Healing Hands Healthcare LLC

“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 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the drug profile was current, which resulted in the reconciliation being incomplete. Clinical Record 2/ Home Visit 2: This patient elected the Hospice Benefit 03/18/2024 with a diagnosis of hypertensive heart and chronic kidney disease. The Registered Nurse (RN) assessment on 10/16/2024 documented that the patient had chest pain requiring nitroglycerine and oxygen. This was the first documentation of the patient receiving oxygen. A physician order was obtained 10/16/2024 for oxygen 2-4 liters per minute as needed. The plan of care from dates of 10/16/2024-11/14/2024 was reviewed and included oxygen therapy and patient education. In review of the medication profile dated 11/12/2024, there was no documentation of oxygen. During the home visit, on 11/12/2024 to observe the Master’s Social Worker (Personnel Record 2), a concentrator was observed in the home. The patient stated that she had experienced some shortness of breath a couple of weeks ago and the nurse had ordered oxygen for her and instructed her to use it when she became short of breath or experienced chest pain. In an interview with the Registered Nurse/Executive Vice President of Systems and Processes on 11/14/2024, it was confirmed that the nitroglycerine was listed on the medication profile, but the oxygen was not listed on the medication profile. The Registered Nurse/Executive Vice President of Systems and Processes, and the Registered Nurse/Hospice Director both stated that the oxygen had a physician’s order and was in the plan of care, but the nurse must have forgotten to add it to the medication profile.”

“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 the following: measurable outcomes anticipated from implementing and coordinating 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, the agency did not ensure that the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 7: This patient elected the Hospice Benefit 08/22/2023 with a diagnosis of senile degeneration of the brain. On the initial comprehensive assessment (08/22/20230 the Registered Nurse (RN) stated the patient goal for pain was “0”. The Registered Nurse (RN) assessment on 08/16/2024 documented that the patient was unable to answer questions or rate pain. The plan of care dated, 08/05/2024 and 11/14/2024, documented that “pain would be managed at a level acceptable to the patient,” without documentation as to what was acceptable to the patient. In an interview with the Registered Nurse/Hospice Director on 11/14/2024, it was confirmed that the plan of care did not reflect measurable outcomes as the patient was unable to verbalize if the level of pain was manageable. The RN Hospice Director stated the staff nurse assessed the patient’s comfort level, but no documentation was present of a non-verbal scoring tool for pain.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments: 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 1 of 2 (50%) clinical records reviewed that required care orders for wounds, the agency did not ensure that the plan of care included the treatment for a surgical wound. Clinical Record 7: This patient elected the Hospice Benefit 08/22/2023 with a hospice diagnosis of senile degeneration of the brain and history of surgical repair of a right hip fracture on 08/18/2023. In the comprehensive assessment, dated 08/22/2023, the Registered Nurse documented the presence of a bandage covering the incision from the surgery of the right hip. The nurse documented orders received from the physician on 08/25/2023 to remove the staples and leave incision open to air. The wound care sheet was completed for visits made 08/23/2023 and 08/25/2023. The plan of care dated 08/22/2023 and 11/22/2023, was reviewed and it did not include interventions for treatment of the wound. In an interview with the Registered Nurse/Executive Vice President of Systems and Processes on 11/14/2024, it was confirmed that the nurse documented the wound and removal of staples, but the plan of care did not include interventions for care of the wound. It was stated that the electronic medical record was set up to automatically transfer physician’s orders to the plan of care, but this did not occur.”