Yellow Rose Hospice Care, Inc.

“It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members must provide the care and services offered by the hospice, and the group, its entity, must supervise the care and services provided to the patient and family. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that the IDG provided the care and services offered by the hospice, and the group, its entity, and did not supervise the care and services provided to the patient and family. Clinical Record 1: The initial comprehensive psychosocial assessment was completed on 3/05/2024. The MSW identified that the patient was a body donor and was not aware that he had to complete an application form for body donation. The MSW documented that she will be assisting the patient in obtaining and completing an application for his body donation. The Chaplain completed an initial comprehensive assessment on 03/05/2024 and documented that the Social Worker will be assisting the patient in completing the application for body donation. No follow-up visit was completed to assist the patient in completing the application for his body donation as was documented. The Administrator/Alt DON was interviewed 03/25/2024 during a joint clinical record review and confirmed that no follow-up visit was documented to assist the patient in completing his application for body donation.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed revealed the hospice did not ensure the implementation of the interdisciplinary plan of care. Clinical Record 1: The patient elected hospice care on 02/29/2024. Primary Diagnosis Heart Disease. The initial comprehensive assessment completed on 02/29/2024 revealed that the patient had a foley catheter that was inserted on 01/27/2024. The order written on 02/29/2024 was to change foley catheter every month. The RN documented that the foley catheter was changed on 03/09/2024. There was no documented evidence that the catheter was changed during the month of February or why the catheter was not changed. The Administrator/Alternate DON was interviewed during a joint clinical record review on 03/25/2024 and confirmed that the foley catheter was not changed as ordered.”

“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. The documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed revealed that the agency did not ensure that the patient’s individualized plan of care reflects patient and family goals and identified planned interventions based on problems identified in the initial and updated assessments. Clinical Record 1: The patient elected hospice care on 02/29/2024 with a diagnosis of heart disease. The initial comprehensive assessment completed on 02/29/2024 identified dyspnea on minimal exertion. The hospice plan of care effective 02/29/2024 did not include treatment orders, interventions or goals for dyspnea. Clinical Record 3: The patient elected hospice care on 03/01/2024 with a diagnosis of chronic obstructive pulmonary disease. The initial comprehensive assessment completed on 03/01/2024 identified dyspnea on minimal exertion. The hospice plan of care effective 03/01/2024 did not include treatment orders, interventions, or goals for dyspnea. The Administrator/Alternate DON was interviewed during a joint clinical record review on 03/25/2024 and confirmed that the individualized plan of care did not include problems identified during the initial comprehensive assessment.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group, included in the plan of care, and permitted to be performed under state law and regulation. 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 that Hospice aides are assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group. Written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of this section HCDT.15.I/L625}; Failed to ensure Hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to {HRSM.25.I/L629}; and Failed to ensure that the aide provided services ordered by the Interdisciplinary Group (IDG) and included in the plan of care (POC) (HCDT.16 /IL626}. 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 418.76. 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 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 and interview. 9 of 14 (64%) clinical records reviewed revealed that the agency did not ensure the hospice Interdisciplinary Group (IDG) completed an initial comprehensive assessment within five (5) calendar days of the patient electing hospice services. Clinical Record 1: The initial nursing assessment and the patient’s election of hospice care were completed on 07/11/2023. The Chaplain documented a completed comprehensive spiritual assessment on 07/18/2023 (seven (7) days after the hospice election), and the Medical Social Worker (MSW) documented a psychosocial and emotional comprehensive assessment was completed on 07/28/2023 (17 days after the hospice election). The clinical record did not contain documented evidence to support that the Interdisciplinary Group completed an initial comprehensive assessment within five (5) calendar days of the patient electing hospice care or documentation to support additional attempts by the IDG to contact and schedule the psychosocial assessment within the required 5 days and the patient’s refusal. Clinical Record 2: The initial nursing assessment and the patient’s election of hospice care were completed on 09/25/2023, and it was documented that the patient refused a visit from the chaplain. The Medical Social Worker (MSW) documented a completed psychosocial and emotional comprehensive assessment along with a bereavement risk assessment on 10/03/2023 (eight (8) days after the hospice election). The clinical record did not contain documented evidence to support that the Interdisciplinary Group completed an initial comprehensive assessment within five (5) calendar days of the patient electing hospice care or documentation to support attempts by the IDG to contact and schedule the psychosocial assessment within the required 5 days and the patient’s refusal. Clinical Record 4: The initial nursing assessment, including a brief spiritual assessment, and the patient’s election to hospice care was completed on 10/11/2023. The MSW documented a communication note on 10/15/2023 that completion of the psychosocial and emotional assessment was pending communication with the patient. The MSW documented a completed psychosocial and emotional comprehensive assessment on 10/21/2023 (ten (10) days after the hospice election). The clinical record did not contain documented evidence to support that the Interdisciplinary Group completed an initial comprehensive assessment within five (5) calendar days of the patient electing hospice care or documentation to support additional attempts by the IDG to contact and schedule the psychosocial assessment within the required 5 days and the patient’s refusal. Clinical Record 5: The initial nursing assessment and the patient’s election of hospice care were completed on 09/05/2023, and the chaplain completed a detailed spiritual assessment on 09/07/2023. The clinical record did not contain documented evidence of a completed psychosocial and emotional assessment by the MSW, thus documented evidence to support that the Interdisciplinary Group completed an initial comprehensive assessment within five (5) calendar days of the patient electing hospice care or documentation to support additional attempts by the IDG to contact and schedule the psychosocial assessment within the required 5 days and the patient’s refusal. Clinical Record 8: The initial nursing assessment, including a bereavement risk assessment, and the patient’s election of hospice care was completed on 06/27/2023, and it was documented that the patient refused a visit from the chaplain. The Medical Social Worker (MSW) documented a completed psychosocial and emotional comprehensive assessment on 07/06/2023 (nine (9) days after the hospice election). The clinical record did not contain documented evidence to support that the Interdisciplinary Group completed an initial comprehensive assessment within five (5) calendar days of the patient electing hospice care or documentation to support additional attempts by the IDG to contact and schedule the psychosocial assessment within the required 5 days and the patient’s refusal. Clinical Record 10: The initial nursing assessment, including a brief spiritual assessment, and the patient’s election to hospice care was completed on 07/26/2023. The MSW documented a communication note on 07/30/2023 that completion of the psychosocial and emotional assessment was pending communication with the patient/family. The MSW documented a completed psychosocial and emotional comprehensive assessment on 08/02/2023 (six (6) days after the hospice election). The clinical record did not contain documented evidence to support that the Interdisciplinary Group completed an initial comprehensive assessment within five (5) calendar days of the patient electing hospice care or documentation to support additional attempts by the IDG to contact and schedule the psychosocial assessment within the required 5 days and the patient’s refusal. Clinical Record 12: The initial nursing assessment and the patient’s election of hospice care were completed on 08/21/2023, and the chaplain documented a completed spiritual and bereavement risk assessment on 08/26/2023. Although the Medical Social Worker (MSW) documented an attempt to contact the family on 08/25/2023, the completed psychosocial and emotional comprehensive assessment was not documented until 09/05/2023 (15 days after the hospice election). The clinical record did not contain documented evidence to support that the Interdisciplinary Group completed an initial comprehensive assessment within five (5) calendar days of the patient electing hospice care or documentation to support additional attempts by the IDG to contact and schedule the psychosocial assessment within the required 5 days and the patient’s refusal. Clinical Record 13: The initial nursing assessment, including a bereavement risk assessment, and the patient’s election to hospice care was completed on 09/19/2023. The MSW/Chaplain documented completed psychosocial, emotional, and spiritual comprehensive assessments on 09/25/2023 (six (6) days after the hospice election). The clinical record did not contain documented evidence to support that the Interdisciplinary Group completed an initial comprehensive assessment within five (5) calendar days of the patient electing hospice care or documentation to support additional attempts by the IDG to contact and schedule the psychosocial assessment within the required 5 days and the patient’s refusal. Clinical Record 14: The initial nursing assessment, including a bereavement risk assessment, and the patient’s election to hospice care was completed on 01/10/2023. The MSW and Chaplain documented completed psychosocial, emotional, and spiritual comprehensive assessments on 01/16/2023 (six (6) days after the hospice election). The clinical record did not contain documented evidence to support that the Interdisciplinary Group completed an initial comprehensive assessment within five (5) calendar days of the patient electing hospice care or documentation to support additional attempts by the IDG to contact and schedule the psychosocial assessment within the required 5 days and the patient’s refusal. On 02/15/2023 joint clinical record reviews and interviews were conducted with the Administrator, Alternate Administrator, and the Director of Nursing, who confirmed that the clinical records identified did not include documented evidence supporting comprehensive assessments were completed within five (5) days of the patient electing hospice care. Leadership also confirmed that the clinical record did not contain documented evidence to support why the comprehensive assessments were not completed in the required time frame.”

“It is required that medical social services are provided per the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 11 (18%) clinical records reviewed, in which Medical Social Worker (MSW) services were accepted, revealed the agency did not ensure that MSW services were provided per the plan of care. Clinical Record 1: The plan of care orders, effective for the benefit period 07/11/2023 through 09/08/2023, included a frequency for visits by the MSW of one (1) visit per month. The MSW completed an initial psychosocial assessment on 07/28/2023. The clinical record did not contain documented evidence to support that a visit was completed by the MSW during September 2023 or documentation of why the visit was missed. Clinical Record 3: The plan of care orders, effective for the benefit period 11/30/2023 through 02/27/2024, included a frequency for visits by the MSW of one (1) visit per month. The MSW documented a completed initial psychosocial assessment on 12/05/2023 and conducted Home Visit 1 on 02/13/2024. The clinical record did not contain documented evidence to support that a visit was completed by the MSW in January 2024 or documentation of why the visit was missed. On 02/15/2024 joint clinical record reviews and interviews were conducted with the Administrator, Alternate Administrator, and the Director of Nursing, who confirmed that the clinical records identified did not include documented evidence to support visits were completed by the MSW as ordered (one (1) visit per month) or documentation to support why the visits were missed.”

“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 3 of 8 (38%) clinical records reviewed, in which hospice aide services were accepted, revealed that the agency did not ensure the Registered Nurse (RN) provided specific written instructions for the aide to follow. Clinical Record 2: The hospice aide care plan, effective 09/25/2023, documented instructions to assist the patient with ambulation and to provide a complete shower every visit. The initial nursing assessment completed on 09/25/2023 documented a fall risk score of nine (9) indicating the patient was at high risk for falls and had a history of multiple falls. The aide care plan did not alert the aide to the patient’s high fall risk. Clinical Record 8: The hospice aide care plan effective 01/30/2024 documented instructions for the aide to perform two types of baths: a partial bath/shower and a complete shower every visit. The care plan did not provide clear, specific instructions to the aide regarding the type of bath to be given, forcing the aide to make decisions outside of the aide’s scope of practice. Clinical Record 9: The initial nursing assessment on 09/29/2023 documented that the patient had a suprapubic catheter in place, a Percutaneous Endoscopic Gastrostomy (PEG) tube in place, and multiple wounds. The hospice aide care plan, effective on 09/29/2023 and updated on 12/28/2023, included instructions to perform catheter care; however, the care plan did not alert the aide to the type of catheter the patient had or the specific care to be provided. The care plan did not alert the aide that the patient had a PEG tube and wounds or if the aide was to provide any site care. On 02/15/2024 joint clinical record reviews and interviews were conducted with the Administrator, Alternate Administrator, and Director of Nursing, who confirmed that the clinical records did not contain evidence of specific patient care instructions for the aide regarding patient-specific care needs and risks.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 8 (12%) clinical records reviewed, in which hospice aide services were accepted, revealed that the agency did not ensure that the aide provided services ordered by the Interdisciplinary Group (IDG) and included in the plan of care (POC). Clinical Record 2: The plan of care (POC), effective 12/24/2023, included a visit frequency for the aide of five (5) visits per week, and on 01/11/2024 the POC was updated to include a visit frequency for the aide of two (2) visits per week. The aide documented three (3) visits were completed each week from 12/25/2023 through 02/13/2024. The clinical record did not contain visit frequency orders for the aide to provide three (3) visits per week. On 02/15/2024 joint clinical record reviews and interviews were conducted with the Administrator, Alternate Administrator, and Director of Nursing, who confirmed that the aide performed three (3) visits per week based on the care plan instructions; however, the clinical record did not contain POC or physician orders increasing the aide’s visit frequency to three (3) visits per week.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 8 (25%) clinical records reviewed, in which aide supervisory visits were required, revealed that the agency did not ensure the Registered Nurse (RN) documented an assessment of the quality of care and services provided by the hospice aide no less frequently than every 14 days. Clinical Record 2: The plan of care orders, effective 09/25/2023, included an aide visit frequency of five (5) visits per week. An order to change the frequency was documented by the RN on 10/30/2023 to a frequency of two (2) visits per week. The RN completed an aide supervisory visit on 10/02/2023, and the next aide supervisory visit was documented on 11/27/2023 which was 56 days apart. The RN also documented aide supervisory visits were completed on 12/04/2023 and 12/25/23 which were 21 days apart. Clinical Record 8: The plan of care orders, effective 09/25/2023, included an aide visit frequency of two (2) visits per week. The RN completed the first aide supervisory visit on 10/24/2023 (29 days after aide services began). Although the aide continued to provide two (2) visits per week, the clinical record did not contain documented evidence to support that the RN completed aide supervisory visits between 10/24/2023 and 12/12/2023 (49 days) when aide services were discontinued. On 02/15/2024 joint clinical record reviews and interviews were conducted with the Administrator, Alternate Administrator, and Director of Nursing, who confirmed that the clinical records identified did not include documentation to support that the aide supervisory visits were completed by the RN no less frequently than every 14 days.”

“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 physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure the clinical records contained physician orders for all care and services provided to the patient. Clinical Record 1: The initial nursing assessment completed on 07/11/2023 documented the patient was wearing a Thrombo-Embolic-Deterrent (TED) Hose on both legs to help with lower extremity edema. The clinical record did not contain documented evidence of a physician’s order for the TED Hose. Clinical Record 2: The hospice aide documented three (3) visits per week were completed from 12/25/2023 through 02/13/2024. The clinical record did not contain documented evidence of a physician’s order for aide visit frequency of three (3) visits per week. A physician’s order for an Occupational Therapist (OT) “to evaluate and treat effective 11/08/2023 for one visit only” was documented on 11/08/2023. The documented visit notes from OT visits dated 11/08/2023 and 11/13/2023 were uploaded to the electronic medical record (EMR). The clinical record did not contain a documented physician’s order for the second OT visit completed on 11/13/2024. On 02/15/2024 joint clinical record reviews and interviews were conducted with the Administrator, Alternate Administrator, and Director of Nursing who confirmed that the clinical records identified did not include physician orders for the TED Hose, changes in aide frequency of visits, and the second visit completed by the OT.”

“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. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed, in which the patient was transferred to another Medicare certified hospice, revealed that the agency did not ensure that a copy of the hospice discharge summary was forwarded to the receiving facility. Clinical Record 12: A transfer of a designated hospice provider form, signed by the patient’s representative, was uploaded into the agency’s electronic medical record documenting the effective date of the transfer as 10/19/2023. The clinical record did not contain documented evidence to support that a copy of the discharge summary was forwarded to the receiving hospice. On 02/15/2024 a joint clinical record review and interviews were conducted with the Administrator, Alternate Administrator, and Director of Nursing, who confirmed that the clinical record did not contain documented evidence to support a discharge summary was forwarded to the receiving hospice agency.”

“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 1 of 2 (50%) clinical records reviewed, in which the patient was discharged from hospice services, revealed that the agency did not ensure a hospice discharge summary was forwarded to the patient’s attending physician. Clinical Record 12: A discharge note completed by the Registered Nurse on 10/19/2023 documented that the patient was transferred to another hospice. The clinical record did not contain documented evidence to support that a copy of a discharge summary was forwarded to the patient’s attending physician. On 02/15/2024 a joint clinical record review and interviews were conducted with the Administrator, Alternate Administrator, and Director of Nursing, who confirmed that the clinical record did not contain documented evidence to support that a 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 a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed, in which the patient was discharged from hospice services, revealed that the agency did not ensure a discharge summary was created and included a summary of the patient’s hospice stay, treatments, symptoms, pain management, current plan of care (POC), and physician orders to assist in the continuity of care post-discharge. Clinical Record 12: A physician’s order to discharge the patient to another hospice was obtained and documented on 10/19/2023. The clinical record did not contain documented evidence to support a discharge summary, including information on the patient’s hospice stay, treatments, symptoms, pain management, plan of care, and physician orders at the time of discharge, was created. On 02/15/2024 a joint clinical record review and interviews were conducted with the Administrator, Alternate Administrator, and Director of Nursing, who confirmed that the clinical record identified did not include documented evidence to support that a discharge summary was created to include all required elements needed to ensure continuity of care post-discharge from the agency.”