Ameriprime Hospice LLC

“It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed revealed that the agency did not ensure the written plans of care (POC) included measurable outcomes. Clinical Record 1: The patient elected hospice benefit on 8/12/2023 with a diagnosis of Alzheimer’s disease. The recertification comprehensive assessment by the Registered Nurse (RN) dated 11/2/2023, documented “ target pain goal using PAINAD was noted as 4.” The POC dated 8/12/2023 to current, documented the following relevant goals: “Problem: Pain. Goal: The patient will achieve and maintain optimal physical comfort. Patient pain will be managed at a level identified as acceptable by the patient.” The plan of care did not include measurable outcomes or descriptions of acceptable pain levels for the patient. Additionally, the POC included the following: “Problem: Quality of Life. Goal: Patient to enjoy the best quality of life” without further description or definition of how this goal would be measured. Clinical Record 2: The patient elected hospice benefit on 4/18/2023 with a diagnosis of malignant neoplasm of the prostate. An interdisciplinary team (IDT) nursing note dated 10/3/2023 stated: “Patient can still walk with the use of his walker for support but gait is slow and very unsteady related to his weakness and low endurance”. The POC dated 10/15/2023 to current, had an identified problem of increased weakness with a goal of “patient will maintain optimal mobility, as expected for normal disease process.” The goal did not include any additional statements to clarify how this would be measured. Clinical Record 6: The patient elected hospice benefit on 10/26/2023 with a diagnosis of senile degeneration of the brain. The initial comprehensive assessment by the RN dated 10/26/2023 stated the patient’s target pain goal was 5 out of 10. The POC dated 10/26/2023 to current, had the following relevant goals; “Problem; Pain Goal: Patient will achieve and maintain optimal physical comfort. Patient pain will be managed at a level identified as acceptable by the patient.” Additionally, the plan of care included the following: “Problem: Global needs. Goal: Assess and address patient’s global needs.” There was no documented evidence on the POC for specific parameters to clarify how this would be measured. Clinical Record 8: The patient elected hospice benefit on 8/30/2023 with a diagnosis of senile degeneration of the brain. The recertification comprehensive assessment by the Registered Nurse (RN) dated 10/13/2023, stated, “shows difficulty swallowing food and fluids, taste of food changing. Patient and family feel not eating or drinking enough.” The POC dated 8/30/2023 to current, documented the following relevant goals: “Problem: Nutrition Goal: The patient will maintain an adequate nutritional status as evidenced by adequate nutrition as desired by patient.” The goal did not include any additional statements to clarify how this would be measured. A joint review of the clinical records and interviews were conducted on 11/29/2023 and 11/30/2023 with the Administrator/Director of Nursing and the Quality Nurse. The Administrator/Director of Nursing agreed that the plans of care needed to include specific measurable goals for each patient.”

“It is required that written patient care instructions for a hospice aide are prepared by a Registered Nurse (RN) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, in which aide services were accepted, revealed that the agency did not ensure the aide care plans contained written instructions specific to the care of the patient. Clinical Record 1: The patient elected hospice benefit on 8/12/2023 with a diagnosis of Alzheimer’s Disease. The RN initial comprehensive assessment dated 8/12/2023 identified that the patient had a peripheral intravenous catheter (IV) in the right forearm. The aide care plan included relevant tasks of bed bath five days per week and dressing the patient. There was no documented evidence of specific instructions on the aide care plan dated 8/12/2023 informing the aide that the patient had an IV present nor provide instructions on whether to cover the IV during bathing. Clinical Record 4: The patient elected hospice benefit on 8/30/2023 with a diagnosis of Senile Degeneration of the Brain. The RN initial comprehensive assessment dated 8/30/2023 identified that the patient had a Stage IV wound on the sacrum covered with bordered gauze. The aide care plan dated 8/30/2023 had the following relevant tasks: bed bath three times weekly and dressing patient every visit. There was no documented evidence on the aide care plan that the aide had been informed that the patient had a wound on the sacrum or any specific instructions for the aide to protect the wound dressing during bathing. Clinical Record 11: The patient elected hospice benefit on 10/6/2023 with a diagnosis of malignant neoplasm of the upper lobe, left bronchus, and a secondary diagnosis of colon cancer. The patient had a colostomy. The aide care plan dated 10/6/2023 had the following relevant tasks: shower three times weekly, assist with dressing every visit, check for bowel movement, and notify RN if no bowel movement in greater than 3 days. There was no documented evidence on the aide care plan that the aide was informed that the patient had a colostomy or specific instructions for the care of the skin around the colostomy. Clinical Record 13: The patient elected hospice benefit on 7/8/2023 with a diagnosis of Alzheimer’s Disease. The RN initial comprehensive assessment dated 7/8/2023 identified a wound on the left heel. The hospice aide services were added on 8/15/2023 with a care plan that included the relevant tasks of bed bath on Tuesdays and Thursdays, showers on Mondays, Wednesdays, and Fridays, and dressing the patient every visit. There was no documented evidence on the aide care plan informing the aide that the patient had a wound on the left heel which was dressed with an island dressing and no specific instructions on whether to cover the dressing during bathing. During a joint clinical record review and interview with the Administrator/Director of Nursing and the Quality Nurse, on 11/30/23, it was agreed that the aide care plans did not contain specific instructions to the aide for the IV, wounds, or colostomy. The Quality Nurse stated that the aides would call or text the nurse if “something happened to a dressing, so they didn’t realize they had to put them (wounds) on the care plans.””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum, clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 14 (29%) clinical records reviewed revealed that the agency did not ensure the clinical notes were entered into the clinical record in accordance with agency policy. Agency policy IM.10 Timelines (last revised 8/1/2015) stated in relevant parts, “F. All clinical and progress notes will be written the day service is rendered. G. Daily progress notes are turned in twice a week.” The policy further stated, “III. All medical record information will be incorporated into the patient’s medical record within fourteen (14) business days of providing service.” Clinical Record 1: The POC dated 8/12/2023 to 11/9/2023 and 11/10/2023 to 2/7/2024 identified the order for skilled nurse (SN) frequency was one visit per week. There was no documented evidence of SN visit notes for the week of 10/29/2023, 11/5/2023, and 11/12/2023. Clinical Record 2: The POC dated 10/15/2023 identified the order for SN frequency was one nursing visit per week. There was no documented evidence of SN visit notes for the week of 11/5/2023 and 11/12/2023. Clinical Record 4: The POC dated 8/30/2023-11/27/2023 identified the order for SN frequency was one nursing visit per week. There was no documented evidence of SN visit note for the week of 10/29/2023 and 11/5/2023. Clinical Record 6: The POC dated 10/26/2023 identified the order for SN frequency was one nursing visit per week. There was no documented evidence of SN visit note for the week 10/29/2023, 11/5/2023, and 11/12/2023. On 11/28/2023 an interview was conducted with the Administrator/DON who reported that all visits had been made but some were documented on paper and the nurses would be contacted immediately to submit the visit documentation. On 11/29/23 an interview and review of the agency policy regarding documentation and the above clinical records was performed with the Administrator/Director of Nursing who confirmed the staff was documenting on paper but not uploading into EMR (electronic medical record) within 14 days per policy. During the record review on 11/29/23, all of the above nursing visit documentation was present in the clinical records.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure the clinical record contained a physician order to discontinue medication. Clinical Record 1: The patient elected hospice benefit on 8/12/2023 with a diagnosis of Alzheimer’s Disease. A physician’s order dated 8/24/2023 stated: “May start IV (intravenous fluid), D5 1/2 NS at 75 cc hr. continuously. Discontinue previous dose and frequency,” During the home visit at the SNF with the RN, Staff 4, on 11/29/2023, the patient was not observed to have an IV in place. There was no documented evidence in the clinical record of a physician order discontinuing the IV. A joint clinical record review with the Administrator/Director of Nursing on 11/30/2023 confirmed that the last order regarding the IV was from 8/24/2023 with the instructions for the continuous IV and they were unable to locate the order for discontinuation of the IV.”

“It is required that hospice care of the patient/resident in a SNF/NF has a hospice plan of care which identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed, in which a patient resided in a skilled nursing facility (SNF) revealed that the agency did not ensure the plan of care included a delineation of responsibilities between the hospice agency and the facility. Clinical Record 1: The patient elected the hospice benefit on 8/12/2023. The Registered Nurse (RN) initial comprehensive assessment dated 8/12/2023 identified that the patient resided in a SNF and was being admitted to hospice with a terminal diagnosis of Alzheimer’s Disease. The hospice plan of care, dated 8/12/2023 to current, stated “facility staff medication aide may administer medications.” There was no documented evidence that the plan of care specified which provider was responsible for performing the other functions that were included in the plan of care. A joint clinical record review was conducted with the Administrator/Director of Nursing (Staff 2) on 11/30/2023 during which it was confirmed there was no further delineation of responsibilities in the plan of care within the electronic medical record nor did the agency utilize any other paperwork to meet this requirement.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: The most recent hospice plan of care. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) home visit observations at a Skilled Nursing Facility (SNF) revealed that the agency did not ensure the designated IDG member provided the SNF/NF with the most recent plan of care. Home Visit 3: The patient elected hospice benefit on 8/12/2023 for a terminal diagnosis of Alzheimer’s Disease. The clinical record/hospice binder was reviewed during the home visit observation with Staff 4 conducted at the SNF on 11/29/2023 and did not contain evidence that the most recent plan of care had been provided. The hospice nurse (Staff 4) who was present for the home visit was asked about this process and stated, “We haven’t brought those here, we only fax the medication orders.” An interview with the Administrator/Director of Nursing was conducted on 11/29/2023 during which the Administrator/Director of Nursing advised he was aware they “needed to fax orders to the facility” but kept the other items in a chart in the hospice office.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: Hospice election form and any advance directives. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) home visit observations at a Skilled Nursing Facility (SNF) revealed that the agency did not ensure the designated IDG member provided the SNF/NF with the hospice election form and any advance directives. Home Visit 3: The patient elected hospice benefit on 8/12/2023 for a terminal diagnosis of Alzheimer’s Disease. The clinical record/hospice binder was reviewed during the home visit observation with Staff 4 conducted at the SNF on 11/29/2023 and did not contain evidence that the election of benefits or any advance directives had been provided. The hospice nurse (Staff 4) who was present for the home visit was asked about this process and stated, “We haven’t brought those here, we only fax the medication orders.” An interview with the Administrator/Director of Nursing, Staff 2, was conducted on 11/29/2023 during which acknowledged he was aware they “needed to fax orders to the facility” but kept the other items in a chart in the hospice office.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: Physician certification and recertification of the terminal illness. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) home visit observations at a skilled nursing facility (SNF) revealed that the agency did not ensure the designated IDG member provided the SNF/NF with the physician certification/recertification of the terminal illness. Home Visit 3: The patient elected hospice benefit on 8/12/2023 for a terminal diagnosis of Alzheimer’s Disease. The clinical record/hospice binder was reviewed during the home visit observation with Staff 4 conducted at the SNF on 11/29/2023 and did not contain evidence that the certification of terminal illness had been provided. The hospice nurse, Staff 4, who was present for the home visit was asked about this process and stated, “We haven’t brought those here, we only fax the medication orders.” An interview with the Administrator/Director of Nursing, Staff 2, was conducted on 11/29/2023 during which acknowledged he was aware they “needed to fax orders to the facility” but kept the other items in a chart in the hospice office.”