Angel Care Hospice LLC

“It is required that each patient’s individualized written plan of care 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. In 6 of 14 (43%) clinical records reviewed revealed the agency did not ensure that each patient’s individualized written Plan of Care included all identified problems and interventions based on the comprehensive and updated comprehensive assessments. Document 1: The hospice policy Medical Record Content (IM.30) dated 11/02/2022 included in part:”...Each medical record will contain, but not be limited to ... Initial and ongoing interdisciplinary plans of care including identification of problems, interventions, goals, and the patient’s response to the Plan of Care...” Agency policy Patient Assessments (PE.5) dated 01/31/2024 read in part that “...Updates to the comprehensive assessment will be accomplished by the IDG/IDT (Interdisciplinary Group/Team) ... to include, but not limited to ... Care, treatment ... to be provided ... Identified needs that ae not related to the terminal illness and related conditions should be documented that the IDT/IDT is aware of these needs and note who is addressing them ... The Hospice is responsible for including services and treatments in the POC (Plan of Care) that address how they will meet the patient ... needs ...” Agency policy Plan of Care Process (PC.30) dated 01/26/2026 included in part that “... All hospice care and services furnished to patients and their families will follow an individualized written POC (Plan of Care) established by the Hospice Interdisciplinary Group/Team (IDG/IDT) ....in accordance with the patient’s needs ...The POC must reflect patient and family goals and interventions based on problems identified in the ...comprehensive and updated comprehensive assessments... The updated of the comprehensive assessment will be accomplished by the Hospice IDG/IDT .... will include information on the patient’s progress toward desired outcomes, as well as a reassessment of the patient’s response to care... The POC includes ... Interventions to manage .... identified issues/problems...” Clinical Record 1: The patient elected the hospice benefit on 03/25/2021. There was a Physician’s Order dated 03/25/2021 for Metolazone 5mg daily by mouth and Lasix 20mg daily by mouth. On 01/12/2024, the registered nurse (RN) documented in part, “...no peripheral edema, she is optimally treated with diuretics...” Then, on 01/19/2024, the RN documented, “...Pt does not have any edema. Her heart failure is managed with two diuretics...” The RN documented on visit noted dated 02/02/2024: “...Pt has no edema as edema is controlled by her legs elevated daily and she is on diuretic therapy...” The patient’s Plan of Care (POC) had an identified problem documented as a “Deficit related to airway and breathing secondary to CHF and acute and chronic respiratory failure.” The interventions included the facility nurse administering Roxanol or Ativan for a respiratory rate above 24, educating the facility nurse on position and good pulmonary toilet for optimal lung expansion, and instructing facility staff on energy conservation. Another problem identified: “Patient requires numerous medications both on and off formulary to manage pain and uncomfortable symptoms - has psychotropic medication.” The interventions included the hospice RN conducting a medication review every two weeks, hospice providing all medications related to the patient’s terminal illness and comfort, medication adjustments being made based on patient need and physician, pharmacist, and RN’s clinical judgment, sulfa allergy, and the patient has comfort medication which has to be reviewed by hospice medical director at least every 14 days and ensure the medications remain medically necessary to treat uncomfortable symptoms: anti-depressant (Cymbalta, Trazodone) benzodiazepine (Lorazepam). The patient’s edema and need for diuretic therapy was not addressed in any identified problem or intervention on the patient’s POC. Clinical Record 2: The patient elected the hospice benefit on 12/01/2023. During the initial admission visit on 12/01/2023, the RN documented in part that the patient had a “Deep tissue injury to right (R) buttock 100% epithelial tissue covered. The wound care nurse at facility reported that she was showing it as closed...” The RN documented on 02/05/2024 in part was “Deep tissue injury to R buttock being treated with calcium alginate and island dressing.” During the Interdisciplinary Group Meeting (IDG) on 02/07/2024, the nurse reported that the patient had a deep tissue injury to the (R) buttocks, and a low air loss mattress was ordered and delivered. The patient’s POC had no identified problem related to the patient’s wound and no interventions regarding the wound dressing or any new DME ordered. Clinical Record 5: The patient elected the hospice benefit on 05/50/2022.The RN visit note dated 12/26/2023 stated, the patient “reported that she is having problems with itching on her arms...pt requested oral medication for itching...” A Physician’s Order was documented on 01/02/24 for Hydroxyzine 25mg by mouth daily for rash/itching. There was no documented problem or interventions for the identified problem of the patient’s itching. The nurse documented in a visit on 01/01/2024 that the patient “...reported that she is still having problems and must focus on swallowing at times ...” Then, on 02/02/2024, the RN noted, “...This morning she drank from a sippy cup and had a mild coughing episode after ...” On 02/12/2024, the RN noted, “...Today during RN visit she drank from a sippy cup and had a coughing episode afterward that lasted 3-4 minutes...” There was no identified problem or interventions documented for the patient’s observed and reported dysphagia. During a PRN visit by the RN on 02/07/2024, the nurse documented that “...Pt is sleeping and did not attempt to respond to verbal commands to tactile stimulation ...Pt has been on room air less than 10 minutes and resting O2 is only 85%...Pt has slight crackles to upper airway...MD notified awaiting response ...” A Physician Order was dated 02/07/2024 for Augmentin 500mg by mouth three times a day and a Medrol Dose Pak by mouth for five days for an upper respiratory tract infection. There was no identified problem or intervention for the patient’s upper respiratory infection. Clinical Record 8: The patient elected the hospice benefit on 09/14/2022. On 12/21/2023, the RN documented that “Pts (R) shoulder is swollen, red and warm to touch. Redness and swelling extend down onto the chest and scapula areas... F2F completed with doctor and Amoxicillin .... ordered.” A Physician Order was documented on 12/21/2023 for Amoxicillin 500mg by mouth twice a day for seven days for cellulitis. There was no problem or intervention identified related to infection or cellulitis. Clinical Record 12: The patient elected the hospice benefit on 08/29/2022 and died on hospice on 03/24/2023. There was a Physicians Order documented on 08/29/222 for Warfarin 5mg tab: one tablet by mouth three times a week (Monday/Wednesday/Friday) and ½ tablet by mouth (2.5mg) four times a week (Tuesday/Thursday/Saturday/Sunday (8/29/2022). The RN documented in the Interdisciplinary Group Meeting (IDG) on 01/25/2023 that the patient’s International Normalized ratio (INR) was 1.1, and this result was then called in by the patient’s daughter to the patient’s cardiologist. The nurse documented on 03/21/2023 that the patient’s INR level was high at 5.1, and the cardiac clinic was notified. Instructions were received to hold the dose that day and call back the next day. The patient’s POC included the identified problem of Cardiac/Circulatory function and fluid volume overload alteration due to Chronic Obstructive Pulmonary Disease (COPD) and heart disease. This problem included interventions for the hospice nurse to assess and monitor related discomfort such as shortness of breath, palpitations, angina, and edema and assess for the presence and grade of edema. Educate and instruct in the use of diuretics and cardiac drugs per physician order, instruct on signs of medication toxicity, encourage optimal activity with frequent rest periods, and instruct/educate on the patient’s diet and fluids per physician order. Another identified problem was that the patient requires numerous medications, both on and off formulary, to manage pain and uncomfortable symptoms. The interventions included providing medications via the patient’s pharmacy and the hospice RN conducting a comprehensive medication review to ensure needs are met every two weeks; medication adjustments will be made based on the patient’s needs and physician, pharmacist, and RN’s clinical judgment. The problem of polypharmacy was documented with one of the interventions related to Warfarin Sodium and for the hospice nurse to observe for bleeding. There were no interventions in the patient’s plan of care to address the monitoring of the INR levels, frequency of INR checks, or when to call the cardiology clinic. Clinical Record 13: The patient elected the hospice benefit on 05/20/2023. There were Physician Orders documented on 05/20/2023 for Duloxetine HCL 60mg by mouth twice a day for depression, Narcan 4mg/0.1 ml by nasal spray every three hours as needed for over-sedation, and Diphenhydramine HCL 25mg to 50mg by mouth at bedtime as needed for insomnia. Another physician order on 05/22/2023 entered for Trazodone HCL 50mg every night for insomnia. There were no identified problems and interventions for depression or insomnia, and no documentation as to the need for Narcan. During interviews and discussion with the Director of Nursing (DON) (Staff 2) and the Administrator (Staff 1) on 02/21/2024 and 02/22/2024, they confirmed that missing identified problems and interventions were not located in the clinical record.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the patient’s written Plan of Care (POC) included treatments necessary to meet the patient’s specific needs. Document 1: The agency policy Medical Record Content (IM.30) dated 11/02/2022 read in part that “...Documentation of care provided will include ...Clinical notes documenting ... all actions, interventions, and procedures provided by the Hospice, including... treatments and services, the responses to interventions ...Interdisciplinary Plans of care, including problems, interventions, goals, and progress toward goals... physician orders... care provided through contracted facility and services ...” Clinical Record 2: The patient elected the hospice benefit on 12/01/2023. During the admission visit dated 12/01/2023, the registered nurse (RN) documented in part that the patient had a “Deep tissue injury to right buttock 100% epithelial tissue covered. Wound Care nurse at facility reported that she was showing it as closed...” The RN documented on 02/05/2024 in part was “Deep tissue injury to R buttock being treated with calcium alginate and island dressing.” During the Interdisciplinary Group Meeting (IDG) on 02/07/2024, the nurse reported that the patient had a deep tissue injury to the right buttocks, and a low air loss mattress was ordered and delivered. There was no documented evidence on the POC for the wound care dressing or frequency of dressing changes. During interviews with the Director of Nursing (DON) and the Administrator on 02/22/2024 and joint review of the patient’s clinical record, it was confirmed that there were no orders for the patient’s wound care, dressing, or frequency of dressing changes.”

“It is required that a qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or a pseudo patient: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; and appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. And also evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation: observation, reporting, and documentation of patient status and the care or service provided; basic infection control procedures; basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; maintenance of a clean, safe, and healthy environment; recognizing emergencies and the knowledge of emergency procedures and their application; the physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; adequate nutrition and fluid intake; and any remaining task(s) that the hospice chooses to have an aide perform. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 1 (100%) Hospice Aide Competencies reviewed revealed the agency did not ensure that the Aide was assessed as competent in all tasks assigned. Document 1: The hospice policy Employee Supervision (HR.60) dated 10/01/2021 read in part that “...The Supervising Registered Nurse must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each Hospice Aide while he or she is performing care. The Supervising Registered Nurse must assess a Hospice Aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include but is not limited to ... demonstrating competency with assigned tasks.” Personnel Record 6: The Hospice Aide, with a hire date of 01/28/2015, was observed during Home Visit 3 on 02/21/2023 to assist the patient with feeding. The patient had begun to feed herself, but the Hospice Aide repositioned the patient several times and fed her the last half of her breakfast. The Hospice Aide Care Plan dated 12/01/2023 included assisting the patient with feeding when the Aide was present. However, the Hospice Aide Competency Skills list did not include feeding/feeding assistance of the patient by direct observation of the registered nurse (RN) 10/06/2023 or 12/08/2023. During an interview with the Administrator and the Director of Nursing on 2/22/2024, they confirmed that the task of feeding the patient was not included on the Hospice Aide’s Competency form. Discussion occurred regarding the potential risk related to the Aide feeding the patient without the proper competency testing documented. The DON felt that since the Hospice Aides have feeding a patient included in their Certified Nurse Aide curriculum, they did not require the Hospice to verify competency. Further discussion included that the Nurse Aide curriculum includes personal care, showers, peri-care, etc., yet the Hospice is still required to verify competency in these areas yearly.”

“It is required that hospice aides are 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 a registered nurse ) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 8 (12%) clinical records reviewed in which Hospice Aide services were accepted revealed the agency did not ensure that the RN provided written instruction for the Aide about the patient’s wound. Document 1: The agency policy Implementing Care and Treatment (PC.35) dated 04/04/2023 read in part “...The Hospice Aide (HA) will be provided with written instructions for patient care prepared by an RN...” Clinical Record 2: The patient elected the hospice benefit on 12/01/2023. The Plan of Care effective 12/01/2023 included orders for the Hospice Aide to visit the patient three times a week. The RN documented on 02/05/2024, in part, that the patient had a “Deep tissue injury to R buttock being treated with calcium alginate and island dressing.” Documentation in the Interdisciplinary Group Meeting (IDG) on 02/07/2024 that the patient had a deep tissue injury (DTI) to the right buttocks and a low air loss mattress was ordered and delivered. The active Hospice Aide Care Plan was dated 12/01/2023 and included in part a bed bath and peri-care. The Hospice Aide Visits documented on 02/05/2024, 02/07/2024, and 02/09/2024 did not include instructions from the RN to the Aide in case the wound dressing became wet or soiled. During an interview on 2/21/2023 with the Director of Nursing and the Administrator, they confirmed that the instructions for the wound were not provided to the Hospice Aide and agreed that the RN should include instructions for the Aide on what to do if the dressing became wet or soiled.”