Amatus Hospice and Palliative Care LLC

“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 7 (57%) records reviewed, in which the addendum for non-covered items was requested, revealed the agency did not ensure the patient/representative were provided with a completed list of the non-covered items, services and drugs. Clinical Record 1: The patient’s election of hospice benefit was 01/19/2024. On the election of benefit document, the box was checked for “I elect to receive the ‘Patient Notification of Hospice Non-Covered Items, Services, and Drugs’” and was initialed by the power of attorney (POA) and dated 01/15/2024. The clinical record did not contain evidence that the addendum was provided. Clinical Record 6: The patient’s election of hospice benefit was 12/22/2023. On the election of benefit document, the box was checked for “I elect to receive the ‘Patient Notification of Hospice Non-Covered Items, Services, and Drugs’” and was initialed by the power of attorney (POA) and dated 12/22/2023. The clinical record did not contain evidence that the addendum was provided. Clinical Record 9: The patient’s election of hospice benefit was 10/3/2023. On the election of benefit document, the box was checked for “I elect to receive the ‘Patient Notification of Hospice Non-Covered Items, Services, and Drugs’” and was initialed by the patient representative and dated 10/2/2023. The clinical record did not contain evidence that the addendum was provided. Clinical Record 14: The patient’s election of hospice benefit was 12/7/2021 with a diagnosis of cerebral vascular accident (CVA). On the election of benefit document, the box was checked for “I elect to receive the ‘Patient Notification of Hospice Non-Covered Items, Services, and Drugs’” and was initialed by the patient representative and dated 12/6/2021. A document titled, “Hospice Election Addendum: Patient Notification of Hospice Non-Covered Items, Services and Drugs” was signed by the patient representative and hospice witness on 12/07/2021. The following areas on the document were left blank: Date of Request; Diagnoses related to terminal illness and related conditions; Diagnoses unrelated to terminal illness and related conditions; non-covered items, services, and drugs determined by hospice as not related to my terminal illness and related conditions. The review of the drug profile revealed the following medications were ordered on 12/07/2021 and were marked as not being covered by hospice: Zioptan Ophthalmic Solution, Upneeq Ophthalmic Solution, Cosopt Ophthalmic Solution, and Lubricating eye drops (all for glaucoma); Metoprolol Tartrate (for hypertension). This record was reviewed by the Administrator/DON, on 2/15/2024, who confirmed that there were non-covered medications that “should have been written on the addendum.” On 2/15/2024 the Administrator/DON confirmed there was no additional documentation to present and that the above patients/representatives were not provided with the information requested on the non-covered items, services, and drugs.”

“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 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the social worker completed the initial comprehensive assessment within the five (5) day requirement. Clinical Record 4: The initial plan of care orders, effective 12/27/2023, included social work visit orders for 1 time week one. The initial social work visit was documented on 1/17/2024, this was 21 days after the patient elected the hospice benefit. On 2/14/2024 the Administrator/DON confirmed that the social worker was late making this initial visit and reported they were unable to locate any documentation as to why the visit was not completed within the 5-day requirement.”

“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. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) records reviewed revealed the agency did not ensure the drug profile included all prescription medications, specifically oxygen. Document 1: Policy titled, Medication Management (2/22/2022) stated in part, “The hospice will develop a medication profile, upon admission, with all medications the patient is taking, including over the counter and herbal medications and obtain a physician order.” Clinical Record 9: The patient’s election of the hospice benefit was 10/3/2023 with a diagnosis of congestive heart failure. The plan of care order dated 01/10/2024 documented “Patient O2 (oxygen) dependent.” Nursing visit note dated 01/30/2024 included documentation that the patient was on oxygen 2-3 liters per nasal cannula. The drug profile, effective from 01/10/2024 to current, did not include oxygen. During an interview on 2/14/2024 the Administrator/DON confirmed that the oxygen had not been added to the drug profile. Upon review of the agency policy the Administrator/DON stated, “it doesn’t specifically say oxygen, but it is a prescription medication and we have been working with the nurses on making sure it is included.””

“It is required that each patient’s individualized written plan of care: 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 1 of 14 (7%) records reviewed revealed the agency did not ensure the plan of care included specific interventions based on the problems identified in the comprehensive assessments. Clinical Record 1: The patient’s election of the hospice benefit was 01/19/2024 with a diagnosis of senile degeneration of the brain. The initial comprehensive nursing assessment dated 01/19/2024, stated, “The patient is hyper-somnolent with drowsiness noted. She must be cued while being fed and is a high aspiration risk; diet is pureed and requires honey thickened liquids.” The diagnosis list included “dysphagia” as a comorbidity. The plan of care, effective 01/19/2024 to current, did not include any problems, goals, or interventions related to the dysphagia, aspiration precautions, or the dietary modifications. On 2/12/2024 the record was reviewed with the Administrator/DON who said, “the nurse missed adding the aspiration risk and diet, we have been working hard on the care plans.””

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) records reviewed, in which aide services were accepted, revealed the agency did not ensure the hospice aides were following the ordered services within the care plan. Clinical Record 1: The patient’s election of the hospice benefit was 01/19/2024 with a diagnosis of senile degeneration of the brain. The hospice aide care plan, effective from 01/19/2024 to current, included visit frequency orders of 5 times per week with the following relevant tasks: bed bath 3 times per week, partial bath 2 times per week, and shampoo one time per week. For the week beginning 01/29/2023 the following tasks were documented as completed during the hospice aide visits: bed bath documented as completed on 01/29/2023, 01/30/2023, 01/31/2023, and 02/01/2023 (four times that week); partial bath documented as completed on 01/31/2023; shampoo documented as completed on 01/30/2023 and 02/01/2023 (two times that week). Clinical Record 7: The patient’s election of the hospice benefit was 07/05/2023 with a diagnosis of chronic obstructive pulmonary disease (COPD). The hospice aide care plan, effective from 01/01/2024 to current, listed visit frequency orders of 5 times per week with the following relevant tasks: nail care one time per week and shampoo 2 times per week. For the week starting 2/5/2024 the aides documented that the nail care and shampoo were completed on 2/5/2024, 2/6/2024, 2/7/2024, 2/8/2024, and 2/9/2024 ( five times that week). On 2/13/2024 these records were reviewed with the Administrator/director of nursing (DON) who confirmed that the aides did not follow the orders and said, “it’s too easy for them to just to mark yes for everything.””

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: Assess the quality of care and services provided by the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) records reviewed, in which aide services were provided, revealed the agency did not ensure the RN completed the supervisory visit every 14 days as required. Clinical Record 4: The initial plan of care, effective 12/27/2023, hospice aide services were ordered for three (3) times per week. An aide supervisory visit was conducted on 01/22/2024 and the next one documented occurred on 02/7/2024 which was 16 days apart. The aides documented completion of 3 visits per week during that time period. On 02/13/2024 this record was reviewed with the Administrator/DON who confirmed the aide supervisory visit was completed after the 14-day requirement and said, “the RNs are not supposed to change their schedules, but this nurse did, and it made the visit late.””

“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. (L670) Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) records reviewed revealed the agency did not ensure the patient/representative signed an election of benefit form that contained the correct effective date that the hospice benefit started. The Code of Federal Regulations (CFR) stated in part: “§ 418.24 Election of hospice care. (b) Content of election statement. The election statement must include the following:(4) The effective date of the election, which may be the first day of hospice care or a later date but may be no earlier than the date of the election statement.” Clinical Record 1: Review of the election of benefit form, signed by both the patient representative and hospice representative on 01/15/2024, revealed that the section, “hereby elect hospice services effective: (date)”, was left blank. A review of the registered nurse (RN) initial assessment and the initial certification of terminal illness were dated 01/19/2024. Clinical Record 2: Review of the election of benefit form, signed by both the patient representative and hospice representative on 12/09/2023, revealed that the section, “hereby elect hospice services effective: (date)”, was left blank. . A review of the RN initial assessment and the initial certification of terminal illness were dated 12/11/2023. Clinical Record 4: Review of the election of benefit form, signed by both the patient representative and hospice representative on 12/27/2023, revealed that the section, “hereby elect hospice services effective: (date)”, was left blank A review of the RN initial assessment and the initial certification of terminal illness were dated 12/27/2023. Clinical Record 8: Review of the election of benefit form, signed by both the patient representative and hospice representative on 10/27/2023, revealed that the section, “hereby elect hospice services effective: (date)”, was dated “10/28/2024” which was over one year from the date the form was signed. A review of the RN initial assessment and the initial certification of terminal illness were dated 10/28/2023. On 2/15/2024 the Administrator/DON confirmed that the above election of benefit documents was signed by the patient/representative with the effective date of hospice services either incorrect or blank. The Code of Federal Regulations (CFR) stated in part: “§ 418.24 Election of hospice care. (b) Content of election statement. The election statement must include the following:(4) The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement.””

“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 and interview. In 1 of 14 (7%) records reviewed revealed the agency did not ensure the clinical record contained physician orders for all prescribed medications. Clinical Record 9: The election of the hospice benefit was 10/03/2023 with a diagnosis of chronic systolic (congestive) heart failure. The plan of care (POC) for benefit period of 1/1/2024 to 3/30/2024 documented, “patient O2 (oxygen) dependent.” The registered nurse visit note dated 01/30/2024 documented the patient was on 2-3 liters via nasal cannula, as needed, for shortness of breath. The clinical record did not contain a physician order for the oxygen at 2-3 liters, as needed. On 02/15/2024 the Administrator/DON confirmed that there was no additional documentation to present and said that there were no physician orders for the oxygen.”