerated the procedure well. Reports that pain continues to be an issue. Meds recently changed by PCP.” The pain assessment documented that the location was the upper arm, and the pain level was five (5). The pain assessment “description,” “aggravated by,” “duration,” and “frequency” were blank. There was no documented evidence that the patient’s pain was assessed as part of the assessment during each visit. During the joint record review and interview on 12/13/2023, the Executive Director confirmed the RN did not perform any pain assessment on the PRN visit on 10/9/2023. In addition, the pain assessment completed by the RN on 10/12/2023, 10/16/2023, and 10/20/2023 was incomplete, as the RN did not assess the pain’s duration or frequency.”

“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, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. 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, document review, interview and observation. Agency policy # 2-004, “Medication Profile” (revised May 2020), stated in part, “A drug regimen review will be performed at the time of the initial and the comprehensive assessment when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication.” In 2 of 19 (11%) clinical records reviewed and home visits observed, the hospice did not ensure that the comprehensive assessment included a drug profile that included the patient’s current regimen. Clinical Record 1/Home Visit 1: The patient elected hospice care on 9/15/2023 and resides in an Assisted Living Facility (ALF). Medication reconciliation was performed during the home visit with the registered nurse (RN) [Personnel Record 2] on 12/12/2023, comparing the hospice medication profile to the patient’s medication regimen. The hospice medication profile dated 12/12/2023 documented, “Metoprolol tartrate 25 mg, take one (1) tablet orally two (2) times daily.” The Assisted Living Facility (ALF) medication list/administration record dated 12/12/2023 documented, “Metoprolol tartrate 25 mg, take one-half tablet orally two (2) times daily.” Clinical Record 4/Home Visit 4: The patient elected hospice care on 11/25/2023 and resides in a skilled nursing facility (SNF). Medication reconciliation was performed during the home visit with the RN [Personnel Record 3] on 12/12/2023, comparing the hospice medication profile to the patient’s medication regimen. The hospice medication profile dated 12/12/2023 documented, “Famotidine 40 mg, take one (1) tablet orally once a day.” The SNF medication list/medication administration record documented, “Famotidine 25 mg, take one (1) tablet daily.” During a joint record review interview on 12/12/2023, the Director of Patient Care Services, who was present at the home visits, confirmed the hospice medication profile did not match the patient’s current medication regimen.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes: information on the patient’s progress toward desired outcomes;reassessment of the patient’s response to care. The assessment update is completed: as frequently as the condition of the patient requires; no less frequently than every 15 days. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-018, “Pain Assessment” (revised May 2020), stated in part, “All patients will receive a pain assessment. When pain is identified, a more comprehensive pain assessment will be completed when warranted by the patient’s condition. Pain assessments will be appropriate and documented to facilitate regular reassessment and follow-up by clinicians.” Agency policy #9-014, “Admission for General Inpatient Services” (revised May 2020), stated in part. “One (1) or more of the following clinical criteria must be present in order for the patient to be considered appropriate for admission for general inpatient care. Admission decisions are made on an individual case-by-case basis after evaluation by the hospice interdisciplinary group and in consultation with the patient’s attending physician... “Pain control that is unable to be managed appropriately in the home setting.” In 1 of 19 (5%) clinical records reviewed, the hospice did not ensure that the patient’s assessment was completed as frequently as the condition of the patient required to reassess the patient’s response to care. Clinical Record 9: The patient elected hospice care on 4/8/2023. The registered nurse (RN) assessment dated 10/9/2023 documented the patient verbalized a pain level of eight (8) with a pain level goal of five (5). The pain was documented as “abdominal.” The physician ordered “Fentanyl 25 mcg, apply one (1) patch every three (3) days.” The RN made a PRN (as needed/pro re nata) visit on 10/9/2023 to administer an intramuscular (IM) injection of Promethazine 25 mg. The RN assessment note documented, “Medication injected safely. The patient tolerated the procedure.” The RN visit note did not document a pain assessment. During a joint record review and interview on 12/13/2023, the Executive Director stated, “I think the physician ordered Promethazine because the patient reported the pain was abdominal in location.” Documentation of the social worker’s phone call to the patient on 10/11/2023 read in part, “Patient presents frail and well groomed. The patient reports pain at seven (7) out of ten (10). Current medications are ineffective. Nurse notified. There are no unmet needs.” A clinical record review revealed no evidence the case manager completed a visit on 10/11/2023. In a joint record review and interview on 12/13/2023, the Executive Director stated, “It looks like the Social Worker went at 5:30 PM, and the Case Manager was already done with her workday, so the RN Case Manager went the next workday on 10/12/2023 at 2:15 PM. There were no skilled nurse visits on 10/10/2023 or 10/11/2023. The RN visit note dated 10/12/2023 documented, “Pain medication administered by a spouse before this visit. The patient continues to C/O nausea. This writer administered Promethazine 25 milligram IM in the right buttocks.” In addition, the RN documented the patient’s abdominal pain level of eight (8). The pain was documented as aching and aggravated by activity; “duration” and “frequency” were blank. “Pain medication administered by a spouse before this visit. The patient continues to C/O nausea. This writer administered Promethazine 25 milligram IM in the right buttocks.” No SN visits were documented on 10/13/2023, 10/14/2023, and 10/15/2023. The RN visit note dated 10/16/2023 documented, “The patient continues to complain of (C/O) pain level of eight (8) the location was back, the description was aching, aggravated by was general activity, duration was blank, and frequency was blank and nausea. She informed this writer that pain medication is not effective. I notified Dr. (Doctor Name), and he ordered Dronabinol five (5) milligrams (mg) to be increased from two (2) times daily to three (3) times daily.” No SN visits were documented on 10/17/2023, 10/18/2023, and 10/19/2023. The Licensed Practical Nurse (LPN) visit note dated 10/20/2023 documented, “Routine visit administered Promethazine injection per MD order to right gluteal. The patient tolerated the procedure well. Reports that pain continues to be an issue. Meds recently changed by PCP.” The pain assessment documented that the location was the upper arm, and the pain level was five (5). The pain assessment “description,” “aggravated by,” “duration,” and “frequency” were blank. The care plan dated 10/20/2023 stated in part, “The patient will experience less interfering pain as evidenced by improved activities of daily living, and the goal was fifty percent (50%) complete.” There were medications changed: on 10/30/2023, Fentanyl was increased from 25 mcg to 50 mcg; on 11/10/2023, Fentanyl was increased from 50 mcg to 100 mcg; and on 11/17/2023 the Fentanyl was increased to 150 mcg. The Executive Director confirmed the hospice record did not contain evidence that the Social Worker or the RN Case Manager discussed any level of care change with the patient due to the patient’s pain. The Executive Director confirmed the patient’s documented pain level of eight (8) was not at the stated acceptable level of five (5) for eleven (11) days from 10/9/2023 until 10/20/2023, when the pain was reported at an acceptable level of five (5).”

“Hospice aides are required to be 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 an RN responsible for supervising the hospice aide. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy # 9-017, titled Plan of Care (revised November 2021), stated in part, “The plan of care will identify the patient’s needs and services to meet those needs. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs...The written plan of care will contain, but will not be limited to the following...detailed statement of scope and frequency of service... individualized interventions to assist with end-of-life care.” In 4 of 18 (22%) clinical records reviewed of patient’s that received hospice aide services, the hospice did not ensure that the hospice aide received specific written instructions, thus leaving the aides to make decisions outside their scope of practice. Clinical Record 1: The patient elected hospice care on 9/15/2023 with the terminal diagnosis of hypertensive heart without failure. The initial assessment completed by the registered nurse (RN) dated 9/15/2023 documented,” The patient has experienced a decline over the several months with increased falls, increased sleep, and increased confusion.” The mental status section of the initial assessment documented, “patient is alert to self only...Patient is able to ambulate freely. Although she still uses her walker, she frequently does not use it. Likely because her dementia prohibits her from remembering that she needs it.” The patient’s son signed the hospice benefit election form as the Patient’s Power of Attorney (POA). The hospice aide care plan dated 9/17/2023 (no end date) assigned the hospice aide the tasks: “partial bed patient prefers mornings, and patient can shower with assist-patient prefers mornings.” The hospice aide visit notes dated 10/2/2023, 10/3/2023, and 10/4/2023 documented that a partial bed bath was completed. The hospice aide visit note dated 10/6/2023 documented that a shower was completed. On 12/11/2023, the hospice aide visit note documented that a bed bath and a shower were completed. During a joint record review and interview on 12/11/2023 and 12/11/2023, the Executive Director confirmed the hospice aide care plan did not include a specific bath type. Clinical Record 3/Home Visit 3: The patient elected hospice care on 10/26/2023. The hospice aide care plan dated 10/26/2023 through 1/23/2023 ordered HA services two times a week. The hospice aide care plan assigned the HA the tasks: personal care, shower bath, observe fall prevention. The HA assigned tasks did not include the frequency of completion of the assigned tasks. During an interview on 12/11/2023, the Executive Director confirmed the hospice aide care plan did not document frequencies for the tasks to be completed. Clinical Record 10: The patient elected hospice care on 5/30/2022. The hospice aide care plan dated 9/8/2023 through 11/6/2023 ordered hospice aide services three times weekly and assigned the HA the tasks: seated shower/shower bath, bed bath, brushing teeth, mouth care, routine hair and skin maintenance, and fingernail care. During a joint record review and interview on 12/13/2023 and 12/11/2023, the executive director confirmed the hospice aide care plan was not specific, assigned the HA two types of bath, and did not document frequencies for the tasks to be completed. Clinical Record 12: The patient elected hospice care on 9/16/2023. The hospice aide care plan dated 9/16/2023 ordered hospice aide services five times per week and assigned the HA the task: complete bath. The week of 11/19/2023 through 11/25/2023, the HA visit notes dated 11/21/2023, 11/22/2023, 11/24/2023, and 11/25/2023 documented a complete bath was completed. During a joint record review and interview on 12/13/2023, the Executive Director confirmed the task of complete bath was not specific and did not document a frequency. The Executive Director stated, “It is unclear if the patient receives a shower or a bed bath.” The Executive Director phoned the hospice aide assigned to the patient’s daily care and the hospice aide reported that the patient receives a bed bath each visit.”

“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, document review, interview and observation. Agency policy # 9-017 “Plan of Care” (revised November 2021) stated in part, “The care provided to the patient must be in accordance with the plan of care...The plan of care will identify the patient’s needs and services to meet those needs...” In 1 of 18 (6%) clinical records reviewed of patients that received hospice aide services, the hospice did not ensure the hospice aide performed tasks ordered by the Interdisciplinary Group (IDG) and included in the care plan. Clinical Record 3/Home Visit 3: The patient elected hospice care on 10/26/2023, the hospice aide (HA) care plan dated 10/26/2023 through 1/23/2023 ordered HA services two times a week and assigned the HA the tasks: personal care, shower bath, observe fall prevention. The HA visit note dated 11/28/2023 documented, “Arrived to find patient too weak for the shower. Brother insisted I provide a complete BB (bed bath), linen change, brushed teeth, and rinsed mouth.” The HA visit note dated 11/30/2023 documented “complete care provided, oral care, linen changed, the patient continues to decline, left patient resting aftercare. brushed teeth, washed hair, and tidied the work area.” During the home visit with the hospice aide (HA) [Personnel Record 4] on 12/12/2023, the hospice aide was observed providing a bed bath. The hospital aide stated they would update the registered nurse (RN) that the care plan needed to be updated to contain a bed bath instead of a shower. The HA care plan did not include the tasks of dressing and undressing the patient, brushing the teeth, oral care, rinsing the mouth, and changing the linen. A clinical record review revealed no evidence the hospice aide communicated with the RN that the patient received a bed bath instead of a shower. During an interview on 12/11/2023, the Executive Director confirmed the hospice aide performed a bed bath, even though a shower was on the care plan and the hospice aide did not update the RN about the change in the patient’s needs, and the tasks performed were not on the hospice aide care plan.”

“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, document review and interview. Agency policy # 9-017 “Plan of Care” (revised November 2021) stated in part, “The care provided to the patient must be in accordance with the plan of care...The plan of care will identify the patient’s needs and services to meet those needs. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs... detailed statement of scope and frequency of service.” In 1 of 18 (6%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure the hospice aide provided services ordered in the care plan. Clinical Record 12: The patient elected hospice care on 9/16/2023. The hospice aide care plan ordered hospice aide services five times a week. During the week of 11/19/2023 through 11/25/2023, the hospice aide documented that visits were completed on 11/21/2023, 11/22/2023, 11/24/2023, and 11/25/2023; the actual frequency was four times a week. A clinical record review revealed no evidence of a documented missed visit for 11/23/2023. During a joint record review and interview on 12/13/2023, the Executive Director confirmed the record did not contain any documentation by the hospice aide or the RN about the missed hospice aide visit on 11/23/2023.”

“Hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and social needs to a registered nurse as the changes relate to the care plan. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #9-017 “Plan of Care” (revised November 2021) stated in part, “Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of new services.” Agency policy #1-006, “Care/Service Coordination” (revised May 2020) stated in part, “Each patient will be assigned a Hospice Case manager upon admission. It will be the responsibility of the Hospice Case Manager to facilitate communication about changes in the patient status among assigned personnel.” In 2 of 18 (11%) clinical records reviewed of patients that received hospice aide services, the hospice did not ensure the hospice aide reported changes in the patient’s medical, nursing, rehabilitative, and social needs to a registered nurse (RN) as the changes related to the care plan. Clinical Record 3/Home Visit 3: The patient elected hospice care on 10/26/2023, the hospice aide (HA) care plan dated 10/26/2023 through 1/23/2023 ordered HA services two times a week and assigned the HA the tasks: personal care, shower bath, observe fall prevention. The HA visit note dated 11/28/2023 documented, “Arrived to find patient too weak for the shower. Brother insisted I provide a complete BB (bed bath), linen change, brushed teeth, and rinsed mouth.” The HA visit note dated 11/30/2023 documented “complete care provided, oral care, linen changed, the patient continues to decline, left patient resting aftercare. brushed teeth, washed hair, and tidied the work area.” During the home visit with the hospice aide (HA) [Personnel Record 4] on 12/12/2023, the hospice aide was observed providing a bed bath. The hospital aide stated they would update the registered nurse (RN) that the care plan needed to be updated to contain a bed bath instead of a shower. The HA care plan did not include the tasks of dressing and undressing the patient, brushing the teeth, oral care, rinsing the mouth, and changing the linen. A clinical record review revealed no evidence the hospice aide communicated with the RN that the patient received a bed bath instead of a shower and that the additional tasks were completed to meet the patient’s needs. During an interview on 12/11/2023, the Executive Director confirmed the hospice aide performed a bed bath, even though a shower was on the care plan and the hospice aide did not update the RN about the change in the patient’s needs, and the tasks performed were not on the hospice aide care plan. During a joint record review and an interview on 12/11/2023, the Executive Director confirmed that the hospice aide completed a bed bath and that the clinical record did not contain evidence that the HA updated the RN about the changes in the patient’s needs. Clinical Record 10: The patient elected hospice care on 5/30/2022. The hospice aide care plan dated 9/8/2023 through 11/6/2023 ordered hospice aide services three times weekly and assigned the HA the tasks: seated shower/shower bath, bed bath, brushing teeth, mouth care, routine hair and skin maintenance, and fingernail care. The HA visit notes dated 9/11/2023, 9/13/2023, and 9/15/2023 documented the assigned tasks: “assist with ambulation, bed bath, complete bed rest, assist with toileting” were not completed. A clinical record review revealed no documented evidence that the RN was notified of the assigned HA tasks that were not completed. During a joint record review and interview on 9/11/2023, the Executive Director confirmed the record did not contain evidence the hospice aide updated the RN about tasks not completed.”

“It is required that a patient’s clinical record contain physician orders. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy #6-022, “Clinical Services/Service Data Collection” (revised February 2023), stated in part, “A clinical service record will be initiated and maintained for each patient receiving care or services, and will include at a minimum...physician (or other licensed independent practitioners) orders.” In 1 of 19 (5%) clinical records reviewed, the hospice did not ensure the clinical record contained physician orders for care and services provided. Clinical Record 4: The patient elected hospice care on 11/25/2023. The patient assessment documented two (2) wounds. The registered nurse (RN) visit note dated 12/6/2023 documented, “Stitches were removed from the finger, and she tolerated it well.” The plan of care dated 12/11/2023 for the benefit period dated 11/25/2023 through 2/22/2024 did not include documentation of an order to remove the sutures on 12/6/2023. A clinical record review revealed no evidence of a physician’s order to remove the sutures. During a joint record review and interview on 12/2/2023, the Executive Director confirmed the clinical record did not contain a physician’s order to remove sutures. The Executive Director stated, “Yes, I expect a physician’s order to be in the record for us to remove the stitches.””

“It is required that all entries in the patient record are complete, appropriately authenticated, and in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 18 (6%) clinical records reviewed of patients receiving hospice aide services, the hospice aide did not accurately document the patient care and services provided according to the agency policy. Agency policy #6-022, “Clinical Services/Service Data Collection” (revised February 2023), stated in part, “Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided.” Clinical Record 1: The patient elected hospice care on 9/15/2023 with the terminal diagnosis of hypertensive heart without failure. The hospice aide care plan dated 9/17/2023 with no end date assigned the hospice aide the task: “partial bed patient prefers mornings, and patient can shower with assist-patient prefers mornings.” The hospice aide visit note dated 12/11/2023 documented the hospice aide completed a bed bath and a shower. During a joint record review and an interview on 12/11/2023, the Executive Director confirmed the record contained an aide care plan for two (2) types of baths, and the hospice aide documented they completed two kinds of baths on 12/11/2023.”