Redeemer Hospice

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 14 14%) clinical records reviewed revealed the organization did not ensure a medication reconciliation was completed and medications updated to the medication profile. Home Visit 3: The date of the election of the hospice benefit (Clinical Record 1) was dated 05/14/2024. The medication profile dated 06/12/2024 documented Levothyroxine 50mcg tablet, one tablet by mouth daily. During the home visit (Home Visit 3) with the medical social worker (MSW) (Personnel Record 7) on 06/12/2024, the medication bottles were reviewed with the patient’s daughter. The Levothyroxine bottle was for 100mcg, one by mouth daily, dated 05/12/2024. The daughter stated that the Levothyroxine was increased to 100mcg by mouth daily on 05/12/2024. There was no documented evidence that the Levothyroxine was reconciled and updated to the hospice medication profile during the registered nurse comprehensive assessment dated 05/14/2024. Clinical Record 10: The registered nurse (RN) comprehensive assessment note dated 05/02/2024 stated, “Patient with signs and symptoms of UTI, MD made aware, U/A collected 04/18/2023, continues on Macrodantin as directed, lab results to PCP, yeast infection, as per physician will start Diflucan medication, HOLD Macrodantin. The skilled nurse (SN) instructed daughter, voiced understanding.” documented, “Fluconazole 100mg 1 daily x 7 days.” There was no documented evidence that the medications were reconciled and updated to the hospice medication profile and plan of care. During a joint clinical record review and interview on 06/12/2024 with the DON and Quality Assurance/Compliance Officer/LVN the Director of Nursing confirmed that there was no documented evidence the medications were reconciled.”

“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 the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The date of the election was 11/18/2023. The primary hospice diagnosis was senile degeneration of the brain, not elsewhere classified with comorbidities of essential (primary) hypertension, insomnia, muscle weakness, unsteadiness on the feet, severe intellectual disabilities, Alzheimer’s disease, abnormal weight loss, and primary osteoarthritis of the left shoulder. The RN comprehensive assessment dated 04/01/2024 documented that the patient had arthritic pain to left shoulder rating 2/10, currently on tramadol 50mg every 6 hours as needed, and Acetaminophen 500mg 1-2 tablets every 6 hours as needed; urinary incontinence; occasional constipation with bowel incontinence; unsteady gait; dependent of 5/6 ADLs; disorientation, confused, and restless; taking Seroquel 25mg 1 tablet daily, Lorazepam 0.5mg 1 tablet every 4 hours as needed; insomnia, taking Zolpidem 10mg at bedtime. The POC dated 03/17/2024-05/15/2024 and 05/16/2024-07/14/2024 did not include problems, interventions, and goals for risk for skin breakdown, incontinence, impaired mobility, impaired cognition, and insomnia. The POCs did contain problems and goals for bowel elimination, cardiovascular, and pain but did not have interventions. Clinical Record 3: The date of the election was 01/28/2024. The primary hospice diagnosis was Alzheimer’s disease with comorbidities of muscle weakness, contracture of the muscle, shortness of breath, insomnia, and hypothyroidism. The RN comprehensive assessment dated 04/22/2024 documented arthritic joint pain, taking Acetaminophen 500mg 1-2 tablets every 6 hours as needed; urinary incontinence; aspiration precautions; irregular heart sounds, fluctuations, tachycardia, and fatigue; 1+ non-pitting edema to the BLE; bowel incontinence, constipation, taking Senna Plus 1-2 tablets at bedtime as needed, external hemorrhoids, taking Hemorrhoidal relief cream 5% applied topically twice a day as needed for inflammation; contractures to upper and lower extremities, bed bound; patient at risk due to B/B incontinence; disoriented and confused; taking Memantine 10mg twice a day and Quetiapine 25mg twice a day.” The POC dated 04/17/2024-07/15/2024 did not include problems, interventions, and goals for impaired cognition, the risk for skin breakdown, edema, shortness of breath, cardiovascular changes, incontinence, constipation, impaired mobility, and impaired swallowing/aspiration precautions. The POC did have goals for the pain management problem but did not have interventions. Clinical Record 4: The date of the election was 11/17/2024. The primary hospice diagnosis was Parkinson’s Disease without dyskinesia, without mention of fluctuations with comorbidities of muscle weakness, unsteadiness on the feet, bed confinement, hemiplegia and hemiparesis following infarction affecting the right dominant side, other sequelae of cerebral infarction, other speech and language deficits following unspecified cerebrovascular disease, essential (primary) hypertension, and polyarthritis. The RN comprehensive assessment dated 05/28/2024 documented pain 3/10 to the left knee, taking Backaid 500/25mg 2 caplets every bedtime and Tramadol 50mg every 6 hours as needed; bladder and bowel incontinent; high risk for skin breakdown; aspiration precautions. SOB/dyspnea, oxygen 2 LPM via N/C prn; has left hemiparesis; peripheral cyanosis to left lower extremity; purple lips (cyanosis) at times; taking Chlorthalidone, Metoprolol, Valsartan, and Verapamil; constipation taking Lactulose, Senna, and Linzes PRN; bedridden; left arm contracture; dependent for ADLs; amputated right great toe; insomnia taking Temazepam 30mg at bedtime. The POC dated 05/17/2024-07/13/2024 did not include problems, interventions, and goals for impaired mobility, impaired communication, the risk for skin breakdown, impaired swallowing/aspiration precautions, and insomnia. The POC did have problems and goals for bowel elimination, cardiovascular, and pain but did not have interventions. During a joint clinical record review and interview on 06/12/2024, the Quality Assurance/Compliance Officer/Licensed Vocational Nurse confirmed there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the assessments. During a joint clinical record review and interview on 06/12/2024, the Director of Nursing confirmed 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 each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the organization did not ensure a medication reconciliation was completed and medications updated to the medication profile and plan of care. Home Visit 3: The date of the election of the hospice benefit (Clinical Record 1) was dated 05/14/2024. The medication profile dated 06/12/2024 documented Levothyroxine 50mcg tablet, one tablet by mouth daily. During the home visit (Home Visit 3) with the medical social worker (MSW) (Personnel Record 7) on 06/12/2024, the medication bottles were reviewed with the patient’s daughter. The Levothyroxine bottle was for 100mcg, one by mouth daily, dated 05/12/2024. The daughter stated that the Levothyroxine was increased to 100mcg by mouth daily on 05/12/2024. There was no documented evidence that the Levothyroxine was reconciled and updated to the hospice medication profile or plan of care during the registered nurse comprehensive assessment dated 05/14/2024. Clinical Record 10: Clinical Record 10: The registered nurse (RN) comprehensive assessment note dated 05/02/2024 stated, “Patient with signs and symptoms of UTI, MD made aware, U/A collected 04/18/2023, continues on Macrodantin as directed, lab results to PCP, yeast infection, as per physician will start Diflucan medication, HOLD Macrodantin. The skilled nurse (SN) instructed daughter, voiced understanding.” documented, “Fluconazole 100mg 1 daily x 7 days.” There was no documented evidence that the medications were reconciled and updated to the hospice medication profile and plan of care. During a joint clinical record review and interview on 06/13/2024, the Director of Nursing confirmed that there was no documented evidence the Fluconazole and Diflucan were updated to the medication profile and plan of care.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations revealed the organization did not ensure the staff followed the hand hygiene policy. Document 1: Agency Policy, “Infection Control Plan 2018” stated, “Hand Hygiene. Indications for Hand Hygiene. Always perform hand hygiene in the following situations: after glove removal.” Home Visit 1: During Home Visit 1 (Clinical Record 6) on 06/11/2024, the Registered Nurse (RN) (Personnel Record 2) was observed removing the gloves and picking up a pen and paper twice without washing the hands after removing the gloves. During a joint document review and interview on 06/11/2024, the Quality Assurance/Compliance Officer/Licensed Vocational Nurse confirmed that the staff did not follow the hand hygiene protocol.”

“It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, under the direction of a physician. The psychosocial assessment addresses the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, the presence or absence of adequate coping mechanisms, family dynamics and communication patterns, financial resources and any constraints, the caregiver’s ability to function effectively, obstacles and risk factors that may affect compliance with the plan of care, family support systems to facilitate coping with end-of-life issues. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the organization did not ensure that medical social services were provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services. Clinical Record 2: The plan of care dated 03/17/2024-05/15/2024 stated, “Medical Social Worker (MSW) frequency two visits for one month, starting month of 04/01/2024, and one visit for one month, starting month of 05/01/2024.” Physician’s orders on 04/07/2024 and 04/08/2024 stated, “MSW regular service (MSW frequency three visits for one month, starting month of 04/01/2024).” Physician’s orders on 04/09/2024 and 04/11/2024 stated, “MSW regular service (MSW frequency two visits for one month, starting month of 04/01/2024).” There was a missed visit for 04/06/2024 that stated, “Visit scheduled by mistake.” There were MSW visits on 04/11/2024 and 05/02/2024. The record lacked one visit for April. During a joint clinical record review and interview on 06/12/2024, the Director of Nursing confirmed that the records lacked evidence of missed visits documented for medical social worker visits according to the plan of care. During a joint clinical record review and interview on 06/12/2024, the Quality Assurance/Compliance Officer/Licensed Vocational Nurse confirmed that the records lacked evidence of missed visits documented for medical social worker visits according to the plan of care.”

“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, signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 11 of 14 (79%) clinical records reviewed revealed that the agency did not ensure the patient’s signed consents included the date of election. Clinical Record 4: The Hospice Informed Consent forms, signed and dated 11/17/2023, had a space for the date of election, but the space and box were left blank. The registered nurse initial comprehensive assessment, certification of terminal illness (CTI) and the initial plan of care (POC) effective 11/17/2023 were all dated 11/17/2023. Clinical Record 5: The Hospice Informed Consent forms, signed and dated 03/26/2024, had a space for the date of election, but the space and box were left blank. Clinical Record 6: The Hospice Informed Consent forms, signed and dated 02/02/2024, had a space for the date of election, but the space and box were left blank. The Patient Information and Emergency Preparedness/Disaster Preparedness Plan form, the Coordination of Services form, and the CTI document the patient’s start of hospice care was dated 02/03/2024. Clinical Record 7: The Hospice Informed Consent forms, signed and dated 01/29/2024, had a space for the date of election, but the space and box were left blank. The Patient Information and Emergency Preparedness/Disaster Preparedness Plan form, the Coordination of Services form, and the Physician’s Certification of Terminal Illness document the patient’s “start of hospice care “ on 01/30/2024. Clinical Record 8: The Hospice Informed Consent forms, signed and dated 11/18/2023, had a space for the date of election, but the space and box were left blank. The initial comprehensive assessment, CTI and the initial plan of care were all dated 11/18/2023. Clinical Record 9: The Hospice Informed Consent forms, signed and dated 01/12/2024, had a space for the date of election, but the space and box were left blank. Clinical Record 10: The Hospice Informed Consent forms, signed and dated 11/18/2023, had a space for the date of election, but the space and box were left blank. Clinical Record 11: The Hospice Informed Consent forms, signed and dated 11/21/2023, had a space for the date of election revealed “1”. The date of the election was not entered in the space. Clinical Record 12: The Hospice Informed Consent forms, signed and dated 11/22/2023, had a space for the date of election, but the space and box were left blank. Clinical Record 13: The Hospice Informed Consent forms, signed and dated 04/18/2024, had a space for the date of election, but the space and box were left blank. The Patient Information and Emergency Preparedness/Disaster Preparedness Plan form, the Coordination of Services form, the Medication form, the Plan of Care, and the Physician’s Certification of Terminal Illness document the patient’s “start of hospice” on 04/23/2024. Clinical Record 14: The Hospice Informed Consent forms, signed and dated 03/05/2024, had a space for the date of election, but the space and box were left blank. The Patient Information and Emergency Preparedness/Disaster Preparedness Plan form, the Coordination of Services form, the Physician’s CTI and the RN Admission and Comprehensive Assessment document the patient’s “start of hospice care” on 03/07/2024. During a joint clinical record review and interview on 06/13/2024, the Director of Nursing confirmed that the patient’s signed consent lacked the hospice date of election.”

“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 and interview. In 1 of 14 (7%) clinical records reviewed revealed the organization did not ensure the patient’s record includes physician’s orders. Clinical Record 10: The election of the hospice benefit was dated 11/18/2023. The registered nurse (RN) comprehensive assessment dated 05/02/2024 documented Fluconazole 100 mg 1 daily x 7 days, started 05/02/2024. The record lacked a physician’s order for Fluconazole. During a joint clinical record review and interview on 06/13/2024, the Director of Nursing confirmed that there was no documented evidence of physician’s orders for the medication identified.”

“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 for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 11: The patient revoked the election of hospice care on 12/21/2023. The discharge summary dated 12/21/2023 lacks documentation that the discharge summary was forwarded to the patient’s attending physician. Clinical Record 12: The patient revoked the election of hospice care on 12/24/2023. The discharge summary dated 12/24/2023 lacks documentation that the discharge summary was forwarded to the patient’s attending physician. During a joint record review and interview on 06/13/2024, the Director of Nursing confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.”