Refuge Hospice, 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. 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 2 of 5 (40%) records reviewed revelated that the agency did not ensure that the drug profiles contained the patient’s current prescription and over the counter (OTC) drugs. Agency Policy: Medication List and Monitoring PC.17 read in part “I. the hospice will maintain a current, accurate medication profile of all prescription and over the counter (OTC) medications taken by the patient.” Clinical Record 1: The hospice election of benefit was dated 08/23/2023. A physician’s order dated 09/27/2023 read, “Vagisil cream to affected areas for itching and discomfort every day (qd) prn.” A review of the clinical record on 12/18/2023 did not include Vagisil on the medication profile. The interdisciplinary team meeting documentation dated 11/22/2023, 12/05/2023, and 12/14/2023 indicated medication profile reviews were completed. Clinical Record 2: The hospice election of benefit was dated 11/20/2023. A physician order dated 12/11/2023 read “Azithromycin 250mg tablet 2 tablets by mouth first day, then 1 tablet daily for 4 days for upper respiratory infection.” A review of the clinical record on 12/18/2023 did not include Azithromycin on the medication profile. The interdisciplinary team meeting documentation dated 12/14/2023 indicated medication profile reviews were completed. During interview on 12/20/2023, the Alternate Administrator reviewed the associated records and stated that the medication profiles had since been reviewed and corrected.”

“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 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 5 (60%) records reviewed revealed that the agency did not ensure the hospice plan of care included a detailed statement of the scope and frequency of all services provided. Agency Policy: Plan of Care Process PC.8 read in part, “The POC includes but is not limited to: B. A detailed scope and frequency of services necessary to meet the specific patient and family needs, including level of care D. Drugs and treatments necessary to meet the needs of the patient.” Clinical Record 1: The hospice election of benefit was dated 08/23/2023. The hospice Plan of Care (POC) dated 11/21/2023 did not include an aide visit frequency. The interdisciplinary team meeting documentation dated 11/22/2023, 12/05/2023, and 12/14/2023 did not include an aide visit frequency at the time of the record review on 12/18/2023. The aide visit notes dated 11/22/2023, 11/27/2023, 11/29/2023, 12/01/2023, 12/04/2023, 12/06/2023, 12/08/2023, and 12/11/2023 stated that care was provided. Clinical Record 3: The hospice election of benefit was dated 08/21/2023. The hospice POC dated and the updated hospice POC dated 11/22/2023 included a Chaplain frequency that read, “2prn.” There was no detailed scope and frequency for the Chaplain at the time of the clinical record review on 12/18/2023. There was documentation on 08/24/2023 that the patient refused Chaplain services. Clinical Record 4: The hospice election of benefit was dated 08/23/2023. A physician’s order dated 8/29/2023 and the updated hospice POC dated 08/31/2023, 09/14/2023, 09/28/2023, 10/12/2023, and 10/23/2023 included a Social Worker (MSW) and Chaplain (CH) frequency that read “2prn.” There was no detailed scope or frequency for the MSW and CH at the time of the clinical record review on 12/19/2023. There was a MSW assessment completed on 08/28/2023. There was documentation on 08/28/2023 by the CH that the patient refused CH services. During interview on 12/20/2023, the Alternate Administrator reviewed the associated records and stated that the aide frequency had inadvertently been omitted and had since been corrected. She also added that she was unaware that as needed (PRN) visits could not serve as a stand-alone frequency and had placed them so disciplines could still provide services per patient request. Stated that she has reviewed policy and understood the need for a detailed service frequency and had since conferred with the interdisciplinary team and corrected the frequency with an updated hospice plan of care.”

“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 the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 5 (60%) records reviewed the agency did not ensure the hospice plan of care included the drugs treatments necessary to meet the needs of the patient. Agency Policy: Plan of Care Process PC.8 read in part, “The POC includes but is not limited to: B. A detailed scope and frequency of services necessary to meet the specific patient and family needs, including level of care D. Drugs and treatments necessary to meet the needs of the patient.” Clinical Record 1: The hospice election of benefit was dated 08/23/2023. A physician order dated 09/20/2023 read, “’Abdominal wound: cleanse wound with Dakin’s 1/2 strength, Pat dry, apply silver AG to wound bed and cover with dry dressing qd/PRN.” There was not an as needed (PRN) qualifier at the time of the clinical record review on 12/18/2023. Clinical Record 3: The hospice election of benefit was dated 08/24/2023. A physician order dated 08/24/2023 read “wound care to left breast: cleanse with Normal Saline, pat dry and apply dry dressing.” The comprehensive assessment dated 08/24/2023 stated the wound care was to be performed daily with caregiver assistance. There was no documented evidence that the physician order included a frequency for the wound care to be performed. The 10/23/2023 through 12/11/2023 registered nurse visit notes documentation read “cleanse wound with Normal Saline or wound cleanser, pat dry, apply CA Alginate to wound bed and cover with dry dressing daily with caregiver assistance.” There was no documented evidence of additional physician order for wound care. Clinical Record 4: The hospice election of benefit was dated 08/29/2023. A registered nurse (RN) visit note dated 11/08/2023 stated “initiation of Oxygen @ 2-4Liters via nasal cannula as needed.” There was no documented evidence in the clinical record that included an order for the Oxygen. The Oxygen was not on the initial POC or updated POCs by the interdisciplinary team on 08/31/2023, 09/14/2023, 09/28/2023, 10/12/2023, 10/23/2023, and 11/09/2023. During interview on 12/20/2023, the Alternate Administrator reviewed the associated records and stated that the Registered Nurse had since updated the medication and treatment orders per agency policy.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. and written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) records reviewed with the provision of aide services revealed that the agency did not ensure written instructions for aide were provided. Clinical Record 1: The hospice election of benefits was dated 08/23/2023. The 08/23/2023 comprehensive assessment dated 08/23/2023 stated that the patient had a dehisced abdominal wound and caregiver was providing daily wound care. There was no documented evidence on the plan of care dated 08/23/2023 and the updated POC dated 11/21/2023 that included specific instructions related to the wound for the aide who was assigned and documented weekly visits 08/23/2023-12/13/2023. The aide POC dated 08/23/2023 did not include specific instructions for the wound. During interview on 12/20/2023, the Alternate Administrator reviewed the associated record and stated that while the aide did not need to do anything with the wound, she understood the aide needed directions as to how to manage protection of the dressing while providing personal care and that the Registered Nurse had since updated the aide care plan and added the instructions.”

“It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 5 (40%) records reviewed revealed that the agency did not ensure that all entries in the patient record were appropriately authenticated and dated. Agency Policy: Authorization and Authentication of Medical Record Entries IM.7 read in part, “IV. Each medical record entry will be dated and signed with the complete name and title/credential of the person making the entry.” Clinical Record 1: The hospice election of benefit was dated 08/23/2023. The 08/23/2023 bereavement assessment and the 11/16/2023 visit documentation completed by the Chaplain (CH) did not include credentials with the associated signature and date. An aide visit note documentation for 12/06/2023 did not include a date with the associated signature and credentials. Clinical Record 2: The hospice election of benefit was dated 11/20/2023. The 11/21/2023 visit documentation completed by the CH did not include credentials with the associated signature and date. During interview on 12/20/2023, the Alternate Administrator reviewed the associated records and stated that the missing dates and credentials had since been corrected.”