Ultimate Hospice

“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 1 (100%) clinical record reviewed, the agency did not ensure that the patient’s written plan of care included medications necessary to meet the needs of the patient. THIS IS A CONTINUING REQUIRED ACTION. Clinical Record 1: The plan of care dated 12/22/2023 through 03/20/2024 did not include medications. The plan of care was a preprinted paper form that stated, “medications on medication profile” and the Registered Nurse documented “yes.” Review of the medication profile revealed that the patient was on numerous medications. During an interview and review of the record on 01/16/2024, the Director of Nursing and Administrator explained the forms are preprinted and they are working on getting new ones.”

“It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by clinical record review, interview, and home visit observation which revealed the agency failed to ensure equipment and supplies were provided by a provider that was accredited and met the CMS DMEPOS Supplier and Accreditation Standards [HSLG.10.I/L703]; 57% of clinical records revealed the agency failed to ensure all physician orders were documented in the clinical record [HSIM.3.1/ L678]; failed to ensure nursing services were available on a 24-hour basis, seven days a week to meet the needs of the patient and family [HCDT.4.I/L653]; and failed to ensure that all medications were documented on the individualized plans of care in 57% of records reviewed [HCPC.21.I/L549]. The cumulative effect of these deficiencies reveals a lack of oversight of care and services that could impact the quality of patient care and the provision of safe patient care.”

“It is required that the written Patient Bill of Rights includes the right to voice grievances to the hospice, CHAP, or a state entity without fear of discrimination or reprisal. This standard was not met as evidenced by document review, interview and observation. In 3 of 3 (100%) home visit observations it was revealed that the agency did not ensure that the written Patient Bill of Rights contained information related to voicing grievances or how to contact the hospice, CHAP or a state entity to report grievances. Home Visit 1: Review of the patient handbook on 12/7/2023 and during the home visit performed 12/8/2023, the written Patient Bill of Rights did not contain any information related to voicing grievances or how to contact the hospice, CHAP, or a state entity to report grievances. Home Visit 2: Review of the patient handbook during the home visit performed 12/7/2023, the written Patient Bill of Rights did not contain any information related to voicing grievances or how to contact the hospice, CHAP, or a state entity to report grievances. Home Visit 3: Review of the patient handbook during the home visit performed 12/7/2023, the written Patient Bill of Rights did not contain any information related to voicing grievances or how to contact the hospice, CHAP, or a state entity to report grievances. The Alternate Administrator was present during the home visit on 12/7/2023 and confirmed that the patient handbook did not contain information related to voicing grievances or how to contact the hospice, CHAP, or a state entity to report grievances.”

“It is required that each patient’s individualized written plan of care include 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 4 of 7 (57%) clinical records reviewed it was revealed that the agency did not ensure that the patient’s written plan of care included medications. Clinical Record 1: The plan of care dated 9/20/23 - 12/19/23 did not include medications. The plan of care was a preprinted form that stated “medications on med profile” and the RN documented “yes”. The medication profile dated 9/20/2023 included six medications. The medication profile did not have a physician’s signature. Clinical Record 2: The plan of care date 9/22-12/21/23 did not include medications. The plan of care was a preprinted form that stated “medications on med profile” and the RN documented “yes”. The medication profile dated 9/22/2023 included 7 medications. The medication profile did not have a physician’s signature. Clinical Record 3: Plan of care date 10/19/2023-1/17/2024 did not include medications. The plan of care was a preprinted form that stated “medications on med profile” and the RN documented “yes”. The medication profile dated 10/19/2023 contained 8 medications. The medication profile did not have a physician’s signature. Clinical Record 4: Plan of care date 07/28/23-10/25/23 did not include medications. The plan of care was a preprinted form that stated “medications on med profile” and the RN documented “yes”. The medication profile dated 07/28/2023 included 8 medications. The medication profile did not have a physician’s signature. Interview on 12/6/2023 with the alternate administrator/DON, she stated that she thought the purchased forms were acceptable.”

“It is required that hospice nursing services, physician services, drugs and biologicals are made routinely available on a 24-hour basis, seven (7) days per week to meet the needs of the patient and family. This standard was not met as evidenced by document review, interview and observation. Review of the patient handbook, interview with the alternate administrator/DON and home visit observation revealed that the agency did not ensure hospice nursing services were available on a 24-hour basis, seven days a week to meet the needs of the patient and family. Document 1: During the home visit on 12/7/2023, the site visitor verified the phone number given to patients and families to reach hospice on a 24-hour basis, seven days per week. The number was called at 9:18 p.m. on 12/7/2023. The phone was not answered and there was no option to leave a voicemail. The message indicated the voicemail was full. During an Interview conducted on 12/8/2023, the alternate administer/DON stated she only answers the phone if she recognizes the phone number due to a high volume of spam calls. Review of the patient handbook, interview with the alternate administrator/DON and home visit by site visitor revealed that the agency did not ensure hospice nursing services were available on a 24-hour basis, seven days a week to meet the needs of the patient and family.”

“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. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed it was revealed that the agency did not ensure that the clinical record contained physician orders for medications. Clinical Record 1: Clinical record did not include evidence of physician orders for medications. Plan of care dated 9/20/2023 did not include a list of medications. Medication profile dated 9/20/23 including carvedilol, atropine, gabapentin, lactulose, Tylenol and hydrocodone, did not include physician signature or evidence of physician oversight. Clinical Record 2: Clinical record did not include evidence of physician orders for medications. Plan of care dated 9/22/2023 did not include a list of medications. Medication profile dated 9/22/23 including isosorbide, atorvastatin, ergocalciferol, aspirin, losartan, vitamin D and acetaminophen did not include physician signature or evidence of physician oversight. Clinical Record 3: Clinical record did not include evidence of physician orders for medications. Plan of care dated 10/19/2023 did not include a list of medications. Medication profile dated 10/19/23 including hydralazine, amlodipine, losartan, tylenol, vitamin B 12, vitamin D3, aspirin and atorvastatin did not include physician signature or evidence of physician oversight. Clinical Record 4: Clinical record did not include evidence of physician orders for medications. Plan of care dated 07/28/2023 did not include a list of medications. Medication profile dated 07/28/23 including atorvastatin, losartan, amlodipine, aspirin, tylenol, vitamin C supplement, centrum for women and vitamin D3 did not include physician signature or evidence of physician oversight. The Alternate Administrator stated in an interview date 12/6/2023 that she thought the forms met the conditions of participation.”

“It is required that a hospice may contract for durable medical equipment services with a Medicare-certified DME point-of-service (POS) supplier that meets the CMS DMEPOS Supplier Quality and Accreditation standards and has a letter verifying that the DMEPOS supplier is accredited by a recognized accreditation organization. This standard was not met as evidenced by document review and interview. 2 of 2 (100%) durable medical equipment contracts reviewed revealed that the agency did not ensure that the durable medical equipment providers utilized were accredited by a recognized accreditation organization. Contract 3: “Durable Medical Equipment Contract Agreement” signed on 11/1/2020 and reviewed on 12/7/2023 revealed that the Durable Medical Equipment (DME) provider did not have a letter verifying accreditation. Contract 7: “DME Contract Agreement” signed on 2/12/2019 and reviewed on 12/7/2023 revealed that the Durable Medical Equipment (DME) provider did not have a letter verifying accreditation. The DON stated in an interview on 12/7/2023 that the contracted DME company is working on being acquired and the new company will be accredited. 2 of 2 (100%) durable medical equipment contracts reviewed revealed that the agency did not ensure that durable medical services utilized were accreditated by a recognized accreditation organization.”