Archway 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. 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. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure that the patient’s Plan of Care included all of the patients’ medications. Agency policy “Medication List and Monitoring (PC17), dated 01/01/2021, read in part that “...The hospice will maintain a current, accurate medication profile for all prescription and over-the-counter medications taken by the patient... Changes in the medication regimen will be documented in the medical record either on the Medication Profile, on a verbal order, and in the Plan of Care... Changes in medications will be updated as frequently as necessary to keep the profile accurate. Clinical Record 5: The patient elected the hospice benefit on 01/17/2024. The licensed vocational nurse (LVN) visit note dated 01/23/2024 included “oxygen saturation of 91% on room air and noted, New order for Robitussin and Mucinex... Lungs clear upper lobes, diminished bases...” The RN documented in the Interdisciplinary Group Meeting dated 02/21/2024 in part “...Notes rales to upper lobes and new order for zpack...” There was no documented evidence for a physician order for Z-pack (Azithromycin) and Z-pack is not included in the patient’s current or discontinued medication lists, or the patient Plan of Care. Clinical Record 11: The patient elected the hospice benefit on 08/22/2023 and transferred to another hospice effective 09/29/2023. The LVN visit note dated 09/25/2023 stated in part, “oxygen sat 80% on 3lpm O2 NC. Tumor to neck appears larger and spreading across the trachea ... O2 sat at 80% RA. Put O2 on resident at 2L and only came up to 82%. Increased O2 to 3.5L and O2 sats came up to 85-87%. Noted rubs on expiratory to right lobe ... received order for Keflex 500mg TID x 10 days for tumor redness and warmth ...continues on nebulizer treatments...” The LVN note dated 9/28/23 stated in part “...The tumor to the neck is growing and could possibly be blocking the trachea and making it more difficult to swallow. Ordered a suction machine to be delivered ...” There was no documented evidence on the plan of care dated 08/22/2023-11/19/2023 for problems or interventions related to the tumor to the neck, suction machine and need for oxygen. During a joint record review and interview with the Patient Care Director on 04/04/2024, it was confirmed that no orders were documented for these medications described in the nursing notes, nor were the medication listed in the medication profile or the plan of care.”

“It is required that the hospice designates a registered nurse member of the IDG to ensure continuous assessment of each patient’s and family’s needs and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the RN ensured implementation of the plan of care and continuous assessment. Agency policy “Implementing Care and Treatment (PC.7) dated 10/01/2020 included in part that “... The agency designates a qualified registered nurse ... who will oversee ... the continuous assessment of each patient’s/family’s needs, the implementation of the IDG POC (Interdisciplinary Group Plan of Care) ...” Agency policy “Plan of Care Process” (PC.6), dated 05/01/2020, read in part that “... All hospice care and services furnished to patients ... will follow an individualized written POC (Plan of Care) established by the hospice Interdisciplinary Group ... A detailed statement of the scope and frequency of services necessary to meet the patient and family needs ...” Clinical Record 1: The patient elected the hospice benefit on 07/20/2023 with the primary diagnosis of Alzheimer’s disease. The Plans of Care effective 10/18/2023 to 1/15/2024 and 1/16/2024 to 3/15/2024 included the RN visit frequency of one RN visit every other week per the family’s request. The RN documented visits on 12/20/2023, NP/RN on 01/03/2024, 01/24/2024, 02/07/2024, 02/21/2024, and 03/06/2024. There was a twenty-one-day gap in RN visits from 01/03/2024 to 01/24/2024. There were no Licensed Vocational Nurse visits during the 01/03/2024 to 01/24/2024 time period. The Clinical Director/RN documented a call to the patient/family on 01/17/2024 to update them on the change in RN Case Manager and to determine if the patient/family had any needs. The RN documented on visit note dated 12/20/2023 that the “Pt sitting in the kitchen of home with husband ... continues a steady decline. VS WNL. LCTAB with diminished lung sounds in bilateral bases. BS x4, abdomen soft, non-distended. 1+ edema noted in BLLE ... no refills needed ...” Then on 01/03/2024, the NP/RN documented, in part, that the patient “...exhibits symptoms of fatigability and anxiety...requiring 24 hrs. supervision...mild dysphagia ...Lorazepam was recently increased due to exacerbations in anxiety symptoms. She does not participate in evaluation. Her husband assists with identifying her needs ...appears weak and tired. Walks with minimal assist ... Patient requires minimal to extensive assistance with ADL activities ... has had weight loss .. continent with bowel and bladder but requires assistance with toileting ... On 01/24/2024, the RN noted in part that the patient has “...poor coordination/balance; max assist by family ... Does ambulate but is not steady on feet ... frequent behaviors with cares. She is currently on medications for behaviors that are effective ... “ During the Interdisciplinary Team Meeting (IDT) on 01/10/24, the RN noted in part that ..”. Pt requires full assist for all ADLs. Pt with increased weakness and fatigue, sleeping more during the day than previously reported by husband.” Then the RN documented during the IDT 01/24/2024 in part that “Patient continues on hospice services ... She continues to reside in private home with her husband, who is also her primary caregiver. Patient does ambulate, but without intent. She is a fall risk. ...” On 01/17/2024, the PCD phoned the patient/family to update them regarding the change in their RNCM and inquire as to any medication or supply needs. The PCD also notified the hospice’s Medical Director on 01/24/2024 about the missed visit secondary to the previous nurse’s lack of documentation the week of 01/14/2024. The nurse visit resumed the next week as per order. It was confirmed during an interview with the Patient Care Director (PCD) Personnel Record 2) on 04/04/2024 that there was a gap of documented Registered Nurse (RN) visits of twenty-one days from 01/03/2024 to 01/24/2024. Per the PCD, the patient’s RN Case Manager (RNCM) abruptly left employment at the hospice on 01/16/2024. She reportedly had made a visit to the patient but left her employment before completing the documentation of the visit, but the PCD did not know that the nurse would not complete the documentation for the visit. On 01/17/2024, the PCD phoned the patient/family to update them regarding the change in their RNCM and inquire as to any medication or supply needs. The PCD also notified the hospice’s Medical Director on 01/24/2024 about the missed visit secondary to the previous nurse’s lack of documentation the week of 01/14/2024. The nurse visit resumed the next week as per order.”

“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, document review, and interview. In 3 of 14 (21%) clinical records reviewed revealed the agency did not ensure that the patient’s Plans of Care were updated with identified problems and interventions based on the information obtained in the updated assessments. Agency policy “Review and Revision of Patient Care (PC.9) dated 08/01/20024 read in part that “... Upon identifying that patient care needs have changed, adjustments to the care planning documents will be made ... to the IDT (Interdisciplinary Team) Plan of Care by the RN ... each change will be accompanied by specific interventions. All written changes to th Plan of Care will be incorporated into the patient’s medical record as changes occur. Clinical Record 4: The patient elected the hospice benefit on 02/06/2024. The Registered Nurse (RN) Admission visit dated 02/06/2024, stated in part, “new onset of dysphagia and the need for a mechanical soft diet.” A physician’s order dated 02/06/2024 included Lamotrigine 25mg: 2 tablets by mouth twice a day. The RN visit note dated 02/20/2024 stated in part, “the patient was on oxygen two liters per minute per nasal cannula.” The patient’s history and physical referral notes from a neurology visit dated 09/13/2023,” included in part that ...” Since last visit, she has had several seizures ... stares off, becomes unresponsive, whole-body shakes ... She has had about 6 in the past year. They seem to be happening more frequently now ... Seizures: Start Lamotrigine 25mg daily and slowly titrate up to 50mg twice daily. Seizure precautions discussed ...” There were no identified problems or interventions in the patient’s Plan of Care dated 02/6/2024-05/05/2024 to address the patient’s dysphagia, seizures, or use of oxygen. Clinical Record 5: The patient elected the hospice benefit on 01/17/2024. The Licensed Vocational Nurse (LVN) visit on 01/23/2024 included documentation that the patient’s oxygen saturation of 91% on room air and noted, “New order for Robitussin and Mucinex... Lungs clear upper lobes, diminished bases...” The RN documented in the Interdisciplinary Group Meeting dated 02/21/2024 in part “...Notes rales to upper lobes and new order for zpack...” The only identified nursing-related problems noted in the patient’s Plan of Care date 01/17/2024-04/15/2024 included deficits related to quality of life and cardiac/circulatory function and fluid volume alteration. There was no documented evidence of problems or interventions on the plan of care for the active respiratory infection nor interventions related to the infection, its treatment, or symptom management. Clinical Record 11: The patient elected the hospice benefit on 08/22/2023 and transferred to another hospice effective 09/29/2023. The LVN visit note dated 09/25/2023 stated in part, “oxygen sat 80% on 3lpm O2 NC ...Tumor to neck appears larger and spreading across the trachea ... O2 sat at 80% RA. Put O2 on resident at 2L and only came up to 82%. Increased O2 to 3.5L and O2 sats came up to 85-87%. Noted rubs on expiratory to right lobe ... received order for Keflex 500mg TID x 10 days for tumor redness and warmth ...continues on nebulizer treatments...” The LVN note dated 9/28/23 stated in part “...The tumor to the neck is growing and could possibly be blocking the trachea and making it more difficult to swallow. Ordered a suction machine to be delivered ...”. There was no documented evidence on the plan of care dated 08/22/2023-11/19/2023 for problems or interventions related to the tumor to the neck, suction machine and need for oxygen. During a joint record review and interview with the Patient Care Director on 04/03/2024 and 04/04/2024, it was confirmed that the patients’ Plans of Care had not been updated with the identified problems documented in the assessment notes.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program includes defined data details and frequency of collection. This standard was not met as evidenced by document review and interview. A review of the agency’s QAPI documentation revealed that the agency did not ensure that the hospice documented two meetings in 2023 as required by the agency’s policy “Quality Assessment Performance Improvement Program (QAPI.4) dated 12/01/2019. The policy reads in part that “...The QAPI Committee will meet at least twice a year or more often if needed and will maintain a written record of the meetings with appropriate signatures...” The agency had documented Hospice Quality Assessment and Performance Improvement Quarterly Review meetings on 05/02/2022, 07/27/2022, and 07/12/2023. During an interview on 04/04/2024 with the Patient Care Director responsible for the QAPI program, she confirmed that there was only one QAPI meeting during 2023. Due to staffing changes and the agency’s staffing shortages, other operations and needs took priority. A review of the agency’s QAPI documentation revealed that the agency did not ensure that the hospice documented two meetings in 2023 as required by the agency’s policy “Quality Assessment Performance Improvement Program (QAPI.4) dated 12/01/2019. The policy reads in part that “...The QAPI Committee will meet at least twice a year or more often if needed and will maintain a written record of the meetings with appropriate signatures...” The agency had documented Hospice Quality Assessment and Performance Improvement Quarterly Review meetings on 05/02/2022, 07/27/2022, and 07/12/2023. During an interview on 04/04/2024 with the Patient Care Director responsible for the QAPI program, she confirmed that there was only one QAPI meeting during 2023. Due to staffing changes and the agency’s staffing shortages, other operations and needs took priority.”

“It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 11 (9%) clinical records reviewed in which Hospice Aide services were accepted revealed the agency did not ensure that the Hospice Aide visit frequency met the ordered frequency documented in the patient’s Plan of Care. Agency’s policy “Implementing Care and Treatment” (PC.7), dated 10/01/2020, read in part that “... The hospice RN ... will oversee the assignment of a Hospice Aide initiating Hospice Aide services within the time frame to meet the patient’s needs as identified in the Plan of Care and per physician’s orders...” Clinical Record 1: The patient elected the hospice benefit on 07/20/2023. A physician order dated 07/21/2023 ordered the hospice aide to visit the patient twice a week, effective 07/21/2023. There were no additional physician orders updating the hospice aide visit frequency. Hospice Aide visits were documented on 01/02/2024 and 01/08/2024, and a missed visit was documented on 01/15/2024. Then visits resumed on 01/23/2024, 01/30/2024, 02/06/2024, 02/13/2024, 02/20/2024, 02/27/2024, 03/05/2024 and 03/12/2024. The patient was being seen by the aide once a week instead of twice a week as ordered. During a joint record review and an interview with the Patient Care Director on 04/03/2024, it was confirmed that no updated Hospice Aide frequency orders were documented in a physician’s order or the patient’s Plans of Care.”

“It is required that 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 a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which there was a live discharge from hospice services revealed that the agency did not ensure that the agency forwarded the Discharge Summary to the patient’s attending physician. Clinical Record 12: The patient elected the hospice benefit on 08/04/2023 and was discharged on 08/25/2023 for admission to a non-contracted facility. The discharge summary did not indicate that the Discharge Summary or any documentation was sent to the attending physician. No documentation was scanned into the clinical record, and no communication notes or Interdisciplinary Group notes mentioned sharing the patient’s clinical information with the attending physician. During a joint record review and interview with the Patient Care Director (PCD) on 04/04/2024, it was confirmed that there was no documentation that the patient’s discharge summary or any clinical information had been forwarded to the patient’s attending physician. Further, the PCD stated that the patient’s son from out of town arrived to see the patient and wanted to take the patient to the hospital. He requested that the patient be discharged and advised the hospice that he did not want anyone from the hospice to come to the house or meet them at the hospital. The hospice then discharged the patient. The family did not take the patient to the hospital, nor was the discharge summary or any clinical information provided to the attending physician.”

“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 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 1 of 2 (50%) clinical records reviewed in which the patient was a live discharge from the hospice agency revealed the agency did not ensure that the Discharge Summary contained the required elements. Clinical Record 12: The patient elected the hospice benefit on 08/04/2023 and was discharged on 08/25/2023 for admission to a non-contracted facility. The discharge summary did not include a summary of the patient’s hospice stay, the patient’s written Plan of Care, or any physician orders. There was no documentation in the clinical record that any of this information was sent separately to the patient’s attending physician. During a joint record review and interview with the Patient Care Director on 04/04/2024, it was confirmed that the patient’s documented discharge summary did not contain any of the patient’s medications, the patient’s plan of care, a summary of the patient’s care, or any other physician orders.”