San Jose Hospice Care

“It is required that hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by personnel record review and interviews with the Administrator and the Director of Nursing which revealed issues with the agency’s ability to provide core services directly by hospice employees in a manner consistent with acceptable standards of practice in the following areas: Failure to ensure the core services of a spiritual counselor by a hospice employee (the Chaplain (Personnel Record 4) was hired on 10/12/2023 as a 1099 contracted employee) and the Social Worker services by a hospice employee (Personnel Record 3) was hired on 01/25/2024 as a 1099 contracted employee {HCDT.2.I/L587}. The cumulative effect of this deficiency has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.64: Core Services.”

“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 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 and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the drug profile was updated with changes in the comprehensive assessment. Clinical Record 8: The patient was admitted on 05/02/2024. During the benefit period 05/02/2024 to 07/30/2024 the patient was seen by a licensed vocational nurse on 06/10/2024 who documented that the patient had been seen by the dermatologist a few days prior, no date listed, and new medications were ordered. There was no documented evidence what medications were ordered. On 06/12/2024 patient was seen by the registered nurse, who documented that the patient’s new drug regimen included doxycycline, clobetasol solution, triamcinolone cream, and prednisone. New medications were discussed at the interdisciplinary meeting (IDG); however, no order was generated in electronic medical record, and the medication list was not updated with the new medication. During an interview with the Director of Nurses on 10/03/2024, she stated that she had been trying to audit every record but sometimes she misses one.”

“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. This standard was not met as evidenced by clinical record review and document review. In 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure the designated registered nurse IDG member provided coordination of care to ensure continuous assessment of each patient’s and family’s needs and the implementation of the interdisciplinary plan of care. Document 3: The policy titled Hospice Policy and Procedure Manual Interdisciplinary Group (IDG) stated in part “The hospice will designate a Registered Nurse, that is a member of the IDG to facilitate communication about changes in the patient’s status among interdisciplinary group members and the patient’s Attending Physician and facility representatives”. Clinical Record 2: The clinical record revealed that the registered nurse did not ensure that the Plan of Care was updated after the Foley Catheter was removed. Clinical Record 8: The clinical record revealed that the registered nurse did not ensure that the new medications doxycycline 50 mg tabs, clobetasol solution, triamcinolone cream, and prednisone 10 mg were added to the medication list.”

“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: A revised plan of care includes: Information from the patient’s updated comprehensive assessment; Record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure a revised plan of care was updated with the comprehensive assessments. Clinical Record 2: The patient elected hospice on 06/22/2024. In the benefit period 06/22/2024 to 09/19/2024, the patient was seen by the registered nurse (RN) on 09/16/2024. The RN documented the patient had a urologist appointment on 09/14/2024 and the foley catheter was removed. There was no documented evidence of an order noted to remove the Foley catheter. The clinical documentation was sent to the interdisciplinary team on 09/25/2024. The plan of Care for the benefit period 09/20/2024 to 12/17/2024 was not updated. The Foley catheter remained on the Plan of Care, and no problems were included to monitor urinary retention. During an interview with the Director of Nurses on 10/03/2024 she stated that she forgot to update the problems on the Plan of Care.”

“It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that sharing of information occurs between all disciplines providing care and services in all settings and is ongoing whether or not the care and services are provided directly or under arrangement. This standard was not met as evidenced by clinical record review and document review. In 1 of 14 (7%) clinical record review revealed the agency did not ensure that the licensed vocational nurse communicated patient changes between all disciplines providing care. Document 2: The policy named Hospice Policy and Procedure Manual Nursing Services states in part “The LVN, supplements the nursing care needs of the patient as provided by the RN and as specified in the plan of care including, ensuring communication of information to appropriate team members.” Clinical Record 8: The patient elected hospice services on 05/02/2024. During the benefit period 05/02/2024 to 07/30/2024 the patient was seen on 06/10/2024 by the licensed vocational nurse (LVN). The LVN documented that the patient had blisters to her upper extremities and that the patient was seen by a dermatologist who ordered new medications. There was no documented evidence in the clinical record that the LVN communicated to the registered nurse about the changes in the patient’s condition.”

“It is required that a hospice aide provides services: Included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 7 (14%) clinical record reviews for patients receiving aide services revealed that the aide did not complete task ordered in the aide plan of care. Home Visit 3: During a joint visit with the hospice aide (Personnel Record 2) on 10/02/2024, it was observed that tasks listed on the current aide plan of care for the benefit period 08/01/2024 to 10/29/2024 were not completed. The following tasks were on the plan of care and not completed during the visit, comb hair, lotion, nails clean/file, oral care, and shave. We exited the home together, the aide stated that she needed to leave immediately. During an interview with the Director of Nurses on 10/02/2024 regarding home visit 3, she stated that she did not know why the aide plan of care was not followed.”

“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, document review and interview. In 2 of 2 (100%) clinical records reviewed in which the patient was a live discharge revealed that that agency did not ensure that a complete discharge summary was completed and provided to the attending physician. Document 1: The agency’s policy titled Hospice Policy and Procedure Manual Discharge from Hospice Care states “If a patient is discharged from hospice, the hospice must forward to the patient’s attending physician, a copy of the following: The hospice Discharge Summary, which includes: a summary of the patient’s stay including treatment, symptoms and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.” Clinical Record 13: The patient elected hospice on 05/13/2024. The patient elected to transfer to another hospice on 06/12/2024. The clinical record contained no evidence of a documented discharge summary, or a discharge summary being sent to the alternate hospice or any care coordination with the alternate hospice. Clinical Record 14: The patient elected hospice on 10/18/2023. The patient revocated services on 03/15/2023. The clinical record contained no evidence of a documented discharge summary, or a discharge summary being sent to the attending physician. During a joint review of the clinical records on 10/03/2024 the Director of Nurses stated that she could not find a discharge summary or any indication that one was sent to the 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 the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) clinical records reviewed in which the patient elected a live discharge revealed that the agency did not ensure that a discharge summary was completed. Document 1: The agency’s policy titled Hospice Policy and Procedure Manual Discharge from Hospice Care states “If a patient is discharged from hospice, the hospice must forward to the patient’s attending physician, a copy of the following: The hospice Discharge Summary, which includes: a summary of the patient’s stay including treatment, symptoms and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.” Clinical Record 14: The patient elected hospice on 10/18/2023. The patient requested a transfer to an alternate hospice on 03/15/2024. The clinical record contained no evidence of a documented discharge summary, Clinical Record 13: The patient elected hospice on 05/13/2024. The patient requested a transfer to an alternate hospice on 06/12/2024. The clinical record contained no evidence of a documented discharge summary, During a joint review of the clinical records on 10/03/2024 the Director of Nurses stated that she could not find a discharge summary and did not know how to generate the discharge summary in the electronic medical record.”