Three Oaks Hospice

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that all members of the Interdisciplinary Team (IDT) completed an initial assessment no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 5: The patient elected the hospice benefit on 08/28/2023. The Registered Nurse’s (RN) initial assessment dated 08/28/2023 documented, “Social Worker to evaluate and assess for frequency...” During the IDT meeting on 09/06/2023, the Social Worker (SW) documented, “To be assessed... Initial assessment to be completed....” On 09/20/2023 during IDT, the SW documented, “Family coping well and have a good understanding of their loved ones diagnosis and prognosis, the hospice POC and express healthy coping... to be available to patient, facility, and family to ensure patients comfort and support are in place, and interventions are effective...”The Social Worker assessment was completed on 11/13/2023, with 77 days outstanding. A review of the clinical record revealed no documented missed visits and no communication with the patient/family to schedule the initial assessment. Clinical Record 6: The patient elected the hospice benefit on 10/09/2023. During the IDT meeting on 10/18/2023, the SW documented that the plan was “To be present to ensure patients care and comfort … emotional needs are met... To be present to ensure healthy coping and understanding of disease progression and anticipatory grief of patient and family.” During the IDT meeting on 11/01/2023, the SW documented, “Will assess for psychosocial needs of Pt/family and provide support as needed...” The initial SW assessment was conducted on 11/29/2023, with 51 days outstanding. A review of the clinical record revealed no documented missed visits and no communication with the patient/family to schedule the initial assessment. Clinical Record 7: The patient elected the hospice benefit on 01/09/2024. On 01/12/2024, the SW placed a phone call to the patient/family and documented “SW contacted the pt/ family to inform the patient’s initial assessment will be conducted next week 1/16/24. SW informed family they can reach out to this SW if they need something prior to next week.” The communication note did not document the reason for the delay or that the delay was at the patient/family’s request. The initial SW assessment was documented on 01/18/2024. During an interview on 05/29/2024, the Regional Vice President of Quality & Compliance confirmed the late initial assessments completed by the Social Worker were conducted after the five-day required time period without any documentation as to why the Social Worker delayed these visits.”

“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 medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. 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, and interview. Agency policy #PC.85 “Medication List and Monitoring” (dated 10/01/2021) stated in part, “The hospice Registered Nurse (RN) will be responsible for coordinating the efforts of monitoring the medication regimen by compiling assessment data through a collaborative effort …Medication monitoring will include appropriate date/information to develop an accurate patient medication history and a current, complete medication profile...Changes in the medication regimen will be documented in the medical record either on the medication profile, on a verbal order …will be updated … to reflect changes in the medication regimen...” In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure that the patient’s drug profile was updated when a new medication was added or changes were made to the patient’s existing medications. Clinical Record 7: The patient elected the hospice benefit on 01/09/2024. The Registered Nurse (RN) visit note dated 04/23/2024 documented, “reports urine smells concentrated. Between that and the increased confusion, RN started pt on antibiotic (ABX) for suspected urinary tract infection (UTI) per Dr...” The Interdisciplinary Group Meeting dated 04/24/2024, the RN documented, “Pt has current UTI and is starting ABX today for treatment...” A review of the patient’s clinical record revealed no documented physician order for an antibiotic and no antibiotic with that start date was noted in the patient’s medication profile in either the active or discontinued medications. During a joint record review and interview on 05/29/2024, the Regional Vice President of Quality and Compliance confirmed that there was no physician order for the antibiotic and no antibiotic listed in the patient’s medication profile.”

“It is required that the comprehensive assessment includes the patient’s or family’s need for referrals and further evaluation by appropriate health professionals. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy #PC.110 “Coordination of Care” (dated 10/01/2021) stated in part, “The designated Registered Nurse (RN) will coordinate care with the Interdisciplinary Group/Team (IDG/IDT) to ensure implementation of the Plan of Care (POC) meets the continuous assessed patient and family needs... The IDG/IDT will maintain responsibility for directing, coordinating, and supervising the care and services provided by all medical entities... All communications and coordination of care is documented in the clinical record..” In 1 of 2 (50%) clinical records reviewed of patients with a need for referrals and further evaluation by appropriate health professionals. Clinical Record 1: The patient elected the hospice benefit on 01/19/2024. The Interdisciplinary Group Meeting (IDT) on 03/13/2024, signed by the Hospice Medical Director, included “Patient/Caregiver Plan of Care change requests” and documented that the patient’s niece requested a consultation with a physical therapist. A review of the clinical record revealed no evidence of a follow up communication note, IDT note, or physical therapy evaluation. During a joint clinical record review and interview on 05/29/2024, the Regional Vice President of Quality & Compliance confirmed that no follow-up could be located in the medical record after the nurse noted the request for physical therapy services during IDT and it was signed by a physician.”

“It is required that hospice care and services provided to patients and families follow the individualized plan of care established by: the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #PC.35 “Implementing Care and Treatment” dated 04/04/2023 read in part that “The Hospice will assign appropriate disciplines needed to provide patient care/treatment...The assigned discipline(s) will be provided with information needed to provide care/treatment including, but not limited to, the plan of care (POC)…When the provision of care/treatment cannot be implemented as established on the care planning document(s) … The appropriate documentation will be completed and submitted by the assigned discipline or Clinical Manager...” In 2 of 19 (16%) clinical records reviewed, the agency did not ensure that hospice care and services followed the plan of care Clinical Record 4: The patient elected the hospice benefit on 01/16/2024. For the benefit period dated 01/16/2024 to 04/14/2024, the POC effective 01/16/2024 ordered Skilled Nursing (SN) once a week. A review of the clinical record revealed no evidence of a SN visit documented for the week of 03/24/2024. There was no evidence of a documented missed visit or communication with the physician. Clinical Record 7: The patient elected the hospice benefit on 01/09/2024. A review of the clinical record revealed documented Chaplain visits dated 02/26/2024, 03/26/2024, 04/29/2024, and 05/15/2024. For the benefit periods dated 01/09/2024 to 04/07/2024 and 04/08/2024 to 07/06/2024, the plans of care effective 01/09/2024 and 03/25/2024, respectively, did not order Chaplain services. During an interview on 05/29/2024, the Regional Vice President of Quality & Compliance confirmed the findings.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] 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, document review, and interview. Agency policy #PE.5 “Patient Assessments” (dated 01/31/2024) stated in part, “Updates to the comprehensive assessment will be accomplished by the IDG/IDT to include, but not be limited to … reassessing a patient’s needs when there is a significant health status change in the patient’s condition … Care, treatment, services, and frequency of services to be provided … Information from the updated comprehensive assessment will be used by the IDG/IDT to update the patient/family POC...” In 5 of 19 (26%) clinical records reviewed, the agency did not ensure that the patient’s plan of care identified planned interventions based on problems identified in updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 01/19/2024. On 03/04/2024, the physician ordered: “Sertraline HCL 100mg tablets - take one tablet by mouth daily.” The Registered Nurse (RN) visit note dated 03/28/2024 documented, “CG reports … pt was awake ‘talking’ a lot last night...spoke to niece... discussed trying a sleep aid. She is agreeable...” The physician ordered: “Trazodone HCL 50mg tablets - take one tablet by mouth daily for insomnia.” The plan of care was not updated to include interventions and goals for the patient’s identified problem with insomnia. Clinical Record 3: The patient elected the hospice benefit on 11/14/2023. The face-to-face visit conducted by the Nurse Practitioner on 02/22/2024 documented: “During the assessment, the patient was observed lying in bed with closed eyes, experiencing intermittent agitation and increased confusion, which were managed using as needed (PRN) Lorazepam and Seroquel. The patient relies on 1.5 liters (l) nasal cannula oxygen most of the time and experiences dyspnea without it, utilizing BiPAP at night. Her sleep pattern involves approximately 13-14 hours per day, aided by Ramelteon...” On 02/20/2024, the physician ordered: “Seroquel 25mg - take half a tablet by mouth every night for anxiety and insomnia; on 02/29/2024, the physician ordered: “Melatonin 5mg tablet - take one tablet by mouth every night for sleep” and “Ramelteon 8mg tablet - take one tablet every night at bedtime for sleep;” and on 03/05/2024 the physician ordered: “Lorazepam 1mg tablet by mouth every four hours as needed for agitation and/or restlessness.” The plan of care was not updated to include interventions and goals for the patient’s identified problem with insomnia. The RN visit note dated 05/01/2024 documented that the patient had bilateral lower extremity two-plus edema, mild anxiety, and agitation, and “Pt has occasional periods of anxiety and/or aggression, with more frequent outbursts, requiring PRN lorazepam which is effective...pitting edema in bilateral lower extremities when sitting with feet down...Compression socks worn daily. New onset of crackles noted in lungs, requiring increase of scheduled furosemide, which is ineffective. Pt wears 1.5 L N/C at all times...” The plan of care was not updated to include interventions and goals for the patient’s identified problems with anxiety, agitation, and edema. Clinical Record 4: The patient elected the hospice benefit on 01/16/2024. The Registered Nurse (RN) visit note dated 02/13/2024 documented, “Daughter reports patient is still not sleeping well at night...received order to increase Trazodone to 100mg at bedtime...” On 02/13/2024, the physician ordered: “Trazodone HCL 100mg by mouth every night at bedtime for insomnia.” Then, on 03/01/2024, The RN visit note dated 03/01/2024 documented that the patient was experiencing “3+ pitting edema noted to bilateral lower extremities... orders received for Furosemide 20mg daily PRN edema...” On 03/01/2024, the physician ordered: “Furosemide 20mg by mouth daily as needed for edema. The plan of care was not updated to include interventions and goals for the patient’s identified problems with insomnia and edema. Clinical Record 7: The patient elected the hospice benefit on 01/09/2024. The RN visit note dated 02/09/2024 documented, “Pt is weak and tired, with nausea and decreased appetite. S/S of UTI and treatment started today.” On 02/09/2024, the physician ordered: “Bactrim 800/160mg - take one tab by mouth twice a day for a urinary tract infection.” The RN visit note dated 02/21/2024 documented, “Pt is very confused and disoriented followed by aggressiveness, which has escalated...complain of pain to peri area … MD ordered Cipro 500mg BID x3 days prophylactic for UTI (urinary tract infection).” On 02/21/2024, the physician ordered: “Cipro 500mg tablets - take one tablet twice a day for infection.” The RN visit note dated 02/22/2024 documented, “Facility nurse...reports patient tested positive for COVID... Paxlovid and steroids ordered...” On 02/22/2024, the physician ordered: “Paxlovid 300/100mg - take one therapy pack by mouth twice a day for ten days” and “Dexamethasone 6mg tablets - take one tablet daily.” The Registered Nurse (RN) visit note dated 03/25/2024 documented, “She has chronic bilateral (bilat) 1-2 pitting edema. Recently has been complaining of increased pain in legs, especially at night, causing some disturbance in sleep... “ On 04/01/2024, the physician ordered: “Ramelteon 8mg tablet - take one table by mouth at bedtime for insomnia.” The RN visit note dated 04/23/2024 documented, “reports urine smells concentrated. Between that and the increased confusion, RN started pt on antibiotic (ABX) for suspected UTI per Dr..” The plan of care was not updated to include interventions and goals for the patient’s identified problems with insomnia, edema, urinary tract infections, and COVID-19 infection. Clinical Record 18: The patient elected the hospice benefit on 07/14/2023. The RN visit note dated 11/01/2023 documented, “Patient has had a cough for more than two weeks... crackles to bilateral lungs …Orders received for Amoxicillin 500mg BID for seven days...” A physician’s order was documented on 11/01/2023 for Amoxicillin 250mg/5ml: 10ml by mouth twice a day for congestion and cough and Guaifenesin-DM 100-10mg/5ml: 10ml every six hours as needed for cough. On 11/21/2023, the RN visit note documented that the patient had “frequent wet congested cough...orders received for Levaquin 750mg daily for 7 days...” A physician’s order for Levaquin 750mg by mouth daily was documented on 11/21/2023. On 02/28/2024, the skilled nurse documented, “Daughter reports that patient has really bad wet cough and coughed most of the night... orders received.... for Levaquin liquid 500mg daily for seven days...” On 02/28/2024, the physician ordered: “Levaquin 500mg/5ml: 5ml daily by mouth for cough and congestion.” The RN visit note dated 03/07/2024 documented, “Patient continues to have cough and tracheal secretions. Daughter reports patient coughs during meals. Orders received to change diet to pureed texture...” The physician ordered a pureed diet on the same day. The plan of care was not updated to include interventions and goals for the patient’s identified problems with multiple respiratory infections and new onset of dysphagia symptoms with orders for new meds and diet changes. The Regional Vice President of Quality and Compliance confirmed the findings during joint clinical record reviews and interviews on 05/29/2024, 05/30/2024, and 05/31/2024. update plan of care”

“It is required that medical social services are provided: based on a psychosocial assessment; according to the patient’s and family’s needs and acceptance of these services; [and] per the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #PC.35 “Implementing Care and Treatment” dated 04/04/2023 read in part that “The Hospice will assign appropriate disciplines needed to provide patient care/treatment...The assigned discipline(s) will be provided with information needed to provide care/treatment including, but not limited to, the plan of care (POC)…When the provision of care/treatment cannot be implemented as established on the care planning document(s) … The appropriate documentation will be completed and submitted by the assigned discipline or Clinical Manager...” In 2 of 19 (16%) clinical records reviewed, the agency did not ensure that medical social services were provided per the plan of care. Clinical Record 5: The patient elected the hospice benefit on 08/28/2023. For the benefit periods dated 08/28/2023 to 11/25/2023 and 11/26/2023 to 02/23/2024, the POC effective 08/28/2023, ordered Social Worker (SW) services to conduct an initial assessment and visit the patient once a month, respectively. A review of the clinical record revealed no evidence of SW visits documented for September, October, or December 2023. There was no evidence of documented missed visits or communication with the physician. Clinical Record 9: The patient elected the hospice benefit on 12/27/2022. For the benefit periods dated 02/20/2024 to 04/19/2024, the POC, effective 02/06/2024 ordered SW services once a month. A review of the clinical record revealed no evidence of SW visits documented for February 2024. There was no evidence of documented missed visits or communication with the physician. During an interview on 05/29/2024, the Regional Vice President of Quality & Compliance confirmed the findings.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. 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 and interview. In 2 of 16 (12%) clinical records reviewed in which Hospice Aide services were accepted, the agency did not ensure that the Hospice Aide (HA) reported changes in the patient’s medical, nursing, rehabilitative, and/or social needs to the Registered Nurse (RN) as the changes related to the plan of care. Clinical Record 14: The patient elected the hospice benefit on 08/01/2022. The patient’s plan of care, effective 02/28/2024, for the benefit periods dated 01/23/2024 to 03/22/2024 and 03/23/2024 to 05/21/2024, ordered HA services three times weekly. The Hospice Aide Care Plan dated 03/06/2024 for the period dated 03/06/2024 to 05/05/2024, assigned the HA the relevant personal care tasks: complete bed bath, foot care, nail care (clean and file only), oral care, perineal care, and skin care. The HA visit note dated 03/25/2024 documented, “Pt refused care, stated will wait for regular CNA.” There was no documentation that the RN was notified that the care plan was not completed. Clinical Record 17: The patient elected the hospice benefit on 04/04/2023. The patient’s plan of care, effective 09/20/2023, for the benefit period dated 10/01/2023 to 11/29/2023, ordered HA services three times weekly. The Hospice Aide Care Plan dated 09/29/2023, effective for the period dated 10/01/2023 to 11/29/2023, assigned the HA the relevant personal care tasks: denture care, foot care, nail care (clean and file only), oral care, perineal care, shampoo once weekly, shave, shower, and skin care. The HA visit notes dated 11/01/2023, 11/03/2023, 11/10/2023, and 11/17/2023 documented, “Just focused on bottom of legs and feet,” and did not include documentation that the assigned tasks were completed. There was no documentation that the RN was notified that the care plan was not completed. During a joint clinical record review and interview, the Vice President of Quality & Compliance confirmed that the HA did not complete the assigned tasks or document any communication with the RN.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 4 of 16 (25%) clinical records reviewed in which Hospice Aide services were accepted, the agency did not ensure that the Registered Nurse (RN) documented supervision of the hospice aide at least every fourteen days. Clinical Record 2: The patient elected the hospice benefit on 01/29/2024. The patient’s plan of care, effective 03/20/2024 for the benefit period dated 03/29/2024 to 05/27/2024, ordered Hospice Aide (HA) services three times weekly. The Registered Nurse (RN) documented HA supervision on 04/09/2024. The RN visit notes dated 04/17/2024, 04/23/2024, 05/01/2024, 05/08/2024, and 05/15/2024 did not include documentation of HA supervision at least every fourteen days. Clinical Record 6: The patient elected the hospice benefit on 10/09/2023. The patient’s plans of care, effective 02/20/2024 and 04/03/2024, for the benefit periods, dated 02/06/2024 to 04/05/2024 and 04/06/2024 to 06/04/2024, respectively, ordered HA services three times weekly. The RN documented HA supervision on 04/04/2024. The RN visit notes dated 04/17/2024, 04/24/2024, 05/01/2024, 05/08/2024, and 05/15/2024 did not include documentation of HA supervision at least every fourteen days. Clinical Record 10: The patient elected the hospice benefit on 11/29/2023. The patient’s plan of care, effective 02/06/2024 for the benefit period dated 03/28/2024 to 05/26/2024, ordered HA services three times weekly. The RN documented HA supervision on 04/17/2024. The RN visit notes dated 04/24/2024, 05/01/2024, 05/08/2024, and 05/15/2024 did not include documentation of HA supervision at least every fourteen days. Clinical Record 16: The patient elected the hospice benefit on 7/14/2023. The patient’s plans of care, effective 10/04/2023 and 12/27/2023, for the benefit periods, dated 10/12/2023 to 01/09/2024 and 01/10/2024 to 03/09/2024, respectively, ordered HA services five times weekly. A review of the clinical record revealed no HA supervision documented by the RN for 12/22/2023 to 01/16/2024, with 25 days outstanding. During joint clinical record reviews and interviews on 05/28/2024 and 05/29/2024, the Regional Vice President (VP) of Quality and Compliance (VP of Quality) confirmed that the nurse performing the visits was documenting on paper versus the electronic medical record and had not correctly completed the HA supervision part of the form. On 05/31/2024, the remaining clinical records were jointly reviewed, and the VP of Quality confirmed that there were gaps in HA supervision of more than fourteen days.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and: maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #HR.10 “Staff Competency” (dated 10/01/20021) stated in part, “The Hospice will provide for competency assessment by qualified individuals on hire and annually to assess direct care staff’s basic skill levels for all staff providing care, including paraprofessionals and professionals... The competency evaluation and/or checklist will be completed and retained in the staff’s personnel file.” In 2 of 8 (25%) personnel records reviewed of individuals requiring assessment of clinical competencies, the agency did not ensure that a competency evaluation was completed for staff providing care per agency policy. Personnel Record 5: The Registered Nurse (RN) was hired on 04/05/2021. A review of the personnel record revealed no evidence of an annual competency evaluation or Hospice Nursing Competency Checklist for 2023. Personnel Record 9: The Hospice Aide (HA) was hired on 05/02/2022. A review of the personnel record revealed no evidence of an annual competency evaluation or Hospice Aide Skills Competency Checklist for 2023. During a joint personnel record review and interview on 05/31/2024, the Executive Director confirmed that the personnel records for #5 and #9 did not contain all the annual competencies required.”

“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. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients transferred to a Medicare/Medicaid certified facility, the hospice did not ensure that the discharge summary was sent to the receiving facility. Clinical Record 15: The patient elected the hospice benefit on 05/08/2024 and was discharged due to being admitted to a non-contracted facility to pursue aggressive treatment on 05/20/2024. A review of the clinical record revealed no documented evidence that a discharge summary was forwarded to the receiving facility. During a joint clinical record review and interview with the Vice President of Quality & Compliance on 05/30/2024, it was confirmed that there was no documentation in the clinical record that the discharge summary was sent to the receiving facility.”

“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 a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) clinical records reviewed of patients discharged from hospice services, the agency did not ensure that the discharge summary included the patient’s plan of care, physician orders, and a summary of hospice care provided. Clinical Record 15: The patient elected the hospice benefit on 05/08/2024 and was discharged to seek aggressive treatment at an inpatient facility on 05/20/2024. A review of the clinical record revealed that the patient’s discharge summary did not include the patient’s plan of care, physician orders, and a summary of hospice care provided. During a joint clinical record review and interview on 05/30/2024, the Vice President of Quality & Compliance confirmed that the patient’s discharge summary did not include the patient’s plan of care, physician orders, or summary of the patient’s hospice stay and symptom management.”