Care Plus Palliative and Hospice Care LLC

“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, document review, and interview. Agency policy # PE.1 “Patient Assessments” (revised: 01/01/2020), stated in part, “The Interdisciplinary Group (IDG) in consultation with the patient’s attending physician (if any), will complete the comprehensive assessment no later than five (5) calendar days after the election of the hospice benefit.” In 1 of 15 (7%) clinical records reviewed, the agency did not ensure the hospice Interdisciplinary group completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 5: The patient elected hospice care on 04/29/2022. The initial plan of care dated 4/29/2022 ordered the Chaplain to evaluate and develop a plan of care. The chaplain evaluation was dated 5/18/2022, with 19 days outstanding. During an interview on 11/8/2023, the Executive Director, Area Vice President of Clinical Operations, and Patient Care Manager confirmed the findings.”

“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 7 of 15 (47%) clinical records reviewed, the agency did not ensure that the patient’s plan of care Identified interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected hospice care on 05/02/2023. The initial nursing assessment dated 05/02/2023 documented the patient’s identified problems with urinary retention, hypertension, seizures, pain, and a self-care deficit. The IDG (interdisciplinary group meeting) initial plan of care and updated plan of care did not document goals and interventions for the identified problems. Clinical Record 3: The patient elected hospice care on 12/23/2022. The initial nursing assessment dated 12/23/2022 documented the patient’s identified problems with insomnia, anxiety, hypertension, constipation, and gastroesophageal reflux disease. The IDG initial plan of care and updated plan of care did not document goals and interventions for the identified problems. The updated comprehensive assessment dated 01/10/2023 documented the patient’s problems with severe cough and abdominal cramps. On 01/20/2023, physician orders were received for symptom management. The updated IDG plan of care did not document goals and interventions for the identified problems with severe cough and abdominal cramps. Clinical Record 4: The patient elected hospice care on 11/13/2022. The initial nursing assessment dated 11/13/2022 and the Physician Certification of terminal illness dated 11/14/2022 documented the patient’s identified problems with an enlarged prostate, overactive bladder, incontinence, constipation, and multiple falls. The IDG initial plan of care did not document goals and interventions for the identified problems. The updated assessment dated 11/15/2022 documented that a Foley catheter was inserted. The updated IDG plan of care did not document goals and interventions for the care and maintenance of the Foley catheter. Clinical Record 5: The patient elected hospice care on 04/29/2023. The initial nursing assessment dated 04/29/2023 and the Physician Certification of terminal illness dated 04/29/2023 documented the patient’s identified problems with persistent nausea and vomiting. The IDG initial plan of care did not document goals and interventions for the identified problems. Clinical Record 6: The patient elected hospice care on 02/09/2023. The initial nursing assessment dated 02/09/2023 documented the patient’s identified problems with an enlarged prostate, overactive bladder, gastroesophageal reflux disease, insomnia, constipation, and glucose monitoring. The IDG initial plan of care did not document goals and interventions for the identified problems. Clinical Record 7: The patient elected hospice care on 4/12/2023. The initial nursing assessment was completed on 04/12/2023. The plan of care dated 04/12/2023 through 07/10/2023 and the updated IDG plans of care every two weeks did not document interventions for this patient with complaints of itching beginning on 04/18/2023. A review of the clinical record revealed that the patient was started on steroids on 04/20/2023, with the dose of steroids increased on 04/27/2023, 05/03/2023, and 05/24/2023 due to the status of the rash. The POC intervention documented, “Educate to report changes of skin.” This was not individualized to the patient’s problem of itching and rash. On 4/15/2023 through the patient’s death on 06/16/2023, the patient had a Foley catheter. The updated IDG plan of care did not document goals and interventions for the care and maintenance of the Foley catheter. Clinical Record 11: The patient elected hospice care on 06/20/2023. The plans of care dated 08/09/2023 through 11/06/2023 did not document individualized interventions for falls. A review of the clinical record revealed the patient fell on 08/11/2023 and 08/23/2023. The updated plans of care did not document goals and interventions for the patient’s identified problems with falls. During an interview and a joint review of the records on 11/08/2023, the Executive Director, Patient Care Manager, and Regional Vice President of Clinical Operation agreed that the plans of care did not include planned interventions based on problems identified in the initial and updated comprehensive assessments.”

“It is required that each patient’s individualized written plan of care 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 and interview. In 1 of 15 (7%) clinical records reviewed, the agency did not ensure the plan of care included all drugs necessary to meet the patient’s needs. Clinical Record 7: The patient elected hospice care on 4/12/2023. The skilled nursing visit note dated 04/15/2023 documented that “Omnicef 30 mg daily times 5 days” was started. A review of the clinical record revealed the plan of care did not include documentation of an order for the Omnicef as of the patient’s death on 06/16/2023. During an interview, the Executive Director stated that the on-call nurse who made the visit called for the order but had not documented the order.”

“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, 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, interview, and observation. Agency policy #IC.12 “Bag Technique” (revised 1/1/2020) stated in part, “After cleaning hands, the supplies and/or equipment needed for the visit are removed from bag. Hands are washed again if additional supplies are needed during the visit. Close bag before performing patient care... When visit is completed, reusable equipment is cleaned using alcohol disinfectant wipe and/or antimicrobial soap and water as appropriate, hands are washed, and equipment and supplies are returned to the bag.” In 1 of 2 (50%) home visits observed, the agency did not ensure hand hygiene was performed when indicated per policy. Home Visit 1: During the home visit on 11/8/2023 with the Registered Nurse (RN) [Personnel Record 1], the RN reentered their open bag four (4) times to remove equipment. The RN did not wash or sanitize their hands before reentering the bag for additional equipment per the policy. During an interview, the Regional Vice President of Clinical Operations and Executive Director agreed that the staff member did not follow the required bag technique and hand hygiene to prevent transmission of infection.”

“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 RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical records reviewed of patients receiving hospice aide services, the agency did not ensure the hospice aide received specific written patient care instructions. Clinical Record 2: The patient elected hospice care on 05/02/2023. The hospice aide care plan dated 05/02/2023 and updated on 10/26/2023 and 10/30/2023 assigned the hospice aide the task “Change linens two times a week and PRN (as needed).” The care plan did not provide clear instructions to the hospice aide for the frequency of changing the linens. Clinical Record 6: The patient elected hospice care on 02/09/2023. The hospice aide care plan dated 02/09/2023 assigned the hospice aide the task of “changing linens two times a week and PRN.” The care plan did not provide clear instructions to the hospice aide for the frequency of changing the linens. During an interview and joint review of the records, the Executive Director, Patient Care Manager, and Area Vice President of Clinical Operations agreed the hospice aide plan needed clear instructions for the aide.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which volunteer services were accepted, the agency did not ensure the clinical record included documentation of care and services provided. Clinical Record 11: The patient elected hospice care on 06/20/2023. The skilled nurse documented in the coordination notes on 08/09/2023 that the patient accepted a volunteer. A clinical record review revealed no documentation of an evaluation of the need for volunteer services until the interdisciplinary meeting on 08/22/2023 when it documented that no volunteer was needed. The clinical record did not document how it was determined that the patient no longer wanted a volunteer. During an interview on 11/09/2023, the Volunteer Coordinator confirmed the finding and stated that the family was called, and decided they did not want the volunteer. No further documentation was provided.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid-certified facility, the hospice forwards to the receiving facility a copy of: the hospice discharge summary described in HCDT 40. I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients transferred to a Medicare/Medicaid certified facility, the agency did not ensure that the discharge summary was sent to the receiving facility. Clinical Record 10: The patient elected hospice care on 1/05/2023, and the nurse documented that the patient was transferred to the hospital to seek aggressive treatment. There was no documented evidence that the discharge summary was sent to the receiving facility, the hospital. During an interview on 11/09/2023, the Executive Director stated that the nursing note documented communication with the facility, but the record did not document sending the discharge summary.”

“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 2 of 2 (100%) clinical records reviewed of patients that revoked the election of hospice care, the agency did not ensure the discharge summary was sent to the patient’s attending physician. Clinical Record 10: The patient elected hospice care on 1/05/2023, and the nurse documented that the patient revoked the hospice care benefit on 01/11/2023 for aggressive treatment. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. Clinical Record 13: The nurse documented that the patient and wife revoked the hospice care benefit on 07/22/2023 to seek aggressive treatment. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. During an interview on 11/09/2023, the Executive Director stated that the summary was sent to the attending physicians, but there was no documentation to confirm the summaries were sent.”