Prime Choice Hospice & Palliative Care LLC

“It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment, and the documented discussion of the plan provided to the patient/family and maintained by the hospice. This standard was not met as evidenced by interview and observation. In 3 of 3 (100%) home visit observations, it was revealed that the agency did not ensure the patient/family participated in the development and inclusion of a plan for the patient during a natural or man-made disaster as part of a patient/family comprehensive assessment. Home Visit 1: During the home visit performed on 12/7/23, the patient/family home information reviewed included general emergency preparedness information. There was no evidence of an individualized emergency preparedness plan. Home Visit 2: During the home visit performed on 12/7/23, the patient/family home information reviewed included general emergency preparedness information. There was no evidence of an individualized emergency preparedness plan. Home Visit 3: During the home visit performed on 12/7/23, the patient/family home information reviewed included general emergency preparedness information. There was no evidence of an individualized emergency preparedness plan. . The Administrator/Volunteer Coordinator (personnel record 4), Director of Nursing/Alternate Administrator (personnel record 6), and Consultant stated in an interview on 12/7/23, that the agency did not ensure individualized emergency plans were developed for each patient/family.”

“It is required that during the initial assessment visit and in advance of providing care, the hospice obtains the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities statement. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 6 (50%) clinical records reviewed it was revealed that the agency did not ensure that the patient’s or representative’s signature was obtained to verify receipt of Bill of Rights and Responsibilities statement. Clinical Record 1: Admission paperwork and consents dated 11/23/2023 were signed by a personal care home representative. Clinical Record 2: Admission paperwork and consents dated 9/1/2023 were signed by a personal care home representative. Clinical Record 3: Admission paperwork and consents dated 9/1/2023 were signed by personal care home representative. Document 1: The state HEALTH AND SAFETY CODE, TITLE 4. HEALTH FACILITIES, SUBTITLE F. POWERS AND DUTIES OF HOSPITALS, CHAPTER 313. CONSENT TO MEDICAL TREATMENT ACT, Sec. 313.004. CONSENT FOR MEDICAL TREATMENT., read in part, “(a) If an adult patient of a home and community support services agency or in a hospital or nursing home, or an adult inmate of a county or municipal jail, is comatose, incapacitated, or otherwise mentally or physically incapable of communication and does not have a legal guardian or an agent under a medical power of attorney who is reasonably available after a reasonably diligent inquiry, an adult surrogate from the following list, in order of priority, who has decision-making capacity, is reasonably available after a reasonably diligent inquiry, and is willing to consent to medical treatment on behalf of the patient may consent to medical treatment on behalf of the patient: (1) The patient’s spouse; (2) The patient’s adult children; (3) The patient’s parents; or (4) The patient’s nearest living relative. (a-1) If the patient does not have a legal guardian, an agent under a medical power of attorney, or a person listed in Subsection (a) who is reasonably available after a reasonably diligent inquiry, another physician who is not involved in the medical treatment of the patient may concur with the treatment. During an Interview with the Administrator/Volunteer Coordinator (personnel record 4), Director of Nursing/Alternate Administrator (personnel record 6), and Consultant on 12/7/23, they agreed that the agency did not ensure that the patient’s or representative’s signature was obtained to verify receipt of the Bill of Rights and Responsibilities Statement.”

“If the state court has not judged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient’s rights to the extent allowed by state law. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 6 (50%) clinical records reviewed it was revealed that the agency did not ensure the patient had a designated legal representative in accordance with state law Document 1: The state code titled, HEALTH AND SAFETY CODE TITLE 4. HEALTH FACILITIES, SUBTITLE F. POWERS AND DUTIES OF HOSPITALS, CHAPTER 313. CONSENT TO MEDICAL TREATMENT ACT, Sec. 313.004. CONSENT FOR MEDICAL TREATMENT stated, “(a) If an adult patient of a home and community support services agency or in a hospital or nursing home, or an adult inmate of a county or municipal jail, is comatose, incapacitated, or otherwise mentally or physically incapable of communication and does not have a legal guardian or an agent under a medical power of attorney who is reasonably available after a reasonably diligent inquiry, an adult surrogate from the following list, in order of priority, who has decision-making capacity, is reasonably available after a reasonably diligent inquiry, and is willing to consent to medical treatment on behalf of the patient may consent to medical treatment on behalf of the patient: (1) The patient’s spouse; (2) The patient’s adult children; (3) The patient’s parents; or (4) The patient’s nearest living relative. (a-1) If the patient does not have a legal guardian, an agent under a medical power of attorney, or a person listed in Subsection (a) who is reasonably available after a reasonably diligent inquiry, another physician who is not involved in the medical treatment of the patient may concur with the treatment.” Clinical Record 1: The initial comprehensive assessment dated 11/24/2023 indicated that the patient had a diagnosis of protein calorie malnutrition with confusion and was not able to make informed decisions. The patient resided in a personal car home and family was involved in the care. Consent for the election of hospice benefit dated 11/24/2023 was signed by the owner of the personal care home who stated that she had verbal consent to sign on behave of the patient. The clinical record lacked documentation from a legal representative of stated permission. Clinical Record 2: The initial comprehensive assessment dated 9/1/2023 indicated that the patient had a diagnosis of senile degeneration of the brain, with confusion and was not able to make informed decisions. The patient resided in a personal care home and had family involved in the care. The consent for the election of the hospice benefit dated 9/1/2023 was signed by the owner of the personal care home who stated that she had verbal consent to sign on behave of the patient. The clinical record lacked documentation from a legal representative of stated permission. Clinical Record 3: The initial comprehensive assessment dated 9/1/2023 indicated that the patient had a diagnosis of senile degeneration of the brain, with confusion and was not able to make informed decisions. The patient resided in a personal care home and had family involved in the care. The consent for the election of hospice benefit dated 9/1/2023 was signed by the owner of the personal care home who stated that she had verbal consent to sign on behave of the patient. The clinical record lacked documentation from a legal representative of stated permission. The Administrator/Volunteer Coordinator (personnel record 4), Director of Nursing/Alternate Administrator (personnel record 6), and Consultant stated in an interview on 12/7/23, that the agency did not ensure legal representation was in accordance with the state law.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals, and 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, document review and observation. In 6 of 6 (100%) clinical records reviewed it was revealed that the patient’s individual written plan of care (POC) lacked goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 11/24/23. The initial nursing assessment dated 11/24/23 stated the patient had depression (prescribed Buspar and Sertraline), a colostomy and bladder incontinence. The clinical record interdisciplinary group (IDG) POC dated 11/24/23 and 12/8/2023 included these identified problems, but lacked goals and interventions for depression, colostomy care, and bladder incontinence. Clinical Record 2: The patient elected the hospice benefit on 9/1/23. The initial nursing assessment dated 9/1/23 stated the patient had confusion (prescribed Memantine and Donepezil), full bladder incontinence, and shortness of breath on exertion. The clinical record interdisciplinary group (IDG) POC dated 9/15/23 lacked goals and interventions for confusion, bladder incontinence, and shortness of breath. Furthermore, the nursing note dated 10/5/2023 stated the patient was choking and was placed on aspiration precaution. The clinical record interdisciplinary group (IDG) POC dated 10/13/23 included these identified problems but lacked goals and interventions for choking and aspiration precautions. Clinical Record 3: The patient elected the hospice benefit on 9/1/23. The initial nursing assessment dated 9/1/23 stated the patient had depression (prescribed Sertraline), anxiety (prescribed Ativan) and nausea (prescribed Zofran). The interdisciplinary group (IDG) POC dated 9//23 included these identified problems, but lacked goals and interventions for depression, anxiety, and nausea. Clinical Record 4: The patient elected the hospice benefit on 8/11/23. The initial nursing assessment dated 8/11/23 stated the patient had full bladder incontinence requiring a 16 French foley catheter, aspiration precautions, shortness of breath requiring oxygen at 2 liters nasal cannula. The interdisciplinary group (IDG) POC dated 8/18/23 included these identified problems, but lacked goals and interventions for bladder incontinence, foley care, aspiration precaution, and oxygen safety. Clinical Record 5: The patient elected the hospice benefit on 8/14/23. The initial nursing assessment dated 8/14/23 stated the patient had pain (prescribed Norco), full bladder incontinence and constipation. The interdisciplinary group (IDG) POC dated 8/18/23 included these identified problems, but lacked goals and interventions for pain, bladder incontinence and constipation. Clinical Record 6: The patient elected the hospice benefit on 9/1/23. The initial nursing assessment dated 9/1/23 stated the patient required seizure and fall precautions. The interdisciplinary group (IDG) POC dated 9/15/23 included these identified problems but lacked goals and interventions for seizure and fall precautions. Personnel Record 6: The Director of Nursing/Alternate Administrator stated in an interview on 12/07/23 that the patient’s individualized written plans of care did not include planned interventions based on all problems identified in the initial and updated comprehensive assessments.”

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. In a joint review of the Volunteer Program manual with the Administrator/Volunteer Coordinator on 12/6/23 it was revealed that the agency had no documentation of volunteer recruitment efforts. The Administrator/Volunteer Coordinator confirmed that the agency had not engaged in planned ongoing volunteer recruitment activities and strategies and had not documented recruitment efforts to date. In a joint review of the Volunteer Program manual with the Administrator/Volunteer Coordinator on 12/6/23 it was revealed that the agency had no documentation of volunteer recruitment efforts. The Administrator/Volunteer Coordinator stated that the agency did not ensure ongoing volunteer recruitment activities and this is why recruitment efforts have not been documented.”

“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. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, it was revealed that the agency did not ensure that the discharge summaries were sent to the patient’s attending physician. Clinical Record 4: The patient was discharged on 8/14/23. The record lacked evidence that the discharge summary written 08/14/2023 was sent to the patient’s attending physician. Clinical Record 6: The patient was discharged on 9/3/23. The record lacked evidence that the discharge summary written 09/3/2023 was sent to the patient’s attending physician. . The Administrator/Volunteer Coordinator (personnel record 4), the Director of Nursing/Alternate Administrator (personnel record 6), and the Consultant confirmed during an interview on 12/7/23 that the agency did not send the discharge summaries to the attending physicians.”