Nightingale Hospice Care, Inc.

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 7 of 19 (37%) clinical records reviewed, the agency did not ensure the initial bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 7: The patient elected the hospice benefit on 10/04/2023. Clinical record review revealed no documented evidence that the initial bereavement assessment was completed as part of the start of care comprehensive assessment. The initial bereavement assessment was dated 10/20/2023, 16 days after the patient’s election of hospice benefit date. Clinical Record 10: The patient elected the hospice benefit on 12/19/2023. Clinical record review revealed no documented evidence that the initial bereavement assessment was completed as part of the start of care comprehensive assessment. The initial bereavement assessment was dated 01/09/2024, 21 days after the patient’s election of hospice benefit date. Clinical Record 12: The patient elected the hospice benefit on 02/02/2024. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed as part of the start of care comprehensive assessment. Clinical Record 13: The patient elected the hospice benefit on 04/26/2023. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed as part of the start of care comprehensive assessment. Clinical Record 15: The patient elected the hospice benefit on 02/02/2024. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed as part of the start of care comprehensive assessment. Clinical Record 16: The patient elected the hospice benefit on 11/01/2023. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed as part of the start of care comprehensive assessment. Clinical Record 18: The patient elected the hospice benefit on 11/07/2023. Clinical record review revealed no documented evidence that an initial bereavement assessment was completed as part of the start of care comprehensive assessment. The Administrator/Alternate Director of Nursing (DON)/Owner, DON/Alternate Administrator/Owner, Registered Nurse (RN) (DON in training), and RN (Administrator in training) stated in an interview on 02/15/2024 that the agency did not ensure the initial bereavement assessment was being completed as part of the comprehensive assessment. The DON stated that the current process was for the Chaplain to complete the initial bereavement assessment during the Chaplain initial assessment visit, but for the patients or families that refused or wanted to delay the Chaplain initial visit ended up having a direct impact with meeting this requirement.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and 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 8 of 19 (42%) clinical records reviewed, the agency did not ensure the plan of care (POC) reflected patient and family goals and specific interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The physician documented on the certification of terminal illness (CTI) dated 11/17/2023 that the patient was incontinent of bladder and gets agitated at times. The POC dated 11/17/2023 did not include goal(s) and planned intervention(s) related to the patient’s bladder incontinence and agitation. Clinical Record 2: The physician documented on the CTI dated 10/24/2023 that the patient was incontinent of bladder. The POC dated 10/24/2023 did not include goal(s) and planned intervention(s) related to the patient’s bladder incontinence. Clinical Record 4: The physician documented on the CTI dated 11/20/2023 that the patient was incontinent of bowel and bladder and had shortness of breath (SOB) with minimal exertion. The POC dated 11/20/2023 did not include goal(s) and planned intervention(s) related to the patient’s bowel and bladder incontinence and SOB. Clinical Record 5: The physician documented on the CTI dated 07/17/2023 that the patient was incontinent of bowel and bladder and had shortness of breath (SOB) with moderate exertion. The POC dated 07/17/2023 did not include goal(s) and planned intervention(s) related to the patient’s bowel and bladder incontinence and SOB. Clinical Record 6: The physician documented on the CTI dated 08/14/2023 that the patient’s primary diagnosis was protein calorie malnutrition. The POC dated 08/14/2023 did not include goal(s) and planned intervention(s) related to the patient’s malnutrition needs. Clinical Record 7: The POC dated 10/24/2023 included an order for the Social Worker frequency of visits one time per month with an additional three (3) prn [as needed] visits for psychosocial support. The POC did not include goal(s) and planned intervention(s) related to the patient’s psychosocial status. Clinical Record 8: The POC dated 01/18/2023 included an order for the Social Worker frequency of visits one time per month with an additional three (3) prn [as needed] visits for psychosocial support. The POC did not include goal(s) and planned intervention(s) related to the patient’s psychosocial status. Clinical Record 11: The POC dated 08/01/2023 included an order for the Social Worker frequency of visits one time per month with an additional three (3) prn [as needed] visits for psychosocial support. The POC did not include goal(s) and planned intervention(s) related to the patient’s psychosocial status. The Administrator/Alternate Director of Nursing (DON)/Owner, DON/Alternate Administrator/Owner, Registered Nurse (RN) (DON in training), and RN (Administrator in training) stated in an interview on 02/15/2024 that the agency did not ensure the POC reflected patient and family goals and specific interventions based on problems identified in the initial and updated comprehensive assessments.”

“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 1 of 17 (6%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse (RN) updated the aide care plan. Clinical Record 1: The patient elected the hospice benefit on 11/17/2023 with a terminal diagnosis of senile degeneration of the brain. The aide care plan dated 11/17/2023 assigned the aide visit frequency one time per week. Clinical record review revealed the aide visit frequency increased to three times per week the week of 12/03/2023. The RN did not update the aide visit frequency on the aide care plan. During an interview and review of findings on 02/15/2024, the Administrator /Alternate Director of Nursing (DON) /Owner, DON/Alternate Administrator/Owner, RN (DON in training), and RN (Administrator in training) stated that the agency did not ensure the RN updated the aide care plan assignment to reflect the increased frequency of aide visits needed to meet the patient needs.”

“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. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the Medical Director or physician designee documented a written certification of terminal illness (CTI) that included consideration of the patient’s primary terminal condition. Clinical Record 10: The patient elected the hospice benefit on 12/19/2023. Clinical record review revealed no documented evidence that the Medical Director completed the initial CTI that included consideration of the patient’s primary terminal condition. The Administrator/Alternate Director of Nursing (DON)/Owner, DON/Alternate Administrator/Owner, Registered Nurse (RN) (DON in training), and RN (Administrator in training) stated in an interview on 02/16/2024 that the agency did not ensure there was a completed, signed and dated initial certification of terminal illness.”

“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: Related diagnosis(es), if any. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the Medical Director or physician designee documented a written certification of terminal illness (CTI) that included related diagnosis(es) if any. Clinical Record 10: The patient elected the hospice benefit on 12/19/2023. Clinical record review revealed no documented evidence that the Medical Director completed the initial CTI that included related diagnosis(es). The Administrator/Alternate Director of Nursing (DON)/Owner, DON/Alternate Administrator/Owner, Registered Nurse (RN) (DON in training), and RN (Administrator in training) stated in an interview on 02/16/2024 that the agency did not ensure there was a completed, signed and dated initial certification of terminal illness.”

“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: Current subjective and objective medical findings. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the Medical Director or physician designee documented a written certification of terminal illness (CTI) that included current subjective and objective medical findings. Clinical Record 10: The patient elected the hospice benefit on 12/19/2023. Clinical record review revealed no documented evidence that the Medical Director completed the initial CTI that included current subjective and objective medical findings. The Administrator/Alternate Director of Nursing (DON)/Owner, DON/Alternate Administrator/Owner, Registered Nurse (RN) (DON in training), and RN (Administrator in training) stated in an interview on 02/16/2024 that the agency did not ensure there was a completed, signed and dated initial certification of terminal illness.”

“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: Current medication and treatment orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the Medical Director or physician designee documented a written certification of terminal illness (CTI) that included current medication and treatment orders. Clinical Record 10: The patient elected the hospice benefit on 12/19/2023. Clinical record review revealed no documented evidence that the Medical Director completed the initial CTI that included current medication and treatment orders. The Administrator/Alternate Director of Nursing (DON)/Owner, DON/Alternate Administrator/Owner, Registered Nurse (RN) (DON in training), and RN (Administrator in training) stated in an interview on 02/16/2024 that the agency did not ensure there was a completed, signed and dated initial certification of terminal illness.”

“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: 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 1 of 19 (5%) clinical records reviewed, the agency did not ensure the Medical Director or physician designee documented a written certification of terminal illness (CTI) that included information about the medical management of any of the patient’s conditions unrelated to the terminal illness. Clinical Record 10: The patient elected the hospice benefit on 12/19/2023. Clinical record review revealed no documented evidence that the Medical Director completed the initial CTI that included information about the medical management of any of the patient’s conditions unrelated to the terminal illness. The Administrator/Alternate Director of Nursing (DON)/Owner, DON/Alternate Administrator/Owner, Registered Nurse (RN) (DON in training), and RN (Administrator in training) stated in an interview on 02/16/2024 that the agency did not ensure there was a completed, signed and dated initial certification of terminal illness.”

“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: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by document review, clinical record review, and interview. In 7 of 19 (37%) clinical records reviewed, the agency did not ensure the clinical record included a completed Election of Hospice Benefit form. Agency policy PE.25 Eligibility and Election of the Medicare Hospice Benefit, dated 11/2020, stated in part, “Content of the election statement: The election statement will include: Identification of the particular hospice and of the Attending Physician that will provide care to the patient, and the patient’s or representative’s acknowledgment that the identified Attending Physician was the patient’s choice, or the patient does not wish to choose.” Clinical Record 1: The patient elected the hospice benefit on 11/17/2023. Clinical record review revealed the election of hospice benefit form dated 11/17/2023 contained no documented evidence that the section “Right to choose an attending physician” was completed. The record did not include documentation that the patient acknowledged the identified attending physician was the patient’s choice. Clinical Record 3: The patient elected the hospice benefit on 11/21/2023. Clinical record review revealed the election of hospice benefit form dated 11/21/2023 contained no documented evidence that the section “Right to choose an attending physician” was completed. The record did not include documentation that the patient acknowledged the identified attending physician was the patient’s choice. Clinical Record 5: The patient elected the hospice benefit on 07/17/2023. Clinical record review revealed the election of hospice benefit form dated 07/17/2023 contained no documented evidence that the section “Right to choose an attending physician” was completed. The record did not include documentation that the patient acknowledged the identified attending physician was the patient’s choice. Clinical Record 7: The patient elected the hospice benefit on 10/04/2023. Clinical record review revealed the election of hospice benefit form dated 10/04/2023 contained no documented evidence that the section “Right to choose an attending physician” was completed. The record did not include documentation that the patient acknowledged the identified attending physician was the patient’s choice. Clinical Record 8: The patient elected the hospice benefit on 01/18/2023. Clinical record review revealed the election of hospice benefit form dated 01/18/2023 contained no documented evidence that the section “Right to choose an attending physician” was completed. The record did not include documentation that the patient acknowledged the identified attending physician was the patient’s choice. Clinical Record 14: The patient elected the hospice benefit on 01/15/2023. Clinical record review revealed the election of hospice benefit form dated 01/15/2023 contained no documented evidence that the section “Right to choose an attending physician” was completed. The record did not include documentation that the patient acknowledged the identified attending physician was the patient’s choice. Clinical Record 18: The patient elected the hospice benefit on 11/07/2023. Clinical record review revealed the election of hospice benefit form dated 11/07/2023 contained no documented evidence that the section “Right to choose an attending physician” was completed. The record did not include documentation that the patient acknowledged the identified attending physician was the patient’s choice. The Administrator/Alternate Director of Nursing (DON)/Owner, DON/Alternate Administrator/Owner, Registered Nurse (RN) (DON in training), and RN (Administrator in training) stated in an interview on 02/16/2024 that the agency did not ensure the election of hospice benefit form section that listed “Right to choose an attending physician” was completed.”

“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: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the clinical record contained a physician order. Clinical Record 1: The patient elected the hospice benefit on 11/17/2023. Clinical record review revealed hospice aide visits increased from once a week to three times a week starting the week of 12/03/2023. There was no documented evidence in the clinical record that a physician order was obtained when the aide frequency of visits increased. The Administrator/Alternate Director of Nursing (DON)/Owner, DON/Alternate Administrator/Owner, Registered Nurse (RN) (DON in training), and RN (Administrator in training) stated in an interview on 02/15/2024 that the agency did not ensure there was a physician order obtained for the increased frequency of aide visits.”

“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 2 (50%) clinical records reviewed with patient transfer to a Medicare/Medicaid certified facility, the agency did not ensure a copy of the discharge summary was forwarded to the receiving facility. Clinical Record 6: The patient elected the hospice benefit on 08/14/2023. The patient and family revoked hospice care and signed the revocation on 01/09/2024 to pursue aggressive treatment. The patient was then transferred to the hospital. The clinical record contained no documented evidence that the discharge summary was sent to the receiving facility. The Administrator/Alternate Director of Nursing (DON)/Owner, DON/Alternate Administrator/Owner, Registered Nurse (RN) (DON in training), and RN (Administrator in training) stated in an interview on 02/15/2024 that the agency did not ensure a copy of the discharge summary was forwarded to the receiving facility.”

“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 1 of 2 (50%) clinical records reviewed where the patient revoked the hospice benefit, the agency did not ensure a copy of the discharge summary was forwarded to the patient’s attending physician. Clinical Record 6: The patient elected the hospice benefit on 08/14/2023. The patient and family revoked hospice care and signed the revocation on 01/09/2024 to pursue aggressive treatment. The clinical record contained no documented evidence that the discharge summary was sent to the patient’s attending physician. The Administrator/Alternate Director of Nursing (DON)/Owner, DON/Alternate Administrator/Owner, Registered Nurse (RN) (DON in training), and RN (Administrator in training) stated in an interview on 02/15/2024 that the agency did not ensure a copy of the discharge summary was forwarded to the patient’s attending physician.”