Holding Hands Hospice

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure that the initial comprehensive assessment, including the social work assessment, was completed no later than five calendar days after the election of hospice care. Clinical Record 1: The date of the election was 11/22/2023. The clinical record lacked evidence that a psychosocial assessment occurred in the first five days or at any point throughout the course of care. Clinical Record 2: The date of the election was 03/07/2024. The clinical record lacked evidence that a psychosocial assessment occurred in the first five days or at any point throughout the course of care. Clinical Record 3: The date of the election was 04/11/2023. The clinical record lacked evidence that a psychosocial assessment occurred in the first five days. The date of the Social Worker Assessment was 04/27/2023 (16 days late). Clinical Record 8: The date of the election was 07/15/2023. The clinical record lacked evidence that a psychosocial assessment occurred in the first five days or at any point throughout the course of care. Clinical Record 9: The date of the election was 04/05/2024. The clinical record lacked evidence that a psychosocial assessment occurred in the first five days or at any point throughout the course of care. During a joint clinical record review and interview on 07/03/2024, the Director of Nursing confirmed that the initial comprehensive assessment, including the psychosocial assessment, was not completed no later than five days after the election of 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) drugs, supplements, 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, interview, and observation. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. Home Visit 2: The date of the election was 06/04/2024. The last comprehensive nursing assessment was 07/01/2024. The Medication Profile was printed on 07/01/2024. During the Home Visit (Home Visit 2) on 07/02/2024 with the Registered Nurse (RN) (Personnel Record 6), the medications were reviewed with the Alternate Director of Nurses (Personnel Record 12) and the facility medication aide. The facility medications revealed Refresh tears, give one drop to both eyes three times a day, dispensed on 05/08/2024. The medication aide stated that the patient had been on this for “a while.” The hospice agency most recent comprehensive assessment dated 07/01/2024 did not include the medication reconciliation as the Refresh tears was not included on the hospice medication profile. Home Visit 3: The date of the election was 05/21/2024. The last comprehensive nursing assessment was 06/27/2024. The Medication Profile was printed on 07/01/2024. During the Home Visit(Home Visit 3) on 07/02/2024 with the Chaplain(CH) (Personnel Record 8), the medications were reviewed with the Alternate Director of Nurses (Personnel Record 12) and the facility nurse. The facility medications revealed Primidone 50mg po twice daily, dispensed on 06/02/2024, initially ordered on 05/17/2028 per facility records. The last comprehensive assessment dated 06/27/2024 did not include a medication reconciliation as the Primidone was not on the hospice agency medication profile. During a joint record review and interview on 07/02/2024, the Director of Nursing confirmed that there was no documented evidence the medications were reconciled at the time of each comprehensive assessment and updated to the drug 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 and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient’s date of election was 11/22/2023. The primary hospice diagnosis was chronic systolic heart failure. The initial nursing assessment dated 11/22/2023 documented 3+ edema to both lower extremities (BLE), weeping in both legs and incontinence of bowel and bladder. The comprehensive assessment dated 02/15/2024 documented 3+ edema in the BLE and incontinence in the bowel and bladder. The comprehensive assessment dated 04/10/2024 documented 4+ edema to the BLE, weeping to both legs, incontinence of bowel and bladder, pain to the back at times but refuses medications, and weight loss of 4 pounds. The comprehensive assessment dated 06/05/2024 documented 3+ edema to the BLE, weeping to both legs and incontinence of bowel and bladder. The plans of care effective 11/22/2023, 02/15/2024, 04/10/2024, and 06/05/2024 did not include problems, goals, and interventions for edema, the risk for skin breakdown, pain, and weight loss. Clinical Record 2: The patient’s date of election was 03/07/2024. The primary hospice diagnosis was moderate protein-calorie malnutrition. The initial nursing assessment dated 03/07/2024 documented the inability to walk, needs assistance with transfers, and very weak. The plan of care effective 03/07/2024 did not include problems, goals, and interventions for the risk for falls. Clinical Record 7: The patient’s date of election was 05/21/2024. The primary hospice diagnosis was metabolic encephalopathy with comorbidities of Diabetes Mellitus type 2 and paraplegia. The initial nursing assessment dated 05/21/2024 documented total dependence with activities of daily living, amputation of the left big toe, and neuropathy and numbness to both lower extremities. The medication record reviewed on 07/03/2024 revealed Glyburide 2.5mg po daily, Metformin 500mg po daily, and a Glucagon Kit 1mg intramuscularly as needed. The plan of care effective 05/21/2024 did not include problems, goals, and interventions for hyperglycemia, hypoglycemia, and falls. During a joint clinical record review and interview on 07/03/2024, the Director of Nursing confirmed that there was no documented evidence the plans of care were individualized to include planned interventions and goals based on the problems identified.”