Heart to Heart Hospice of Midlothian

“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. THIS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a drug profile that included all of the patient’s medications. Clinical Record 5: The patient elected hospice care on 10/24/2024 with a diagnosis of prostate cancer. The skilled nurse (SN) admission assessment dated 10/24/2024 documented that the patient was previously discharged from hospice related to hospital admission for shortness of breath. The SN assessment documented that the patient would receive oxygen and an oxygen concentrator in the home. The plan of care dated 10/24/2024 ordered: “to evaluate the patient’s understanding of oxygen safety, provide oxygen as needed, educate on the proper use of DME, and determine if DME is in proper working order,” and documented the patient’s goal: “patient will verbalize understanding related to oxygen safety.” The medication profile did not include oxygen. During an interview and a joint record review on 10/28/2024, the Regional Vice President for Clinical Operations stated, “We have been working hard but didn’t expect it to be perfect. We will keep working and get that oxygen documented appropriately now.””

“It is required that each patient’s individualized written plan of care include drugs and treatment necessary to meet the needs of the patient. THIS IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that the plan of care (POC) included all drugs and treatments necessary to meet the patient’s needs. Clinical Record 5: The patient elected hospice care on 10/24/2024 with a diagnosis of prostate cancer. The skilled nurse (SN) admission assessment dated 10/24/2024 documented that the patient was previously discharged from hospice related to hospital admission for shortness of breath. The SN assessment documented that the patient would receive oxygen and an oxygen concentrator in the home. The plan of care dated 10/24/2024 ordered: “to evaluate the patient’s understanding of oxygen safety, provide oxygen as needed, educate on the proper use of DME, and determine if DME is in proper working order,” and documented the patient’s goal: “patient will verbalize understanding related to oxygen safety.” The POC did not include documentation of the route, the frequency, or the rate of administration of oxygen. During an interview and a joint review of the clinical record on 10/28/2024, the Regional Vice President for Clinical Services stated, “You are right. We will get it documented right now.””

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record reviews, document reviews, and interviews with the Regional Vice President of Clinical Operations, which revealed the hospice: Failed to ensure all drugs and treatments necessary to meet the patient’s needs were included in the plan of care in 2 of 19 (11%) clinical records reviewed [HCPC.21.I/L549]; and Failed to ensure that problems identified in the comprehensive and updated comprehensive assessments were identified on the plan of care with associated planned interventions that reflected patient and family goals of care in 13 of 19 (68%) clinical records reviewed [HCPC.21.I/L545]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.”

“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; 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 measures 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. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a drug profile containing the patient’s medications. Clinical Record 13: The patient elected the hospice benefit on 06/17/2024. For the plan of care dated 06/17/2024 to 09/14/2024, the RN admission assessment dated 06/17/2024 documented, “uses a combination of O2 via NC and room air BiPAP 24/7 based on his symptoms ... O2 at 3.5 LPM via NC during the day with RA BiPAP when sleeping ... foley to gravity ... high risk for respiratory crisis/hypoventilation, infection, bleeding at lesion site, falls, and aspiration ..” The RN comprehensive assessment dated 07/08/2024 documented, “O2 at 3.5LPM via NC and is now wearing the BiPAP 20+ hr/day. Pt has a 10-15 min recovery time with any exertion ... Oxygen was not documented on the patient’s medication profile.”

“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, interview, and document review. Agency policy #TX.08 “Interdisciplinary Group Roles and Responsibilities” (revised 02/26/2021) stated in part, “The Agency will designate an IDG, who ... will work together to provide for the physical, medical, psychosocial, emotional, and spiritual needs of the terminally ill patient and/or family members as delineated in a patient-specific plan of care ... The IDG ... will prepare a written plan of care for each patient/family, which specifies the care and services necessary to meet the patient/family-specific needs identified in the comprehensive assessment ... A revised interdisciplinary POC will include information from the patient’s updated comprehensive assessment and will note the patient’s progress toward outcomes and goals specified in the POC...” Agency policy #TX.9 “Review and Revision of Patient Care’” (revised 08/01/2004)read in part that “... Agency will review and revise patient care in accordance with changes in the patient’s condition ... patient’s response to care; and changes that have occurred regarding diagnosis, treatment, medications, precautions, and limitations ...Upon identifying that patient care needs have changed ... adjustments to the care planning documents will be made ... Each change will be accompanied by specific interventions. All written changes to the plan of care will be incorporated into the patient’s medical record as changes occur...” In 13 of 19 (68%) clinical records reviewed, the agency did not ensure that problems identified in the comprehensive and updated comprehensive assessments were identified on the plan of care with associated planned interventions that reflected patient and family goals of care. Clinical Record 1: The patient elected the hospice benefit on 06/07/2024. The Registered Nurse (RN) comprehensive assessment dated 06/14/2024 documented, “The patient’s right eye is bright red, crusty, and partially closed due to swelling... I spoke with the physician..., and an order was received to start Gentamycin eye drops for seven days…Pt appears very itchy and scratches multiple areas frequently. During the visit, pt went to the bathroom to vomit. Pt says he has felt nauseous on and off for a few days. Pt says he took Zofran this morning. I told pt he could take one every 6 hours as needed for nausea ....” On 07/19/2024, the RN comprehensive assessment documented that “patient’s nausea was significant enough to affect the patient, and he experienced intermittent nausea and vomiting...” The RN recertification assessment dated 08/22/2024 documented, “Pt has intermittent N/V, dry, flaky skin, pruritus, and fatigue ...” And on 9/05/2024, on the RN Comprehensive Assessment, the RN noted that “...Pt said he did have some N/V yesterday and vomited about 3x - brown liquid. Pt states he takes Zofran for the nausea ... brother also noted the persistent itching ...” During the skilled nurse (SN) (as needed/pro re nata) PRN visit dated 09/14/2024, the SN documented, “PRN visit for N/V requested by caregiver. ... Pt described that he had been nauseous and vomiting over the last few days. Claimed that Pepto and Zofran were unsuccessful in relieving the symptoms....” On 06/14/2024, the physician ordered “Gentamycin ophthalmic eye drops, two (2) drops each eye, 5x a day for seven (7) days. On 06/09/2024, the physician ordered “Ondansetron (Zofran) 8mg disintegrating tablet every six (6) hours as needed for nausea. A review of the Interdisciplinary Group (IDG) Meetings dated 06/18/2024, 07/03/2024, 07/16/2024, 07/30/2024, 08/13/2024, 08/27/2024, and 09/10/2024 revealed documentation about the patient’s nausea and vomiting, and eye infection medication order. The plans of care dated 06/07/2024 through 09/04/2024 and 09/05/2024 through 12/03/2024 did not include documented interventions to address the patient’s problem with pruritus. The plans of care did not document patient/family goals based on the patient’s identified problem with nausea and vomiting, pruritus, and an eye infection. Clinical Record 2: The patient elected the hospice benefit on 11/30/2023. The SN focus visit assessment dated 08/26/2024 documented, “Pt is (alert and oriented) A & O to self only. Complaining of (C/O) left FA pain; pt looks to be pointing to where IV was located earlier, extensive ecchymosis noted to both upper extremities (BUE). R forehead is dressed with 4 x 4 gauze and tape, CDI. Left eye is swollen and purple ... “ On 08/28/2024, the RN comprehensive assessment documented a MAHC 10 fall risk score 10, and that patient was at risk for falling... The patient had a fall on Monday and has multiple gashes on her head above the right eye. She has three different gashes with two to four stitches in them. According to the facility, the patient fell the first time at the facility…. was transported to the emergency department, where she had another fall...” On 09/02/2024, the RN recert assessment documented, “Patient continues to have trace edema in both ankles. She does become hypoxic whenever she is attempting to transfer and when she attempts to reposition herself in bed, and she must also limit how many words she says in order to prevent shortness of breath. Patient does not at this time use oxygen and prefers not to. Her O2 sat is normally 92 on room air when sitting still. The patient is now completely unable to stand on her own, and every time she attempts to get out of bed, she falls. Patient is bed and chair bound ... “ The plan of care dated 07/27/2024 through 09/24/2024, updated 08/29/2024 and 09/12/2024 did not include documented interventions for the patient’s identified breathing issues. Additionally, the plan of care did not include documentation of patient/family goals for the patient’s identified problems with falls, breathing, and wounds. Clinical Record 4: The patient elected the hospice benefit on 05/24/2024. On 08/08/202, the RN visit note documented, “PRN visit with pt and spouse (do to) DT pt fall with injury ... patient fell this morning after getting out of bed to go to the bathroom... patient has skin tears x2 to right elbow, skin tear to right wrist, skin tear x2 to left hand, bruising to bilateral upper extremities, right eye, and right side of neck. Patient has deep laceration above right eyebrow. Patient is on Plavix. Patient is reporting pain to neck at a four. Reviewed options with patient and spouse, and due to patient’s complaint of neck pain and laceration above right eye needing stitches, new order received to send patient to (emergency room) ER per request by spouse for eval...” The RN visit note for the PRN visit on 08/08/2024 documented, “tuck-in visit following the patient returning from emergency department for stitches to a laceration above his right eye ...” On 08/08/2024, the physician ordered the wound to be “cleaned and re-bandaged every two (2) days by either the hospice RN or caregiver until stitches are ready to be removed… wound to be cleansed with wound care cleanser and then covered with a dry dressing. On 08/16/2024, the physician ordered the SN to remove the stitches on the patient’s left forehead. The plans of care dated 05/24/2024 through 08/21/2024 and 08/22/2024 through 11/192024 did not include documented interventions to address the patient’s need for bleeding precautions and documentation of patient/family goals for the wounds and bleeding potential. Clinical Record 6: The patient elected the hospice benefit on 06/14/2024. On 08/06/2024, the RN comprehensive assessment documented, “Adult day care nurse reports pt complaining of pain with urination... yellow discharge noted around penis area. Urine is dark, foul odor and sediment noted. Dr. ... notified and new order for antibiotic obtained ...” On 08/07/2024, the physician ordered “Omnicef 300mg by mouth twice (2) daily for seven (7) days for a urinary tract infection.” On 09/04/2024, the SN focus assessment visit note documented, “Pt lying in bed with eyes open upon nurse arrival. Pt seems alert x1 this AM but cg reports pt still not eating since Sunday. He is only drinking a few sips of water. Pt using O2 at 2LPM continuous. Pt bedbound x3 days now. He is incontinent .…bowel and bladder… sleeping 18+ hrs....” On 09/10/2024, the physician’s order discontinued Levothyroxine, Vitamin D2, and Ferrous Sulfate. The Interdisciplinary Group Meetings/Plan of Care updates dated 08/15/2024, 08/29/2024, and 09/12/2024 included SN notes related to the assessment of urinary tract infection, medication order, and change in the patient’s condition. The plans of care dated 06/14/2024 through 09/11/2024 and 09/12/2024 through 12/10/2024 did not include documented patient/family goals for the care provided for these problems. Clinical Record 8: The patient elected the hospice benefit on 07/31/2024. On 07/31/2024, the RN admission assessment documented, “He was dx with esophageal adenocarcinoma of the gastric junction at that time ... was found to have recurrent lesion in his right lung ... earlier this year he developed global weakness and focal vertigo and found to have brain mets ... at risk for falls, new onset seizures, headache, dysphagia ...” The POC did not document planned interventions and goals for the identified problems of fall risk, headaches, dysphagia, or new onset of seizures related to brain metastases. On 08/12/2024, the physician ordered “Restoril 15mg by mouth at bedtime for sleep.” On 08/172/2024, the physician ordered “On 08/17/2024, a physician’s order was noted for Duoneb nebulizer treatments every four hours as needed for wheezing. On 08/22/2024, the RN comprehensive assessment documented “Pt using breathing treatment 1x day due to wheezing. Pt reports breathing tx effective...” On 08/29/2024, the RN comprehensive assessment documented, “Pt reports not feeling well today. He reports having a low-grade temp this AM, 99.9, and having earache. After nurse assessment redness noted at right ear. Dr. ... notified and new order for antibiotics obtained ...” An order was documented on 08/29/2024 for Ceftin 500mg by mouth twice daily for seven days for mildly elevated temperature and ear pain for expected ear infection. On 09/12/2024, an order was entered to discontinue Restoril and to begin Trazodone 50mg by mouth at bedtime for sleep. For the plan of care dated 07/31/2024 through 10/07/2024, the Interdisciplinary Group Meetings/Plan of Care updates dated 08/13/2024, 08/27/2024, and 09/10/2024 documented the order for the antibiotic for an ear infection. The plan of care dated 07/31/2024 through 10/07/2024 did not include documented patient/family goals for the ear infection and the patient’s issues with sleep. DuoNeb was ordered in the plan of care updates, but there were no interventions and goals for the patient’s identified problem with breathing/respiratory. Clinical Record 9: The patient elected the hospice benefit on 08/19/2024. The RN admission assessment dated 08/19/2024 documented the patient’s diagnoses of senile degeneration of the brain, history of stroke, aphasia, dysphagia, and posed aspiration risk. Additionally, the RN documented, “She cannot lay on her side due to a bad surgery. Her ribs are not attached to her sternum. It is very painful for her to be on her side ... “ On 08/29/2024, the RN comprehensive assessment documented, “Pt on regular diet but per daughter (dtr), they will puree her meat only ... educated facility nurse regarding risks for aspiration .... educated caregiver pt needs to be turned but dtr stated she will not turn and it hurts her ... Dr. ordered Acetaminophen 325mg 2x daily scheduled for pain, pt unable to let need known at this point...” The RN visit note dated 09/06/2024 documented, “Pt has mild to moderate pain in her abdomen, cramping. Pt had Tylenol 325mg, helped, but Dr... ordered Tramadol 50mg Q6 HRS PRN....” The physician ordered “Acetaminophen 325mg by mouth twice daily for pain on 08/29/2024 and Tramadol 50mg every six hours by mouth as needed for pain on 09/06/2024. The Interdisciplinary Group Meetings/Plan of Care updates dated 08/29/2023 and 09/12/2024 included orders for pain medication and the patient’s risk for aspiration. The plan of care dated 08/19/2024 through 11/16/2024 did not include documented patient/family goals of care for the patient’s pain or risk of aspiration. Clinical Record 10: The patient elected the hospice benefit on 09/07/2023. The RN comprehensive assessment dated 07/16/2024 documented, “Pt having pain daily, takes Tramadol 100mg PRN, had no doses in last 24 hrs. Takes scheduled Tramadol 100mg ER 1x daily for pain ... Pt has hard time sleeping at night ... Dr... ordered Trazadone 50mg at bedtime ...” On 07/23/2024, the RN comprehensive assessment documented, “Pt will use oxygen as needed ... per pt, oxygen will drop to 90% on exertion ... Pt has trouble sleeping. Dr... started her on Melatonin 3mg at bedtime... discontinued Trazadone 50mg at bedtime ... “ On 08/28/2024, the RN comprehensive assessment documented the patient’s “saturation reading was 93% on 2.5 liters per minute of oxygen per nasal cannula... getting SOB on exertion ... pt has wheezing, inspiratory and expiratory on rt upper and lower bases ... she struggles with insomnia, taking Melatonin at bedtime routinely ... pt stated she will sleep all day when she is feeling fatigued and this is happening daily since she was diagnoses with pneumonia yesterday after chest x-ray revealed bilateral perihilar interstitial markings prominent, likely bronchitis or pneumonia ... Pt started on Doxycycline 100mg BID x 10 days ... “ The physician ordered Doxycycline 100mg by mouth twice daily for ten days on 08/28/2024. The Interdisciplinary Group Meetings/Plan of Care updates dated 07/18/2024, 08/01/2024, 08/15/2024, and 08/29/2024 included SN notes that described the patient’s oxygen use and medications for insomnia and pneumonia. The plan of care dated 07/03/2024 through 08/31/2024 did not include documented patient/family goals for the patient’s identified oxygen use, insomnia, and pneumonia. Clinical Record 12: The patient elected the hospice benefit on 05/03/2022. The RN comprehensive assessment dated 07/24/2024 documented, “Pt eating about 25% of her pureed diet. Pt pocketing food and coughing with meals. SN re-educated about aspiration precautions ...” On 08/28/2024, the RN recertification assessment documented, “She eats less than 25% ... The patient has begun to choke a lot on her food, and the patient’s caregiver is concerned about aspiration...” The Interdisciplinary Group Meetings/Plan of Care updates dated 07/30/2024, 08/13/2024, 08/27/2024, and 09/10/2024 included SN and physician’s notes describing the patient’s dysphagia and the need for a pureed diet. The plan of care dated 07/22/2024 through 09/19/2024 did not include documented patient/family goals for the dysphagia. Clinical Record 13: The patient elected the hospice benefit on 06/17/2024. The RN admission assessment dated 06/17/2024 documented, “uses a combination of O2 via NC and room air BiPAP 24/7 based on his symptoms ... O2 at 3.5 LPM via NC during the day with RA BiPAP when sleeping ... foley to gravity ... high risk for respiratory crisis/hypoventilation, infection, bleeding at lesion site, falls, and aspiration ..” The RN comprehensive assessment dated 07/08/2024 documented, “O2 at 3.5LPM via NC and is now wearing the BiPAP 20+ hr/day. Pt has a 10-15 min recovery time with any exertion ... Foley last changed on 6/14/24...” On 08/12/2024, the RN comprehensive assessment documented, “Patient reports right upper chest pain with productive cough and white sputum, postnasal drainage and sore throat that started on Saturday. He stated he found Augmentin 875mg in the cabinet and started taking it Saturday PM, has one tablet left, requesting more antibiotics... new order for Augmentin 875mg one PO BID x8 days to equal 10 days total of antibiotic.” The physician ordered “Augmentin 875mg by mouth twice daily for eight days for respiratory infection on 08/12/2024. The Interdisciplinary Group Meetings/Plan of Care updated on 06/20/2024, 07/03/2024, 07/18/2024, 08/01/2024, 08/15/2024, 08/29/2024, and 09/12/2024 included SN notes describing the use of oxygen and BiPAP for the patient’s breathing issues. The plan of care dated 06/17/2024 through 09/14/2024 did not include documented interventions or patient/family goals of care for the patient’s breathing issues, respiratory infection, and the patient’s Foley catheter. Clinical Record 14: The patient elected the hospice benefit on 03/11/2024. On 08/26/2024, the SN documented, “Caregiver reports that patient is having very strong smelling dark amber urine and is more confused. I will notify Dr....” The physician ordered “Macrobid 100mg by mouth twice daily for a urinary tract infection on 08/26/2024. The RN PRN visit note dated 09/11/2024 documented, “Caregiver reported that patient was sent to (hospital) for SOB and seizures.... Patient was treated with antibiotics and fluids...patient was sent home because she is already on hospice ...” The Interdisciplinary Group Meetings/Plan of Care updated on 07/03/2024, 07/18/2024, 08/01/2024, 08/15/2024, 08/29/2024, and 09/12/2024 included SN notes that identified the patient’s urinary tract infection and the order for the antibiotic was included. The plans of care dated 06/09/2024 through 09/06/2024 and 09/07/2024 through 11/15/2024 did not include documentation of patient/family goals of care for the urinary tract infection. The plan of care did not include documented interventions and patient/family goals for the patient’s new onset of shortness of breath and seizure activity. Clinical Record 15: The patient elected the hospice benefit on 12/13/2024 and revoked hospice services on 07/03/2024. The RN comprehensive assessment dated 06/28/2024 documented, “Observed odorous urine. Pt shook head yes when asked if it burned during urination ... Dr... ordered Macrobid...” On 06/28/2024, the physician ordered, “Macrobid 100mg by mouth twice daily for seven days for a urinary tract infection.” The Interdisciplinary Group Meetings/Plan of Care updated on 07/03/2024 included the SN notes describing the patient’s urinary tract infection (UTI) symptoms and the antibiotic order. The plan of care dated 06/10/2024 through 08/08/2024 did not include documented goals of care identified by the patient/family for the UTI. Clinical Record 17: The patient elected the hospice benefit on 12/13/2023. On 06/04/2024, the RN comprehensive assessment documented that the patient was having difficulty swallowing, was on a pureed diet, and required thickened liquids. The physician’s Certification of Terminal Illness for the benefit period 06/10/2024 through 08/08/2024 documented a diagnosis of “cerebral infarction with comorbidities, dysphagia, severe protein-calorie malnutrition, and anxiety. Patient has dysphagia related to her CVA and is on pureed diet and honey-thickened liquids...” The Interdisciplinary Group Meetings/Plan of Care updated on 06/18/2024, 07/03/2024, 07/16/2024, 07/30/2024, and 08/13/2024 included SN visit notes describing the patient’s dysphagia and aspiration risk and the physician’s note about the patient requiring a pureed diet and honey-thickened liquids. The plans of care dated 03/12/2024 through 06/09/2024 and 06/10/2024 through 08/08/2024 did not include documented patient/family goals of care for the patient’s dysphagia and aspiration risk. Clinical Record 19: The patient elected the hospice benefit on 07/02/2024 and died on hospice services on 08/04/2024. On 07/02/2024, the RN admission assessment documented that the patient had been diagnosed with “malignant neoplasm of the breast with mets to ribs, shoulder, and pelvis, hx pleural effusions with PleurX drain in place right thorax ..gait unsteady at times due to guarding related to right shoulder pain ... c/o intermittent right scapular, rib, and pelvic pain that is managed with Norco 5/325 PO 1-2X D; abdomen round, firm ... “ and was experiencing daily aching and shooting pain in her hips, ribs, and right shoulder, which affected her appetite, mobility, and sleep. Additionally, the RN assessment documented the patient experienced dyspnea on exertion, and the nurse auscultated absent lower right breath sounds and noted a PleurX drain to the patient’s right thorax with a dry and intact dressing. The patient experienced chronic pleural effusions that required bi-weekly draining of fluid via the PleurX drain. The RN PRN Visit note dated 07/08/2024 documented, “A PRN visit was made to remove the fluid from the lung...The patient stated that she was feeling some pressure and needed her pleural drain drained. 400ccs of liquid were removed ... “ On 08/01/2024, the Licensed Vocational Nurse (LVN) PRN visit note documented, “patient was in bed resting with eyes open. A & O x3. VS WNL ... breath sounds CTA but diminished in upper fields and absent over right lateral base. Abdomen round, firm, and non-tender ... Dtr stated patient on Sunday hit her back on the table. She stated that she notified on call and they ordered x-ray of back and L flank. CXR has yet to be done. Pt c/o pain in the abdomen, stating that it feels like there is a knot in there. Dtr reports no BM for 3+ days. Suppositories unsuccessful... Dtr gave pt 0.25ml morphine prior to my arrival ...” On 07/31/2024, the physician ordered, “Albuterol Sulfate 0.63mg/3ml solution by nebulizer every four hours as needed for shortness of breath.” On 08/01/2024, the physician ordered, “Miralax 17mg/dose by mouth daily for constipation.” On 08/02/2024, the physician ordered, “Fentanyl 25mcg/hr transdermal patch every 72 hours for pain.” The Interdisciplinary Group Meetings/Plan of Care updates dated 07/03/2024, 07/16/2024, 07/30/2024, and 08/13/2024 included the orders for pain medication, and the SN notes describing the patient’s PleurX drain. The plan of care dated 07/02/2024 through 09/29/2024 did not include documented interventions or patient/family goals for the PleurX dressings and drainage, and there were no identified patient/family goals for the treatment of the patient’s pain. During a joint record review and interview on 09/19/2024, the Regional Vice President of Clinical Operations confirmed the findings and stated that some charts had been updated after reviewing the evidence at the end-of-day meetings during the previous days.”

“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, interview, and document review. Agency policy #TX.6 “Plan of Care Process” (dated 01/01/2020) stated in part, “The POC includes ... interventions to manage pain and symptoms and identified issues/problems ... drugs and treatments necessary to meet the needs of the patient, medical supplies, equipment and appliances necessary to meet the needs of the patient ...” In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included all drugs and treatments. Clinical Record 13: The patient elected the hospice benefit on 06/17/2024. For the plan of care dated 06/17/2024 through 09/14/2024, the Registered Nurse (RN) admission assessment dated 06/17/2024 documented, “He also has an extensive history of obstructive sleep apnea (OSA) and associated CO2 retention ... uses a combination of oxygen (O2) via nasal cannula (NC) and room air bilevel positive airway pressure (BiPAP) 24/7 based on his symptoms ... has tubal grip wraps in place over both legs from midcalf to arch, and these are changed every 2 weeks to manage lymphedema ... O2 at 3.5 liters per minute (LPM) via NC during the day with RA BiPAP when sleeping ... foley to gravity ... high risk for respiratory crisis/hypoventilation, infection, bleeding at the lesion site, falls, and aspiration ..” On 07/08/2024, the RN documented, “O2 at 3.5LPM via NC and is now wearing the BiPAP 20+ hr/day... Foley last changed on 06/14/2024...” The RN comprehensive assessment dated 08/05/2024 documented, “Foley last changed on 07/26/2024...” A review of the clinical record revealed the plan of care dated 06/17/2024 through 09/14/2024 did not include documentation of the care and maintenance of the Foley catheter, including the size of the Foley catheter, the balloon size, or the frequency of how often the Foley should be changed, the oxygen, the BiPap, settings, or when/how long the BiPap should be worn and the patient’s lymphedema dressings, the type, or how often the dressings should be changed. Clinical Record 19: The patient elected the hospice benefit on 07/02/2024 and died on hospice services on 08/04/2024. On 07/02/2024, the RN admission assessment documented that the patient had been diagnosed with “malignant neoplasm of the breast with metastasis to ribs, shoulder, and pelvis, hx pleural effusions with PleurX drain in place right thorax ..gait unsteady at times due to guarding related to right shoulder pain ... c/o intermittent right scapular, rib, and pelvic pain that is managed with Norco 5/325 PO 1-2X D; abdomen round, firm ... “ and was experiencing daily aching and shooting pain in her hips, ribs, and right shoulder, which affected her appetite, mobility, and sleep. Additionally, the RN assessment documented the patient experienced dyspnea on exertion, and the nurse auscultated absent lower right breath sounds and noted a PleurX drain to the patient’s right thorax with a dry and intact dressing. The patient experienced chronic pleural effusions that required bi-weekly draining of fluid via the PleurX drain. The RN PRN Visit note dated 07/08/2024 documented, “A PRN visit was made to remove the fluid from the lung...The patient stated that she was feeling some pressure and needed her pleural drain drained. 400ccs of liquid were removed ... “ The plan of care dated 07/02/2024 through 09/29/2024 did not include documentation of orders for the PleurX drain, the dressing, the amount of fluid to be drained, or the drainage frequency. During a joint clinical record review and interview on 09/19/2024, the Regional Vice President of Clinical Operations confirmed the absence of orders noted for clinical records 13 and 19.”