Three Oaks Hospice

“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; [and] 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, document review, and interview. Agency policy #PC.85 “Medication List and Monitoring” (dated 10/01/2021) stated in part, “Changes in the medication regimen will be documented in the medical record either on the medication profile, on a verbal order...will be updated... to reflect changes in the medication regimen...” In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s drug profile was updated when new medication was ordered. Clinical Record 1: The patient elected the hospice benefit on 02/05/2024. The patient resided in an adult living facility (ALF). The Registered Nurse (RN) visit note dated 04/03/2024 documented “Facility c/o increase confusion and pt c/o back pain along with burning when urinating. MD notified. Orders received.” On 04/09/2024, the RN documented, “Antibiotic (ABT) for urinary tract infection (UTI)..” On 04/10/2024, the Licensed Vocation Nurse (LVN) documented, “pt just completed abt for UTI...” The Interdisciplinary Group Meeting on 04/09/2024 documented that patient had “Increase confusion, back pain, and c/o of burning when urinating. Pt currently being treated for UTI...” A review of the clinical record and the hospice medication profile for active and discontinued medications revealed no antibiotic documented for this time period. Clinical Record 8: The patient elected the hospice benefit on 02/22/2024. The patient resided in an ALF. On 04/05/2024, the RN documented, “New order written for antifungal cream for a yeast infection under the patient’s breasts.” A review of the clinical record and the hospice medication profile for active and discontinued medications revealed no antifungal cream documented. During a joint record review and interview on 06/07/2024, the Regional Vice President of Quality and Compliance confirmed that there was no physician order for the antibiotic or antifungal cream, which were not listed in the patients’ medication profiles.”

“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, document review, and interview. Agency policy # PE.5 “Patient Assessments” (dated 01/31/2024) stated in part, “Updates to the comprehensive assessment will be accomplished by the IDG/IDT to include, but not be limited to...reassessing a patient’s needs when there is a significant health status change in the patient’s condition...Information from the updated comprehensive assessment will be used by the IDG/IDT to update the patient/family POC...” In 5 of 19 (26%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected patient and family goals and planned interventions based on problems identified in the comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 02/05/2024. The patient resided in an adult living facility (ALF). The Registered Nurse (RN) visit note dated 04/03/2024 documented, “Facility c/o increase confusion and pt c/o back pain along with burning when urinating. MD notified. Orders received.” On 04/09/2024, the RN documented, “Antibiotic (ABT) for urinary tract infection (UTI)..” On 04/10/2024, the Licensed Vocation Nurse (LVN) documented, “pt just completed abt for UTI...” The Interdisciplinary Group Meeting on 04/09/2024 documented that the patient had “Increase confusion, back pain, and c/o of burning when urinating. Pt currently being treated for UTI...” The plan of care dated 02/05/2024 for the benefit period 02/05/2024 to 05/04/2024 did not document interventions and goals for the identified problem of urinary tract infection. Clinical Record 8: The patient elected the hospice benefit on 02/22/2024. The patient resided in an ALF. On 04/05/2024, the Registered Nurse (RN) documented, “New order written for antifungal cream for a yeast infection under the patient’s breasts.” On 05/10/2024 the RN documented, “Patient must be given Dulcolax suppository (supp) to have BM approximately 1x weekly per family request …” Additionally, on 04/18/2024 the physician ordered: “Bisacodyl 10mg suppository -insert one suppository rectally every 7 days if no bowel movement.” The plan of care dated 02/22/2024 for the benefit period dated 02/22/2024 to 05/21/2024 and the plan of care dated 05/08/2024 for the benefit period dated 05/22/2024 to 08/19/2024 did not document interventions and goals for the identified problems of skin rash/infection and constipation. Clinical Record 9: The patient elected the hospice benefit on 05/01/2024. On 05/10/2024, the Licensed Vocational Nurse (LVN) documented, “left heel noted with eschar, cleansed and applied foam dressing, no drainage. right heel cover with dressing for protection, intact. dressing noted to abdomen, daughter (dtr) states it was a blister caused by pressure from external cath. removed dressing and area intact with no ss of infection. sacrum noted with minimal excoriation but no drainage, foam dressing applied ...pt complains of (co) dysuria and also had urgency during visit...Dr. notified and received orders for Cipro 500 bid x5 days.” The RN visit note dated 05/15/2024 documented “Pt continued (cont) ABT for UTI.” On 05/24/2024, the RN assessment documented “pt a/o x1 with increased confusion noted. pt complained of frequent urination, burning when urinating. MD made aware. New orders received...” Physician orders were documented on 05/10/2024 and 05/24/2024 for “Cipro 500mg by mouth twice daily” for a urinary tract infection. The plan of care did not document interventions and goals for the identified problems of urinary tract infection and wound. Clinical Record 14: The patient elected the hospice benefit on 01/26/2023. The patient resided in an ALF. The comprehensive assessment completed by the RN on 05/01/2024 documented, “Pressure ulcer to left heel - skin intact. Site cleansed with wound cleanser and pat dry, medi-honey applied and bandage covering....” On 05/08/2024, the physician ordered a debridement ointment to the heel “three times a week with dressing changes.” On 05/15/2024, the nurse documented “Staff report that the left foot is more purple than normal with red spots. On assessment, the foot is more purple and cold, but no red spots noted....Site cleansed with wound cleanser, pat dry, compound debridement ointment and dry dressing applied...” The plan of care dated 02/26/2024 for the benefit period dated 03/13/2024 to 05/11/2024 and the plan of care dated 05/08/2024 for the benefit period 05/12/2024 to 07/10/2024 did not document interventions and goals for the identified problems of wounds and skin integrity. Clinical Record 17: The patient elected the hospice benefit on 03/30/2023. The plan of care dated 03/30/2024 ordered Social Worker services once a month. The Social Worker phone call note dated 04/27/2023 documented “LMSW notified by hospice office that daughter (dtr) is seeking resources for possible placement for patient. LMSW spoke with dtr...discussed SNF/PCH/AL. Dtr reports that patient’s spouse may go with patient, but unsure at this point. LMSW provided referrals for facilities...” The coordination of care note dated 05/02/2023 documented “Due to caregiver fatigue from patient decline in condition, family requesting respite. Patient will go to respite on 05/03/2023..” The Social Worker visit note dated 05/11/2023 documented, “SW visit to home to assess patient emotional state and provide emotional support to patient and family as patient prepares to move to PCH tomorrow. SW to assist with coordination of move and education to family. SW to assess family expectations...” The plan of care did not document interventions and goals for the identified problems relating to the family’s seeking placement for the patient due to caregiver fatigue and patient decline. During joint clinical record reviews and interviews on 06/05/2024, 06/06/2024, and 06/07/2024, the Regional Vice President of Quality & Compliance confirmed the lack of a plan of care updates.”

“It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. The hospice administrator: has the education and experience as required by the governing body. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #HR.65 “Agency Inservices” (dated 09/01/2023), read in part, “The Administrator and Alternate Administrator must complete 12 clock hours of continuing education within each 12 month period...Documentation of Administrator and Alternate Administrator continuing education must be on file as the hospice and contain the name of the class or workshop, the topics covered, and the hours and dates of the training...” State hospice administrative code stated in part “An administrator and alternate administrator must complete 12 clock hours of continuing education within each 12-month period beginning with the date of designation. The 12 clock hours of continuing education must include at least two of the following topics and may include other topics related to the duties of an administrator: information on the licensing standards for an agency, information on the state and federal laws applicable to an agency...” In 1 of 2 (50%) personnel records reviewed of the Administrator and Alternate Administrator, the agency did not ensure that the Administrator had the annual state-required continuing education hours. Personnel Record 2: The Executive Director/Administrator was hired on 02/28/2022. A review of the personnel record revealed no documented evidence of the annual state-required twelve (12) continuing education hours for 2023. During a joint personnel record review and interview on 06/07/2024, the Executive Director/Administrator (ED) and the Regional Vice President of Quality & Compliance confirmed that the personnel record did not contain documentation of the 2023 state-required Administrator continuing education hours (CEUs). The ED stated that the CEUs were obtained but the documentation lost.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and: maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. Agency policy #HR.10 “Staff Competency” (dated 10/01/20021) stated in part, “The Hospice will provide for competency assessment by qualified individuals on hire and annually to assess direct care staff’s basic skill levels for all staff providing care, including paraprofessionals and professionals... The competency evaluation and/or checklist will be completed and retained in the staff’s personnel file ..” In 2 of 8 (25%) personnel records reviewed of individuals providing patient care and services, the agency did not ensure that on hire and annually skills competency was assessed and documented in the personnel record per agency policy. Personnel Record 3: The Director of Clinical Services/Registered Nurse (RN) was hired on 11/27/2023. A personnel record review revealed no documented “Registered Nurse Competency Checklist” or competency evaluation completed at hire per agency policy. Personnel Record 12: The Volunteer was hired on 11/10/2022. A review of the personnel record revealed a “Volunteer Competency Checklist” completed and signed on 11/11/2022. There was no documented evidence of an annual competency evaluation or checklist for 2023 per agency policy. During a joint personnel record review and interview on 06/07/2024, the Regional Director of Quality & Compliance confirmed that the competencies for Personnel Record 3 and Personnel Record 12 could not be located.”

“If a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review of a patient discharged for extended prognosis, the discharge summary was not forwarded to the patient’s attending physician. Clinical Record 15: The patient elected the hospice benefit on 02/06/2024 and was discharged on 03/19/2024 for an extended prognosis. There was no evidence that the discharge summary was forwarded to the attending physician. During a joint clinical record review and interview on 06/07/2024, the Regional Director of Quality & Compliance confirmed the finding.”

“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 a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of discharged patients, the agency did not ensure that the discharge summary included a summary of the patient’s hospice stay, current plan of care, and latest physician orders. Clinical Record 15: The patient elected the hospice benefit on 02/06/2024 and was discharged on 03/19/2024 for an extended prognosis. The discharge summary documented did not contain a summary of the patient’s hospice stay, the plan of care, or physician orders. Clinical Record 16: The patient elected the hospice benefit on 03/20/2024 and revoked the hospice benefit on 04/11/2024. The discharge summary documented did not contain a summary of the patient’s hospice stay, the plan of care, or physician orders. During a joint clinical record review and interview on 06/07/2024, the Regional Director of Quality & Compliance confirmed the finding.”