Grayce Enhanced Hospice Care

“It is required that each patient’s individualized written plan of care reflects patient and family goals, 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 5 (20%) clinical records reviewed, the agency did not ensure the individualized plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessment. THIS IS A CONTINUING REQUIRED ACTION. Clinical Record 1: The patient was admitted to home health services on 03/28/2024 with a primary diagnosis of congestive heart failure. The registered nurse documented on the initial comprehensive assessment dated 03/28/2024 that the patient had bi-lateral edema to feet. The plan of care dated 03/28/2024 through 06/25/2024 did not include interventions or goals for the patient’s edema. The Director of Nursing was interviewed on 05/07/2024 during a joint review of records and agreed there was no documented evidence that the plan of care included interventions and goals for the problem identified in the initial assessment. PRIOR REQUIRED ACTION.”

“It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice: Failed to ensure that the hospice medical director or physician designee provided written certification of terminal illness, including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness{HCPC.4. I/L667}; and Failed to ensure that the hospice medical director or physician-designee provided written and signed recertification of the terminal illness (CTI) to meet the hospice care benefit requirement {HCPC. 6. IL668}. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.102: Medical Director. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals, 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 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure that the written plan of care included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient’s date of election was 02/15/2024 with a primary hospice diagnosis of Alzheimer’s disease. The registered nurse (RN) initial assessment on 02/15/2024 documented that the patient was at risk for falling. The benefit period reviewed 2/15/24-05/14/24 did not include problems, goals, and interventions for the fall risk. Clinical Record 4: The patient’s date of election was 01/17/2024 with a primary hospice diagnosis was malignant neoplasm of the brain unspecified. The RN assessment on 01/17/2024 documented that the patient was at risk for falling and had a pain rating of 4. The benefit period reviewed for 1/17/24-4/15/24 did not include problems, goals, and interventions for the fall risk and pain. Clinical Record 7: : The patient’s date of election was 08/30/2023 with a primary hospice diagnosis of Alzheimer’s disease. The RN initial assessment on 08/30/2023 documented that the patient was at risk for falling. The benefit period reviewed for 8/30/23-10/28/23 did not include problems, goals, and interventions for the fall risk. During a joint review of the record and an interview on 03/22/2024, the Director of Nursing agreed there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the assessments.”

“It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 13 of 14 (93%) clinical records reviewed revealed that the agency did not ensure that the hospice medical director or physician designee provided written certification of terminal illness, including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 1: The patient’s date of election was 01/30/2024. There was no documented evidence of a written initial certification of terminal illness, including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 2: The patient’s date of election was 02/15/2024. There was no documented evidence of an initial certification of terminal illness including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 3: The patient’s date of election was 10/31/2023. There was no documented evidence of an initial certification of terminal illness including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 4: The patient’s date of election was 01/17/2024. There was no documented evidence of an initial certification of terminal illness including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 5: The patient’s date of election was 12/02/2023. There was no documented evidence of an initial certification of terminal illness including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 6: The patient’s date of election was 01/24/2024. There was no documented evidence of an initial certification of terminal illness including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 7: The patient’s date of election was 08/30/2023. There was no documented evidence of an initial certification of terminal illness including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 8: The patient’s date of election was 01/12/2024. There was no documented evidence of an initial certification of terminal illness including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 10: The patient’s date of election was 10/25/2023. There was no documented evidence of an initial certification of terminal illness including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 11: The patient’s date of election was 11/08/2023. There was no documented evidence of an initial certification of terminal illness including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 12: The patient’s date of election was 11/22/2023. There was no documented evidence of an initial certification of terminal illness including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 13: The patient’s date of election was 08/30/2023. There was no documented evidence of an initial certification of terminal illness, including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 14: The patient’s date of election was 10/02/2023. There was no documented evidence of an initial certification of terminal illness, including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness. During a joint record review and interview on 03/22/2024, the Director of Nursing confirmed that the record lacked a written initial certification of terminal illness, including the primary terminal diagnosis, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient’s conditions unrelated to the terminal illness.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed revealed that the agency did not ensure that the hospice medical director or physician-designee provided written and signed recertification of the terminal illness (CTI) to meet the hospice care benefit requirement. Clinical Record 3: The patient’s date of election was 10/31/2023. There was no documented evidence a recertification of the terminal illness was completed for the second benefit period starting 01/29/2024. Clinical Record 5: The patient’s date of election was 12/02/2023. There was no documented evidence that a recertification of the terminal illness was completed for the second benefit period starting 03/01/2024. Clinical Record 7: The patient’s date of election was 08/30/2023. There was no documented evidence that a recertification of the terminal illness was completed for the additional benefit period starting 10/29/2023, 12/28/2023, and 02/26/2023. Clinical Record 9: The patient’s date of election was 08/30/2023. There was no documented evidence that a recertification of the terminal illness was completed for the additional benefit period starting 10/29/2023, 12/28/2023, and 02/26/2023. The statement that the patient’s medical prognosis is that their life expectancy is 6 months or less if the terminal illness runs its normal course” and what the patient’s diagnosis was but did not have a narrative with what made the patient eligible. There were no clinical findings written/typed out on the CTIs. Clinical Record 10: The patient’s date of election was 10/25/2023. There was no documented evidence a recertification was completed for the second benefit period starting 01/23/2024. During a joint record review and interview on 03/22/2024, the Director of Nursing confirmed that the record lacked a written and signed recertification of the terminal illness for the benefit periods listed.”

“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 and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed for discharged patients revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 11: The discharge summary dated 12/27/2023 lacked documented evidence that the discharge summary was forwarded to the patient’s attending physician. Clinical Record 12: The discharge summary dated 11/28/2023 lacked documented evidence that the discharge summary was forwarded to the patient’s attending physician. During a joint record review and interview on 03/22/2024, the Director of Nursing confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s 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 the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed for discharged patients revealed that the agency did not ensure the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. Clinical Record 11: The discharge summary dated 12/27/2023 lacked a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. Clinical Record 12: The discharge summary dated 11/28/2023 lacked a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. During a joint record review and interview on 03/22/2024, the Director of Nursing confirmed that the record lacked a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician.”