Faith Hospice Inc.

“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. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 3 (33%) home visits performed revealed the agency did not ensure the drug profile contained the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1: During Home Visit 1(Clinical Record 1) on 07/18/2024 with the registered nurse (RN) (Personnel Record 4), a review of the hospice medication list was compared to the adult foster home medication list. The adult foster home list contained the following medications not listed on the hospice list: Docusate 100 mg twice daily, fish oil daily, and vitamin D3 daily. The hospice medication list contained Lactulose 10 mg/15 ml as needed, Lomotil 2.5 mg as needed, Rynex 10 ml as needed. It was also noted that the dosage on the hospice medication list for the Tylenol was 650 mg and the home had 500 mg on hand. These differences were discussed during the site visit and the hospice adult foster homeowner advised he was asked by the patient’s guardian to “start giving the vitamins again last month”. The hospice nurse suggested that was “fine but hospice needed to be aware.” The Site Visitor interviewed the hospice nurse about the “as needed” medications that were no longer in the home. The nurse advised he “left them on the medication list in case the patient needed them again in the future.” During an interview and joint record review with the Director of Patient Care Services on 07/18/2024, it was confirmed the medication lists had not been reconciled at the time of the comprehensive assessment.”

“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 a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. 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 patient’s individualized plan of care included a detailed statement of the frequency of services necessary to meet the specific patient and family needs. Clinical Record 1: The patient elected the hospice benefit on 1/15/2022 for the diagnosis of Alzheimer’s disease. The initial plan of care dated 1/15/2022 included the following Problem: “Spiritual interventions. Arrange for the patient to receive supportive visits/sacraments/rituals from religious/spiritual leaders.” The patient and guardian declined the spiritual counselor upon admission, however, this problem remained open on her plan of care and has not been updated or revised to reflect the appropriate frequency of services for the spiritual counselor. Clinical Record 2: The patient elected the hospice benefit on 5/26/2023 for the diagnosis of malignant neoplasm of the colon. The initial plan of care dated 5/26/2023 contained the Problem: “Assess spiritual need and visitation. Spiritual goals. Patient and caregiver will identify spiritual needs for end of life by: “ The patient and family have declined the spiritual counselor and have declined having any spiritual needs which were assessed upon admission by the nurse. This plan of care has remained open and has not been revised to include an individualized statement regarding the frequency of services for this patient’s spiritual needs. Clinical Record 14: The patient elected the hospice benefit on 8/19/2023 for the diagnosis of malignant neoplasm of the ovary. The plan of care dated 8/19/2023 included the Problem: “Assess spiritual need and visitation. Spiritual goals. Patient and caregiver will identify spiritual needs for end of life by: “. The patient and family initially declined visits by the spiritual counselor. A nursing visit dated 10/25/2023 noted “SN (skilled nurse) explained to patient’s husband that the disease at this time has no cure as husband is in denial r/t (related to) patient’s prognosis. SN asked daughter to schedule appointment with CH (chaplain) to help with not accepting current situation. A spiritual counselor (SC) visit dated 10/31/2023 noted SC visit patient was not responding at all, and RN called the CH and family was concerned the patient was going to die without last rites. The plan of care was not updated or revised with the frequency changes as the patient and family needs changed. During an interview and joint record review with the Director of Patient Care Services on 07/18/2024, it was confirmed these plans of care had not been individualized or updated since admission.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the individualized plan of care was revised as frequently as the patient’s condition required. Clinical Record 4: The patient elected the hospice benefit on 7/2/2024 for the diagnosis of congestive heart failure. The initial nursing assessment documented the patient’s pain “was 8 on admission and the acceptable level was listed as a 3/10.” The follow-up nursing visit the next day listed the patient’s pain as controlled and at “0 on 1-10 scale”. The plan of care included a pain problem that included a goal that pain would be managed by the end of the benefit period (9/28/2024). It was not adjusted to make it more timely and individualized and to reflect the interventions being provided. Clinical Record 13: The patient elected the hospice benefit on 1/4/2024 for the diagnosis of malignant neoplasm of the pancreas. A nursing visit dated 1/29/2024 noted “SN (skilled nurse) encouraged patient to talk to SN, SC (spiritual counselor) or caregivers r/t (related to) increased anxiety.” Medication changes effective.” The care plan did not reflect any problems, goals or interventions related to patient’s anxiety. During an interview and joint record review with the Director of Patient Care Services on 07/18/2024, it was confirmed the care plans had not been updated as the patient’s conditions changed.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview and personnel record review. In 6 of 10 (60%) personnel records reviewed revealed the agency did not ensure the competencies were assessed of individuals providing care. Document 6: Agency Policy titled “HR.C10 Competency Assessment Dated 2021” stated in relevant part “A hospice must assess the skills and competencies of all individuals furnishing care, including volunteers upon hire and annually” Personnel Record 2: The Administrator/DPCS with a hire date of 10/6/2021 did not have evidence of RN competencies for 2022 and 2023. Personnel Record 3: The nurse practitioner with a hire date of 07/01/2022 did not have evidence of competencies for 2023. Personnel Record 4: The registered nurse with a hire date of 08/16/2021 did not have annual competencies in their personnel file. Personnel Record 5: The social worker with a hire date of 10/06/2021 did not have annual competencies in their personnel file. Personnel Record 9: The volunteer coordinator with a hire date of 06/18/2021 did not have annual competencies in their personnel file. Personnel Record 10: The hospice aide with a hire date of 06/04/2021 did not have annual competencies in their personnel file. During an interview and joint record review with the Director of Patient Care Services on 07/18/2024, it was confirmed the annual competencies had not been completed on “several employees and a new human resources person had been hired and a new process was being put into place to prevent this in the future.””