City Hospice & Palliative Care, LLC

“It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the patient’s written Plan of Care was updated with new goals upon the change in care related to the treatment of an infection. The hospice policy “Orders for Care” (PC.5) dated 10/01/2015 included in part that the “...Agency will obtain orders and provide care in accordance with physician’s orders ... Changes in problems and care and patient’s goals related to care ...” Clinical Record 3: The patient elected the hospice benefit on 12/20/2023. During the Registered Nurse (RN) visit dated 01/27/2024, the patient was complaining of burning, frequency with urination, dysuria, and cloudy urine. The nurse noted that the”...Patient reports pelvic pain ...dysuria, frequency, and urine retention ...Pt taking Azo tablets and drinking cranberry juice as recommended but not effective. Dr ... informed; Bactrim DS Oral tablet 1 tab PO x5 days prescribed for UTI ...” A physician order was documented on 01/27/2024 #31127174427 for Bactrim DS Oral Tablet 800mg/160mg. Take 1 tablet by mouth (dispense 14 tabs) with a start date of 01/28/2024 and a discontinue date of 02/03/2024. There were no identified goals for treating an active urinary tract infection. Personnel Record 1: It was confirmed during an interview with the Director of Nursing (DON) on 04/12/2024 that the patient’s Plan of Care was not updated with any goals of care for the treatment of an active infection.”

“It is required that each patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the patient’s written Plan of Care was updated with all medications the patient was taking per the nurse’s notes. The agency policy “Patient Reassessment” (PE.4) dated 11/01/2013 “...The Comprehensive Health Assessment will be updated with verbal orders from the physician to include but not be limited to ... list of current medications...” The agency policy “Review and Revision of Patient Care” (PC.9) dated 08/01/2004 read in part that the “...Agency will review and revise patient care in accordance with changes in the patient’s condition ... upon identifying that patient care needs have changed ... adjustments to the care planning documents will be made as follows ...IDT Plan of Care by RN...All written changes to the plan of care will be incorporated into the patient’s medical record as changes occur.” The hospice’s policy “Medication List and Monitoring” (PC.17) dated 05/01/2010 included in part that “...Agency will maintain a current, accurate list of all prescription and over-the-counter (OTC) medications taken by the patient (Medication Profile) ...Changes in the medication regimen will be documented in the medical record either on the medication profile, on a verbal order, and in the Plan of Care ... Changes in medication regimen will be updated as frequently as necessary to keep the profile accurate.” Clinical Record 3: The patient elected the hospice benefit on 12/20/2023. During the Registered Nurse (RN) visit dated 01/27/2024, the patient was complaining of burning, frequency with urination, dysuria, and cloudy urine. The nurse noted that the”...Patient reports pelvic pain ...dysuria, frequency, and urine retention ...Pt taking Azo tablets and drinking cranberry juice as recommended but not effective. Dr ... informed; Bactrim DS Oral tablet 1 tab PO x5 days prescribed for UTI ...” A physician order was documented on 01/27/2024 #31127174427 for Bactrim DS Oral Tablet 800mg/160mg. Take 1 tablet by mouth (dispense 14 tabs) with a start date of 01/28/2024 and a discontinue date of 02/03/2024. There was no physician’s order for the Azo tablets mentioned in the nurse’s note dated 01/27/2024, and Azo was not included on the patient’s list of medications - current or discontinued. Personnel Record 1: During an interview with the Director of Nursing (DON) on 04/12/2024, it was confirmed that the patient’s Plan of Care was not updated with the Azo over-the-counter symptom medication documented in the nurse’s note. After it was brought to her attention, the DON corrected the clinical record with the updated information.”

“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 an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 8 (38%) clinical records reviewed in which Hospice Aide services were accepted revealed the agency failed to ensure that the Registered Nurse (RN) provided complete written instructions to the Hospice Aide in order to provide care. The hospice’s policy “Implementing Care and Treatment” (PC.7) dated 08/01/2015 included i part that “...The Agency RN ... will oversee the assignment of a hospice aide to a particular patient ... The aide will be provided with written instructions for patient care prepared by an RN ... “ Clinical Record 4: The patient elected the hospice benefit on 09/01/2023. The Plan of Care Orders dated 12/07/2023 (effective 11/30/2023 to 02/27/2024) and 02/15/2024 (effective 02/28/2024 to 04/27/2024) included orders for the Aide to visit the patient three times weekly. The Aide Care Plan dated 02/27/2024 included the interventions for a complete shower and foot care (clean only) every visit. A two-view x-ray of the right lower extremity was documented in a physician’s order dated 02/26/2024. On 02/27/2024, the Registered Nurse noted in part that “...Patient had a major fall this recert period and sustained a laceration to right lower leg and bruise to right lower shin. Patient is currently bedbound due to injury ..” Then on 03/04/2024, the RN documented that the “... Pt uses a Geri Chair and has the cast to the right leg ... RLE remains immobilized and elevated...” There were no instructions from the RN to the Aide in the care plan on taking care of the patient’s cast right lower extremity during the patient’s shower and foot care. Clinical Record 10: The patient elected the hospice benefit on 04/03/2024. The Plan of Care Order dated 04/03/2024 (effective 04/03/2024 to 07/01/2024) included an order for the Hospice Aide to visit the patient three times a week. The Registered Nurse documented in her visit on 04/03/2024 that the patient had a stage 2 wound to his right plantar foot surface measuring 0.7 x 0.5 x 0. A physician’s order dated 04/03/2024 included wound care orders to cleanse the wound daily with wound cleanser and pat dry with 4x4 gauze. Apply a small amount of Medihoney with calcium alginate and cover with an island dressing. The dressing changes were ordered daily. The Aide Care Plan dated 04/03/2024 included the interventions for a complete shower every visit and for foot care (clean only) every visit. The RN did not include any directions to the Aide on what to do should the dressing become wet, loose, or soiled. Clinical Record 12: The patient elected the hospice benefit on 11/15/2023 and died on hospice services on 02/03/2024. The Plan of Care Orders dated 11/15/2023 (effective 11/15/2023 to 02/12/2024) and 01/05/2024 (effective 11/15/2023 to 02/12/2024) included orders for the Hospice Aide to visit the patient five times a week. The Aide Care Plan dated 11/15/2023 included the intervention for a complete shower every visit. The Care Plan included the functional limitations of endurance and dyspnea, as well as the Durable Medical Equipment (DME) of oxygen, tub/shower bench, and activities up to tolerated per wheelchair. On 01/09/2024, the Registered Nurse (RN) noted in part that the patient was “...short of breath ...increase oxygen from 3L to 4L ... oriented to person, forgetful.” Then, on 01/12/2024, the nurse documented in part that the patient had “... dyspnea at rest despite on continuous oxygen at 4L via nasal cannula ...” oriented to person, forgetful..” On 01/22/2024, the nurse’s visit note documented that the patient had “... On continuous oxygen at 4L via nasal cannula, dyspnea at rest ... increased confusion...” And on 01/29/2024, the nurse wrote in part that the patient was “...now preactive and disoriented ... unable to make needs known ...On continuous oxygen at 4L via nasal cannula ...” The Aide Care Plan dated 11/15/2023 included the interventions for a complete shower every visit but did not include any instructions to the Aide if the oxygen could be removed for care. Personnel Record 1: It was confirmed during an interview with the Director of Nursing (DON) on 04/12/2024 that the Aide Care Plans did not include instructions from the Registered Nurse (RN) to the Aide regarding the care of the wound/dressing, cast or continuous use of oxygen during the provision of care. The DON updated the Aide care plans before the end of the site visit.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 8 (12%) clinical records reviewed in which Hospice Aide services were documented as being accepted revealed the agency did not ensure that the Aide visits were made according to the Plan of Care. The agency’s policy “Implementing Care and Treatment” (PC.7) dated 08/01/2015 read in part that “The Agency RN ... will oversee the assignment of a hospice aide to a particular patient initiating hospice aide services within time frame to meet identified patient’s needs and per physician orders... When the provision of care/treatment cannot be implemented as established in the care planning document(s), the patient’s physician will be notified. The appropriate documentation will be completed and submitted by discipline/Patient Care Manager...” The hospice’s policy “Review and Revision of Patient Care” (PC.9) dated 08/01/2004 included in part that “...Upon identifying patient care needs have changed (according to Agency policy), adjustments to the care planning documents will be made as follows: MD Interim Orders - RN ... Home Health Aide Care Plan - RN...” Clinical Record 5: The patient elected the hospice benefit on 08/24/2023. The Plan of Care Orders dated 11/22/2023 (effective 11/22/2023 to 02/19/2024), 02/29/2024 (effective 2/20/24 to 4/19/24) and 03/14/2024 (effective 02/20/2024 to 04/19/2024) included orders for the Hospice Aide to visit the patient twice a week. The Interdisciplinary Group Meetings (IDG) dated 08/31/2023, 09/14/2023, 09/28/2023, 10/12/2023, 10/26/2023, 10/31/2023, 11/09/2023, 11/22/2023, 12/07/2023, 01/04/2024, 01/18/2024, 02/01/2024, 02/15/2024, 02/29/2024, 03/14/2024, and 03/28/2024 all included twice weekly Hospice Aide visits. There were never any Aide visits documented, and no physician orders to discontinue Aide services. Personnel Record 1: It was confirmed during an interview with the Director of Nursing (DON) on 04/12/2024 that while she was aware of changes in the needs of the patients as it related to Hospice Aide visits, the clinical records were not updated with changes to the orders or Plans of Care.”