Three Oaks Hospice

“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. In 3 of 19 (16%) clinical records reviewed revealed that the agency did not ensure that the patient’s written Plan of Care included specific identified interventions based upon updated assessment data. Document 1: The agency policy “Plan of Care Process” (PC.30) dated 10/2/2022 included in part that “...the Plan of Care includes, but is not limited to, interventions to manage ... identified issues/problems ...” The hospice policy Medical Record Content (IM.30) dated 10/2/2022 included in part that “The Hospice will initiate and maintain an individual and accurate medical record ..for each patient....Each medical record will contain ...identification of problems, interventions, goals ...Documentation of care provided will include ..Interdisciplinary Plans of Care, including problems, interventions, goals... “ Clinical Record 3: The patient elected the hospice benefit on 11/7/2023. During the visit by the RN on 1/12/2024, it was noted in part that the “Medical Director contacted. Patient’s urine is cloudy, foul smelling, dark. He has increased urgency ... ordered Bactrim DS for 10 days. A physician’s order was documented on 1/12/2024 for Bactrim DS (800/160mg) by mouth twice a day for 10 days. The patient’s Plan of Care was not updated with planned interventions based on the newly identified problem of a urinary tract infection (UTI). During the next Interdisciplinary Meeting (IDT) on 1/25/2024, the information about the patient’s treatment for a UTI with an antibiotic was not included. Clinical Record 4: The patient elected the hospice benefit on 8/5/2022. The physician’s recertification of terminal illness for the benefit period of 11/28/2023 to 1/26/2024 included in part that the patient was experiencing “...frequency falls (related to seizures) ... patient continues with multiple seizures, approximately 3-4 per day ....” The recertification for the benefit period of 1/27/2024 to 3/26/2024 again included in part that the patient was having “...intractable seizures, multiple seizures, 3-4 per day despite adjustments to his antiseizure medication...” The patient’s medication list included Topiramate 100mg: 2 tablets by mouth twice a day (11/30/2023), Phenobarbital 100mg: 2 tablets by mouth daily (1/24/2024), and Briviact 100mg by mouth twice a day (1/24/2024). The patient’s Plan of Care did not include any planned interventions based on the identified problem of increasing seizure activity or seizure precautions. Clinical Record 5: The patient elected the hospice benefit on 4/26/2023. The RN Assessment documented on 1/22/24 noted that the patient’s oxygen saturation was 96% while receiving 2 liters per minute of oxygen per nasal cannula and that oxygen usage was continuous. Also documented was a pressure wound to the left lower extremity plantar surface that measured 2 x 1 x 0.1 and was to be kept clean. The nurse also noted that the facility was applying Silvadene cream with dressing wound care daily. Documented during the Interdisciplinary Meeting (IDT) on 1/11/2024 in part was that “Patient/Caregiver POC change requests: Skin tear to left lower extremity is healing appropriately, decreasing in size, closed and scabbed. ....” IDT: RNCM reported that the patient developed a ST to the LLE. ST has scabbed over, and the caregivers are applying TAO daily and leaving it open to air...” Then noted during IDT on 1/25/2024 in part “Patient/Caregiver POC change requests: “...Pt sustained a pressure wound to the left plantar surface. No signs/symptoms of infection have been observed and the wound appears to be healing appropriately...” A physician’s order was documented on 1/26/2024 for normal saline to be used as needed for wound care. The only care plan intervention in the RN notes for the visits dated 01/22/2024 and 01/29/2024 included, “ PCG/SN/FSN will perform wound care as ordered by MD and document wound status ...” The RN noted on 1/29/2024 that the “wounds and bruising have healed ...” However, during Home Visit 1 on 1/31/2024, the left foot was wrapped with Kerlix gauze. There were no specific planned interventions documented in the patient’s Plan of Care to address the wound care dressing in the nurse notes included in the patient’s plan of care. It was confirmed during an interview and joint clinical record review with the Clinical Director (Staff 2) on 2/1/2024 that the clinical records did not include specific interventions based upon the assessment data documented.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and 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, document review and interview. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that the patient’s written Plan of Care included all medications and treatments needed for the care of the patient. Document 1: The hospice’s policy “Plan of Care Process” (PC.30) dated 10/2/2022 included in part that “... The Plan of Care includes, but is not limited to, interventions to manage ... identified issues/problems ...drugs and treatments necessary to meet the needs of the patient, medical supplies ... necessary to meet the needs of the patient...” Clinical Record 5: The patient elected the hospice benefit on 04/26/2023 with a diagnosis of senile degeneration of brain. The registered nurse (RN) Assessment documented dated 01/22/24 noted that the patient had a pressure wound to the left lower extremity plantar surface that measured 2 x 1 x 0.1 and was to be kept clean. The nurse also noted th at the facility was applying Silvadene cream with daily wound care dressing changes. A review of the Interdisciplinary Meeting (IDT) dated 01/11/2024: Patient/Caregiver POC change requests: “ Skin tear to left lower extremity (LLE) is healing appropriately, decreasing in size, closed and scabbed. ....” The IDT RNCM reported that the patient developed a skin tear to the LLE. Skin Tear has scabbed over, and the caregivers are applying triple antibiotic ointment (TAO) daily and leaving it open to air...” The IDT on 01/25/2024 included in part, “Patient/Caregiver POC change requests: ...Pt sustained a pressure wound to the left plantar surface. No signs/symptoms of infection have been observed and the wound appears to be healing appropriately...” A physician’s order dated 01/26/2024 for “normal saline to be used as needed for wound care.” There were no orders for antibiotic ointment, Silvadene cream, or wound care dressings, and the frequency of dressing changes. Silvadene and antibiotic ointment were not included in the patient’s medication profile nor in the IDT Meetings on 01/22/2024 or 01/25/2024 during the time when the nurse mentioned these treatments in her notes. Wound dressings/changes were also not included in the IDT meetings or noted in any care plan intervention. It was confirmed during an interview and joint record review with the Director of Clinical Services (Personnel Record 2) on 02/02/2024 that the clinical record did not contain the medications noted in the nurse’s assessment in the patient’s medication list.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review and observation. In 1 of 4 (25%) home visits observed revealed that the agency did not ensure accepted infection control standards were performed. Document 1: The agency policy “Hand Hygiene” (IC.15) dated 12/15/2022 included in part “Hand Hygiene with an Alcohol-based Hand Rub ...Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Personnel Record may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations...After contact with body fluids or excretions ...Before moving from a contaminated body site to a clean body site during patient care...After contact with blood, body fluids, or contaminated surfaces...” The hospice policy “Cleaning and Management of Supplies and Equipment” (IC.20) dated 10/1/2021 included in part that “...Information regarding disinfecting/cleaning in a home care environment can be found in section 11 in the link below. However, other sections may also apply. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html .” From the provided referenced link in the policy at https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html included in part “...Clean noncritical items that would not be shared between patients (e.g., crutches, blood pressure cuffs) in the home setting with a detergent or commercial household disinfectant...” Home Visit 1: The patient elected the hospice benefit on 4/26/2023 with a diagnosis of senile degeneration of brain. During observation of the Hospice Aide (Personnel Record 6) for Clinical Record #5 on 01/31/2024, the Hospice Aide removed the patient’s soiled brief with gloved hands. Without sanitizing hands or changing gloves, the Aide went from the bathroom to the patient’s room to pick up some wipes, returned to the bathroom where she placed the wipes down, and then grabbed the patient’s toothbrush and toothpaste and provided oral care to the patient. After the patient was showered, the Aide wheeled the shower chair into the room next to the patient’s bed, where she proceeded to change the patient’s bed linens. During this time, the patient urinated on the floor; with the help of facility personnel, the Aide moved the patient to her bed, where peri care was provided. The Aide cleaned the patient, and stool was evident on the wipes. No trash can was nearby, so the Aide placed the soiled wipes onto the shower chair. The wipes fell from the shower chair to the floor. When patient care was completed, the Aide picked up the wipes, placed them in the bathroom trash, and then changed her gloves. After the patient was positioned in her bed, the Aide took the peri/bath wipes and cleaned the area where the patient had urinated on the floor. The Aide did not use any disinfectant, nor was the area where the stool-soiled wipes had fallen on the floor cleaned/disinfected.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. 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, document review, interview, and observation. In 2 of 15 (13%) clinical records reviewed in which Hospice Aide services were accepted revealed that the agency did not ensure that the Hospice Registered Nurse provided specific instructions to the Aide. Document 1: The agency policy “Implementing Care and Treatment” (PC.35) dated 4/4/2023 included in part that “...The Hospice RN ... will oversee the assignment of a Hospice Aide (HA) to a particular patient .... The HA will be provided with written instructions for patient care prepared by an RN which may include but not limited to ...personal care ...Reporting changes in the patient’s medical, nursing, rehabilitative, and social condition/needs to a Registered Nurse as the changes relate to the POC.” Clinical Record 5: The patient elected the hospice benefit on 04/26/2023 with a diagnosis of senile degeneration of brain. The patient resided in an Assisted Living Facility (ALF). The RN Assessment dated 01/22/24 noted that the patient’s oxygen saturation was 96% while receiving 2 liters per minute of oxygen per nasal cannula and that oxygen usage was continuous. Also documented was a pressure wound to the left lower extremity (LLE) plantar surface that measured 2 x 1 x 0.1 and was to be kept clean. The nurse also noted that the facility was applying Silvadene cream with dressing wound care daily. The RN noted on 01/29/2024 that the “wounds and bruising have healed ...” However, during Home Visit on 01/31/2024 with the hospice aide (Personnel Record 6), the left foot was observed to be wrapped with Kerlix gauze. The Plans of Care (POC) effective 10/18/2023 -12/11/2023 included orders for the Hospice Aide to visit the patient five times a week. The Hospice Aide Care Plans dated 11/10/2023 - 12/24/2023, 12/15/2023 - 01/07/2024, and the current Care Plan dated 01/8/2024included the following tasks: shower the patient or provide a bed bath, shampoo the patient’s hair, provide skin, oral, nail, and perineal care, assist with dressing patient and foot care (elevate heels and apply lotion to feet). There was no instruction to the Hospice Aide on caring for the patient’s wound during the shower or if the patient’s oxygen could be removed for the shower. The Aide Care Plan also contained the task to shower or provide a bed bath for the patient. The patient’s hospice diagnosis is Senile Degeneration of the Brain and is minimally verbal and unable to make decisions. During home visit #1 with Hospice Aide (Personnel Record #6) on 01/31/2024, the Hospice Aide removed the patient’s oxygen when she moved the patient to the shower chair for her shower. It was noted that the patient’s left foot was wrapped with a kerlix dressing. The Hospice Aide placed a plastic bag around the patient’s left foot/dressing to keep the foot dry during the shower. Clinical Record 6: The patient elected the hospice benefit on 10/6/2023 with a diagnosis of Parkinson’s. The patient resided in a group home. The Plans of Care effective 10/6/2023 and 12/26/2023 included orders for the Hospice Aide to visit the patient five times a week. The initial RN visit dated10/06/2023 included in part that “...Pt has an ulcer to his inner left foot ... 1.5 x 2 x 0.1. A physician’s order dated 10/06/2023 included wound care orders to clean the left foot with normal saline and pat dry. Then, cover the wound with a hydrocolloid dressing daily and PRN if the dressing falls. There continued to be a documented wound during the visit by the RN on 11/29/2023, with a wound assessed as 6 x 1.5 x 0.1 with granulation tissue requiring wound care to clean with NS, pat dry, and cover with hydrocolloid dressing. The RN’s Recertification nurse visit on 12/20/2023, stated in part, “Pt has an ulcer to his inner left foot; he receives daily wound care by foster home.” The RN visit noted dated 01/17/2024 stated that the wound measured 1.8 x 1.3 x 0.1 with eschar, wound care to clean with NS, pat dry, and cover with hydrocolloid dressing. On 01/24/2024, the nurse documented the wound remained and assessed the size to be 1.7 x 1.2 x 0.1. The Hospice Aide Care Plans dated 10/09/2023 to 10/30/2023, 10/31/2023 to 12/24/2023, 12/25/2023 to 01/7/2024, and the current Hospice Aide Care Plan dated 01/8/2024 included the tasks to shower the patient, shampoo his hair, provide oral, nail, and perineal care, skin care, and foot care (to elevate heels and apply lotion to his feet). There was no specific instruction to the Hospice Aide on caring for the patient’s wound during the shower. During an interview and joint record review with the Clinical Director (Personnel Record 2) and the Regional VP of Compliance (Personnel Record 10) on 01/31/2024 and 02/1/2024, it was confirmed that the RN did not provide specific instruction to the Hospice Aide for Clinical Records 5 and 6 for what the Aide should do with the patient’s wound during care and/or if the dressing became soiled or wet. Additionally, there was no instruction provided to the Aide on parameters for oxygen removal in the Aide Care Plan for Clinical Record 5.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the Hospice election form and any advance directives and the Physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 1 (100%) home visits observed in which a patient resided in a Nursing Facility revealed that the agency did not ensure that the patient’s Election of the Hospice Benefit and the Physician’s Certification/Recertification documents were provided to the facility. Document 1: The agency policy “Hospice Care in a SNF/NF or ICF/IID” (PC.125) dated 10/01/2021 included in part that “The Hospice will provide the facility with the following hospice information/documentation on admission and ongoing... The Hospice election form ... The physician certification and recertification of the terminal illness specific to each patient...” Clinical Record 1/Home Visit 2: The patient elected the hospice benefit on 06/21/2023 with a diagnosis of heart failure. During observation of the patient’s facility chart during the home visit observation with the registered nurse (RN) (Personnel Record 3) on 01/31/2024, the hospice election form and the physician certification/recertifications were missing. During the visit, I questioned the RN (Personnel Record 3) and she said the hospice election forms were not there. The Physician Certification/Recertifications for the benefit periods 06/21/2023 to 09/18/2023, 09/19/2023 to 12/17/2023, and 12/18/2023 to 02/15/2024 were not in the facility binder/paperwork. During the visit, I questioned the RN (Personnel Record 3) and she said the hospice election forms were not there and was unable to locate the other documents. Personnel Record 2: In addition to questioning the RN (Personnel Record 3) during the visit about the missing documentation, during an interview with the Clinical Director (Personnel Record 2) and the Executive Director (Personnel Record 1) on 1/31/2023, no evidence could be provided that this documentation was provided to the nursing facility.”