A Bliss Hospice Care

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: Prescription and over-the-counter (OTC); Herbal remedies; 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 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 and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure medication profile contained the patient’s current prescription and over the counter drugs. CONTINUING PRIOR REQUIRED ACTION. Clinical Record 2: The patient elected the hospice benefit on 01/26/2024 with a terminal diagnosis of CVA. On 02/27/2024, the registered nurse (RN) assessment included that the patient had diarrhea. An order for Imodium 4mg po 2 tablets then 1 tab po loose stool was received. The medication profile was on updated on 02/27/2024 and updated 03/06/2024 did not include Imodium tablets. During a joint clinical record review on 10/16/24, the Director of Nursing confirmed the patient’s medication profile was not updated to include Imodium. CONTINUING PRIOR REQUIRED ACTION.”

“It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; Consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical record reviewed with aide services provided, the agency did not ensure the hospice aide provided services as ordered by the Interdisciplinary Group and included in the plan of care. CONTINUING PRIOR REQUIRED ACTION. Clinical Record 2: The patient elected the hospice benefit on 01/26/2024 with a terminal diagnosis of CVA. The hospice aide plan of care dated 01/26/2024 included an order for the aide to provide complete bedbath, shampoo hair and shave patient on Monday Wednesday and Friday. The aide documented on Tuesday 04/30/24 and 05/02/2024 that patient had a complete bedbath, shampoo and shave on both days. The DON was interviewed during a joint record review on 10/16/2024 and confirmed that the aide did not follow the aide plan of care. CONTINUING PRIOR REQUIRED ACTION.”

“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 1 of 2 (50%) clinical record reviewed with aide services provided, the agency did not ensure the hospice aide reported notified the RN of changes in the patient needs or the plan of care. CONTINUING PRIOR RIQUIRED ACTION. Clinical Record 2: The patient elected the hospice benefit on 01/26/2024 with a terminal diagnosis of CVA. The hospice aide plan of care dated 01/26/2024 included an order for the aide to provide complete bedbath, shampoo hair and shave patient on Monday Wednesday and Friday. The aide documented on Tuesday 04/30/24 and 05/02/2024 that patient had a complete bedbath, shampoo and shave on both days. There is no documented evidence that the RN was notified of additional tasks completed. The DON was interviewed during a joint record review on 10/16/2024 and confirmed that the aide did not inform the RN of the additional tasks completed on nonscheduled days. CONTINUING PRIOR RIQUIRED ACTION.”

“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; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical record reviewed of a transferred patient revealed that the agency did not ensure that the receiving Medicare/Medicaid/Medical Certified facility was provided a copy of a discharge summary. Clinical Record 3: The patient’s election of benefit was dated 03/08/2024 with a diagnosis of Alzheimer’s Disease. The patient transferred to a hospital to seek aggressive treatment. The clinical record did not contain a discharge summary and did not contain any documentation related to sending a discharge summary to the receiving Hospital. The DON was interviewed during a joint clinical record review on 10/16/2024 and confirmed that a discharge summary was not completed and not forwarded to the receiving hospital.”

“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 the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management; The patient’s current plan of care; The patient’s latest physician orders; Any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical record reviewed of a discharged patient revealed the clinical record did not contain a discharge summary. Clinical Record 3: The patient’s election of benefit was dated 03/08/2024 with a diagnosis of Alzheimer’s Disease. The patient transferred to a hospital to seek aggressive treatment. The discharge from hospice date was 04/16/2024. There was no documented evidence in the clinical record that a discharge summary with all the required elements was completed or sent to the receiving facility. The DON was interviewed during a joint record review on 10/16/2024 and confirmed that a discharge summary was not completed.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two(2) years. This standard was not met as evidenced by document review and interview. A review of the emergency preparedness binder indicated the agency did not ensure the emergency preparedness plan was updated at least every two years. The last date of any update to the EP plan was in 2020. An interview with the Administrator was conducted on 12/21/2023 regarding the emergency plan (EP) for the hospice. The administrator stated she “thought it was good since nothing changed.” A review of the emergency preparedness binder indicated the agency did not ensure the emergency preparedness plan was updated.”

“It is required that the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. This standard was not met as evidenced by document review and interview. A review of the emergency preparedness binder and plan indicated the agency did not ensure participation in a community-based exercise. A joint review of the emergency preparedness binder and plan was conducted with the Administrator on 12/21/2023. The binder did not include evidence of participation in a community-based exercise. The Administrator stated they had not participated in one because they were a “small hospice and didn’t know who to contact or that they needed to do one.” A review of the emergency preparedness binder and plan indicated the agency did not ensure participation in a community-based exercise.”

“It is required that the written Patient Bill of Rights includes the right to receive information about the services covered under the hospice benefit. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed in which the patient elected to receive the notice of non-covered items addendum; the agency did not ensure the patient was provided with the information. Clinical Record 5: The patient elected the hospice benefit on 08/25/2023 with a terminal diagnosis of malignant neoplasm of the lung. The consent indicated the patient/representative elected to receive the non-covered items form. The non-covered items form in the patient’s chart was blank except for a signature and did not include a list of non-covered items. Clinical Record 9: The patient elected the hospice benefit on 12/22/2021 with a terminal diagnosis of Alzheimer’s disease. The consent indicated the patient/representative elected to receive the non-covered items form. The non-covered items form in the patient’s chart was blank except for a signature and did not include a list of non-covered items. Clinical Record 13: The patient elected the hospice benefit on 12/22/2021 with a terminal diagnosis of congestive heart failure. The consent indicated the patient/representative elected to receive the non-covered items form. The non-covered items form in the patient’s chart was blank except for a signature and did not include a list of non-covered items. Clinical Record 14: The patient elected the hospice benefit on 11/15/2021 with a terminal diagnosis of congestive heart failure. The consent indicated the patient/representative elected to receive the non-covered items form. The non-covered items form in the patient’s chart was blank except for a signature and did not include a list of non-covered items. A joint clinical record review and interview was conducted with the Director of Nursing (DON) on 12/19/2023. The DON confirmed the forms were blank but stated, “If we explained it to them, we thought that would be enough.””

“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, other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the medication profile contained the patient’s current prescription and over-the-counter drugs. Clinical Record 5: The patient elected the hospice benefit on 08/25/2023 with a terminal diagnosis of malignant neoplasm of the lung. Initial nursing assessment dated 08/25/2023 included documentation “patient taking Advil 200 mg and Tylenol 500 mg q 4-6 hours with good effects.” The medication profile dated 08/25/2023 did not include Advil. During a joint clinical record review and interview on 12/19/2023, the Director of Nursing confirmed the patient’s medication profile did not include Advil.”

“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 8 of 14 (57%) clinical records reviewed, the agency did not ensure the individualized plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 3: The patient elected the hospice benefit on 09/15/2023 with a terminal diagnosis of malignant neoplasm of colon. The plan of care (POC) dated 09/15/2023 to 10/23/2023 included the problem/goal “Problem: Altered comfort. Goal: Abdominal pains generalized.” The goal on the POC did not include how “abdominal pains generalized” would be measured. Clinical Record 4: The patient elected the hospice benefit on 09/27/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. The POC dated 09/27/2023 to 10/07/2023 included the problem/goal “Problem: Respiratory. Goal: Patient will have increased level of respiratory comfort.” The POC did not include how an increased level of respiratory comfort would be measured. Clinical Record 5: The patient elected the hospice benefit on 08/25/2023 with a terminal diagnosis of malignant neoplasm of the lung. The POC dated 08/25/2023 to 09/10/2023 included the problem/goal “Problem: Respiratory. Goal: Patient will have increased level of respiratory comfort. Problem: Muscle weakness. Goal: Patient will have optimal muscle strength for mobility.” The POC did not include how increased level of respiratory comfort and optimal muscle strength for mobility would be measured. Clinical Record 6: The patient elected the hospice benefit on 01/12/2023 with a terminal diagnosis of chronic kidney disease. The POC dated 01/12/2023 included the problem/goal “Problem: Respiratory. Goal: Patient will have increased level of respiratory comfort.” The POC did not include how an increased level of respiratory comfort would be measured. Clinical Record 7: The patient elected the hospice benefit on 09/29/2022 with a terminal diagnosis of Alzheimer’s disease. The POC dated 09/24/2022 to 12/22/2022 included the problem/goal “Problem: Respiratory. Goal: Patient will have increased level of respiratory comfort.” The POC did not include how an increased level of respiratory comfort would be measured. Clinical Record 9: The patient elected the hospice benefit on 12/22/2021 with a terminal diagnosis of Alzheimer’s disease. The POC dated 12/22/2021 to 02/06/2022 included the problem/goal “Problem: Impaired cognitive thinking. Goal: Patient will have optimal level of cognitive functioning and alertness.” The POC did not include how the optimal level of cognitive functioning would be measured. Clinical Record 10: The patient elected the hospice benefit on 06/06/2022 with a terminal diagnosis of end stage heart disease. The POC dated 06/16/2022 to 1/31/2023 included the problem/goal “Problem: Fall Risk. Goal: Maintain the highest possible level of mobility.” The POC did not include how the highest level of mobility would be measured. Clinical Record 14: The patient elected the hospice benefit on 11/15/2021 with a terminal diagnosis of congestive heart failure. The POC dated 12/28/2021 to 04/10/2022 included the problem/goal “Problem: Impaired physical mobility. Goal: Patient will maintain maximum mobility.” The POC did not include how the maximum level of mobility would be measured. During a joint clinical record review and interview on 12/19/2023, the Director of Nursing confirmed the goals on the plans of care were not measurable.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure the patient’s individualized plan of care was updated with condition changes. Clinical Record 7: The patient elected the hospice benefit on 09/24/2022 with a terminal diagnosis of Alzheimer’s disease. The skilled nurse (SN) documented on the SN visit note dated 12/13/2022 “will discuss discharge planning at IDT (Interdisciplinary team meeting) tomorrow as patient seems not to be anymore terminally ill.” Review of the plan of care (POC) revealed it was not updated at the 12/14/2022 IDT meeting to reflect discharge planning or goals. The patient was discharged for extended prognosis on 12/22/2022. Clinical Record 8: The patient elected the hospice benefit on 07/12/2022 with a terminal diagnosis of Alzheimer’s disease. Clinical record review revealed an as-needed (PRN) skilled nursing visit was completed on 07/15/2023 due to the patient experiencing a fall. A PRN visit was completed on 07/19/2023 due to the patient “sleeping after giving morphine.” The nurse documented the patient began having severe pain and needed to utilize the morphine. A PRN visit was completed on 07/20/2022 for the patient “sleeping after severe pain/Morphine.” The nurse noted “The patient is declining physically and mentally. No food/fluid for 48 hours. Spoke to family about end of life.” The plan of care (POC) dated 07/12/2022 included the problem/goal “Problem: Altered Comfort. Goal: Help alleviate the pain by encouraging the patient to change position while in bed or sitting and take pain medication as needed.” The POC was not updated with the patient’s condition changes. Clinical Record 10: The patient elected the hospice benefit on 06/06/2022 with a terminal diagnosis of end stage heart disease. The patient was discharged live for extended prognosis on 01/31/2023. The POC continued to list “continue the same goals” on all active problems and was not updated to reflect the patient’s discharge planning. During a joint clinical record review and interview on 12/19/2023, the Director of Nursing confirmed the plans of care had not been updated when the patients’ condition had changed.”

“It is required that performance improvement activities track adverse patient events, analyze the causes and implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by clinical record review, document review, and interview. A review of quality meeting minutes revealed the agency did not include tracking of adverse patient events nor analyze causes and implement preventive actions. Clinical Record 11: The patient elected the hospice benefit on 09/29/2023 with a terminal diagnosis of chronic myeloproliferative disease. The patient was prescribed antibiotics for a urinary tract infection on 10/27/2023. The agency’s quality data and meeting minutes included no documented evidence that this adverse event was tracked in the agency’s quality program. Clinical Record 12: The patient elected the hospice benefit on 08/31/2022 with a terminal diagnosis of cerebral infarction. Clinical record review indicated the patient had multiple falls on 07/15/2023. The falls were not tracked or reported in the agency’s quality program. During a joint clinical record review and interview on 12/21/2023, the Director of Nursing stated they should have entered infection and incident reports for the antibiotics and the falls but she “forgot to put it in.” A review of quality minutes revealed the agency did not include tracking of adverse patient events nor analyze causes or implement preventive actions.”

“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, per the plan of care, and under the direction of a physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed with medical social services provided, the agency did not ensure visits were provided as ordered in the plan of care. Clinical Record 11: Patient elected the hospice benefit on 09/29/2023 with a terminal diagnosis of chronic myeloproliferative disease. The plan of care dated 09/29/2023 included an order for Social Work (SW) visits one time per month. The initial Social Work evaluation visit was dated 10/02/2023 and included documentation that stated “patient interested in physical therapy and an outside backyard ramp. SW will look into this for the patient.” Clinical record review revealed no documented evidence a SW visit was provided in November 2023. During a joint clinical record review and interview on 12/20/2023, the Director of Nursing confirmed there was not a documented visit for the month of November 2023.”

“It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed with spiritual counseling services provided, the agency did not ensure that spiritual counseling services were provided as ordered in the plan of care. Clinical Record 12: The patient elected the hospice benefit on 08/31/2022 with a terminal diagnosis of cerebral infarction. The plan of care dated 08/31/2022 included an order for Spiritual Counselor (SC) visits one time per month. The SC documented a visit on 09/02/2022 but the clinical record contained no documented evidence of SC visits for October and November 2022. Clinical Record 13: The patient elected the hospice benefit on 12/22/2021 with a terminal diagnosis of congestive heart failure. The plan of care dated 12/22/2021 included an order for SC visits one time per month. The SC documented a visit on 12/14/2021 but the clinical record contained no documented evidence of SC visits for January and February 2021. Clinical Record 14: The patient elected the hospice benefit on 11/15/2021 with a terminal diagnosis of congestive heart failure. The plan of care dated 11/15/2021 included an order for SC visits one time per month. The SC documented a visit on 11/16/2021 but the clinical record contained no documented evidence of SC visits for January, February, and March 2022. During a joint clinical record review and interview on 12/19/2023, the Administrator who is also the Spiritual Counselor confirmed the visit notes were not included in the clinical record.”

“It is required that a hospice aide provide services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed with aide services provided, the agency did not ensure the aide provided services as ordered in the plan of care. Clinical Record 6: The patient elected the hospice benefit on 01/12/2023 with a terminal diagnosis of chronic kidney disease. The aide care plan dated 01/12/2023 assigned the aide frequency of visits three times a week and the task of “change linens once weekly.” Review of the aide visit notes for visits provided three times a week form 01/12/2023 to 04/12/2023 revealed the aide documented linen change completed at each visit indicating the patient’s linens were changed three times a week instead of weekly as assigned. A joint clinical record review and interview on 12/19/2023, the Director of Nursing confirmed the task was marked as being completed three times weekly instead of the assigned once per week.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) of home visit observation revealed the agency did not ensure that volunteer services were used in direct patient care roles. Home Visit 1: During the home visit observation, the patient stated he/she was “lonely and appreciated having company come over.” The patient was asked if he/she had received information about volunteer services. The patient stated he/she was not aware of those services but would “really enjoy the extra company.” During an interview and review of the agency’s volunteer program on 12/20/2023, the Administrator provided the volunteer hours for review. Review of the volunteer hours revealed all volunteer hours listed were for administrative tasks. Site Visitor mentioned the patient from home visit 1 would like to request a volunteer. The administrator replied, “We only have a volunteer that works in the office, so we mark the patients as declined right now.” During a telephone interview with the Volunteer Coordinator on 12/21/2023, the Volunteer Coordinator stated it had been challenging to recruit volunteers and that they currently do not have any volunteers willing to do patient visits, but they continue to try and recruit.”

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. This standard was not met as evidenced by interview and personnel record review. In 5 of 7 (71%) personnel records reviewed, the agency did not ensure initial orientation included the employee’s job specific duties. Personnel Record 2: Spiritual Counselor date of hire 01/01/2011. The personnel record contained no documented evidence that the employee was oriented to job-specific duties. Personnel Record 3: Director of Nursing/Registered Nurse date of hire 01/01/2011. The personnel record contained no documented evidence that the employee was oriented to job-specific duties. Personnel Record 4: Registered Nurse date of hire 11/07/2019. The personnel record contained no documented evidence that the employee was oriented to job-specific duties. Personnel Record 6: Hospice Aide date of hire 09/09/2022. The personnel record contained no documented evidence that the employee was oriented to job-specific duties. Personnel Record 7: Volunteer Coordinator date of hire 11/18/2015. The personnel record contained no documented evidence that the employee was oriented to job-specific duties. During a joint record review and interview on 12/20/2023, the Director of Nursing confirmed staff had been oriented to general items but not been given job-specific orientation.”

“It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by personnel record review and interview. In 1 of 7 (14%) personnel records reviewed, the agency did not ensure background checks were completed for employees with direct patient contact and access to patient records. Personnel Record 6: Hospice Aide date of hire 09/09/2022. Personnel record review revealed no documented evidence that a background check was completed for this direct patient contact employee. During an interview with the Administrator on 12/20/2023, the Administrator stated, “I didn’t do a background check on her.””