Blue Stream Hospice and Palliative Care Inc.

“It is required that a clinical record containing past and current findings is maintained for each hospice patient. The clinical record must contain correct clinical information that is available to the patient’s attending physician and hospice staff. The clinical record may be maintained electronically. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure the clinical record contained initial and updated plans of care {HSIM. 3. I/L672}; Failed to ensure that the clinical records included physician orders {HSIM. 3. I/L678; Failed to ensure the clinical patient record, its content, and the information it contains is safeguarded against loss or unauthorized use and that the hospice complies with state and federal law and regulation addressing privacy, including the Health Insurance and Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH) {HSIM. 5. I/L680}; Failed to ensure patient clinical records must be retained for 6 years after the death or discharge of the patient unless State law stipulates a longer period of time {HSIM.1. D/L681}; Failed to ensure the clinical record, whether hard copy or in electronic form, must be made readily available on request by an appropriate authority {HSIM.6. I/L685}; and Failed to ensure patient has a right to have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164 {HPFC. 2. D/L516}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.104: Clinical Records. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the written Patient Bill of Rights includes the right to have a confidential record per state and federal law and regulation. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 11 (45%) clinical records reviewed that were discharged from the hospice agency revealed that the agency did not ensure that the patient’s clinical record remained confidential per state and federal law and regulation. Document 1: Policy “Patient Rights and Responsibilities” reviewed/revised 12/30/2023 stated in part “A patient has a right to confidential treatment of the patient’s personal and medical records.” Clinical Record 9: The patient’s election of hospice benefit was 3/10/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review Clinical Record 10: The patient’s election of hospice benefit was 4/6/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. Clinical Record 11: The patient’s election of hospice benefit was 4/8/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. Clinical Record 12 The patient’s election of hospice benefit was 4/12/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. Clinical Record 13: The patient’s election of hospice benefit was 4/26/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. The Administrator confirmed the findings and disclosed in interview on 2/14/2024 that she does not know where the clinical records are located and believes that the previous administrator is in possession of the clinical records. She verbalized that she has tried to reach out to the previous administrator and has not received return communication.”

“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 intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review, interview, and personnel record review. 1 of 8 (12%) clinical records reviewed revealed that the agency did not ensure that the patient’s individualized written plan of care reflected the patient and family goals and included interventions to manage pain. Document 1: Policy “Plan of Care” reviewed/revised 12/30/2023 stated in part “The written plan of care, with a focus on palliative care, will include the following: 1. Problems identified. 2. Patient and family goals. 3. Interventions to manage pain and symptoms.” Clinical Record 1/Home Visit 1: The registered nurse (RN) initial nursing assessment dated 2/5/2024 identified pain as an unmanaged problem. The initial plan of care dated 2/5/2024 did not include the identified problem of pain, patient and family goals for pain management, and interventions to manage pain. During the home visit with the RN (Personnel Record 7), the patient disclosed that pain had been an issue before coming to her present location and that she had reported the pain in her shoulder and rib area to the admission nurse. Home Visit 1: During home visit 1 on 2/14/2024, the patient (clinical record 1) disclosed that pain had been an issue before coming to Texas and that she reported her pain at admission to the admission nurse. She reported that the pain was in her shoulder and rib area. The Administrator confirmed findings in a joint record review and interview on 2/15/2024, that the plan of care created 2/5/2024 did not include goals and interventions for the pain as identified in the initial nursing assessment on 2/5/2024.”

“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 intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review, interview, and personnel record review. In 1 of 8 (12%) clinical records reviewed revealed that the agency did not ensure that the patient’s individualized written plan of care reflected the patient and family goals and included interventions to manage pain. Document 1: Policy “Plan of Care” reviewed/revised 12/30/2023 stated in part “The written plan of care, with a focus on palliative care, will include the following: 1. Problems identified. 2. Patient and family goals. 3. Interventions to manage pain and symptoms.” Clinical Record 1/Home Visit 1: The registered nurse (RN) initial nursing assessment dated 2/5/2024 identified pain as an unmanaged problem. The initial plan of care dated 2/5/2024 did not include the identified problem of pain, patient and family goals for pain management, and interventions to manage pain. During the home visit with the RN (Personnel Record 7), the patient disclosed that pain had been an issue before coming to her present location and that she had reported the pain in her shoulder and rib area to the admission nurse. During the joint record review and interview with the Administrator on 2/15/2024, the Administrator confirmed the findings that the plan of care did not include goals and interventions for the pain as identified in the initial nursing assessment.”

“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. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 8 (12%) clinical records reviewed revealed that the agency did not ensure that the clinical record included physician orders for service provided. Document 1: Policy “Clinical Record” reviewed/revised 12/30/23 stated in part “The clinical record will include: physician orders.” Clinical Record 2: The clinical record included documentation of completed nursing visits 11/14/2023, 11/15/2023, 11/29/2023, 12/8/2023, 12/21/2023, 12/29/2023, 1/2/2024, 1/9/2024, 1/20/2024, and 1/25/2024; and completed social worker visits 11/17/2023, 12/15/2023 and 1/8/2024. The clinical record did not contain evidence that physician orders were obtained for nursing and social work services provided. The administrator confirmed findings in joint record review and interview on 2/15/2024, that the clinical record did not contain physician orders for the nursing and social work services provided.”

“It is required that the clinical patient record, its content, and the information it contains is safeguarded against loss or unauthorized use and that the hospice complies with state and federal law and regulation addressing privacy, including the Health Insurance and Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 11 (45%) clinical records reviewed that were discharged from the hospice agency revealed that the agency did not ensure that the patient’s clinical record was safeguarded against loss and that the agency complied with state and federal law and regulation addressing privacy, including the Health Insurance and Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). Document 1: Policy “IM.5 Medical Record Information Confidentiality” reviewed 12/30/2023 stated in part “Agency will ensure that all patient identifiable information in the clinical record remain confidential and will be secured and controlled whether in hard copy, electronic format or a combination of both in compliance with the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).” Clinical Record 9: The patient’s election of hospice benefit was 3/10/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review 2/15/2024. Clinical Record 10: The patient’s election of hospice benefit was 4/6/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. Clinical Record 11: The patient’s election of hospice benefit was 4/8/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. Clinical Record 12 The patient’s election of hospice benefit was 4/12/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. Clinical Record 13: The patient’s election of hospice benefit was 4/26/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. The Administrator confirmed the findings and disclosed in interview on 2/14/2024 that she does not know where the clinical records are located and believes that the previous administrator is in possession of the clinical records. She verbalized that she has tried to reach out to the previous administrator and has not received return communication.”

“It is required that information management policies and procedures (P&P) address how the hospice documents, collects, retrieves, protects, shares, and retains information in accordance with state and federal law and regulation and that patient clinical records are retained for six (6) years after the death or discharge of the patient unless state law stipulates a longer time period. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 11 (45%) clinical records reviewed that were discharged from the hospice agency revealed that the agency did not ensure that the patient’s clinical record was retained for six years in accordance with state and federal law and regulation or ten years per agency policy. Document 1: Policy “Clinical Record” reviewed/revised 1/31/15 stated in part “The hospice will ensure patient clinical records are retained for 10 years after the death or discharge of the patient.” Clinical Record 9: The patient’s election of hospice benefit was 3/10/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. Clinical Record 10: The patient’s election of hospice benefit was 4/6/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. Clinical Record 11: The patient’s election of hospice benefit was 4/8/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. Clinical Record 12 The patient’s election of hospice benefit was 4/12/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. Clinical Record 13: The patient’s election of hospice benefit was 4/26/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. The Administrator confirmed the findings and disclosed in interview on 2/14/2024 that she does not know where the clinical records are located and believes that the previous administrator is in possession of the clinical records. She verbalized that she has tried to reach out to the previous administrator and has not received return communication.”

“It is required that the patient clinical record, whether in hard copy or in electronic form, is made readily available on request by an appropriate authority. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 11 (45%) clinical records reviewed that were discharged from the hospice agency revealed that the agency did not ensure that the clinical record was readily available for review as requested by an appropriate authority. Document 1: Policy “Clinical Record” reviewed/revised 10/13/2022 states in part “The hospice will ensure the clinical record, whether hard copy or in electronic form, will be made readily available upon request by an appropriate authority.” Clinical Record 9: The patient’s election of hospice benefit was 3/10/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review Clinical Record 10: The patient’s election of hospice benefit was 4/6/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. Clinical Record 11: The patient’s election of hospice benefit was 4/8/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. Clinical Record 12 The patient’s election of hospice benefit was 4/12/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. Clinical Record 13: The patient’s election of hospice benefit was 4/26/2021. Date of discharge unknown. Reason for discharge unknown. Clinical record not on site at agency. Agency unable to retrieve records through date of review. The Administrator confirmed the findings and disclosed in interview on 2/14/2024 that she does not know where the clinical records are located and believes that the previous administrator is in possession of the clinical records. She verbalized that she has tried to reach out to the previous administrator and has not received return communication.”