Remarkable Hospice

“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 effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. 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, document review, interview, and observation. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that the drug profile included the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy and as a result, the current medication profile was not reviewed for the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. Policy PC.17 Medication List and Monitoring revised 5/1/2010 stated in part “Agency will maintain a current, accurate list of all prescription and over-the-counter medications taken by the patient. Changes in the medication profile will be documented in the medical record either on the medication profile, on a verbal order and in the Plan of Care, as well as communicated to the patient and/or caregiver. Changes in medication regimen will be updated as frequently as necessary to keep the profile accurate.” Policy PC.6 Plan of Care Process revised 5/1/2019 stated in part “The comprehensive assessment will take into consideration the following factors but is not limited to: Drug profile, including a review of all of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy, which includes, but is not limited to, identification of the following: effectiveness of drug therapy, drug side effects, actual or potential drug interactions, allergies, duplicate drug therapy, drug therapy currently associated with laboratory monitoring and determine the ability of the patient and/or family to safely administer drugs and biologicals in the home.” Clinical Record 2/Home Visit 2: During the home visit with the RN (Personnel Record 2) on 3/6/2024, the medication review revealed a bottle of hydroxyzine 25 mg by mouth every 6 hours as needed was present in the home. The comprehensive assessment was dated 10/25/2023. The clinical record lacked evidence that hydroxyzine was listed on the hospice medication profile during the comprehensive assessment. During an interview and joint record review on 3/6/2024, the Director of Clinical Services/Registered Nurse stated in part “The medication should have been listed on the hospice medication profile. I will add it.””

“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 interview. In 5 of 5 (100%) clinical records reviewed revealed that the agency did not ensure that the plan of care included goals and interventions based on problems identified in the initial and comprehensive assessments. Policy PC.6 Plan of Care Process revised 5/1/2019 stated in part “The hospice will develop an individualized written plan of care (POC) for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments.” Clinical Record 1: The social worker comprehensive assessment was completed on 10/26/2023. The Medical Social Worker (MSW) documentation identified the need for emotional support and grief counseling. The clinical record lacked evidence that goals and interventions to address psychosocial problems identified in the comprehensive assessment were included in the updated plan of care effective 11/2/2023. Clinical Record 2: The social worker comprehensive assessment was completed on 10/27/2023. The Medical Social Worker (MSW) documentation identified a need for emotional support. The clinical record lacked evidence that goals and interventions to address psychosocial problems identified in the comprehensive assessment were included in the plan of care effective 11/2/2023. Additionally, the skilled nursing visit on 2/28/2024 included documentation of a urinary tract infection, that education was provided to the caregiver, and that new orders for antibiotic Bactrim 800mg PO BID for 7 days were obtained. The clinical record lacked evidence that the plan of care included interventions related to the urinary tract infection. Clinical Record 3: The social worker comprehensive assessment was completed on 2/16/2024. The Medical Social Worker (MSW) documentation identified the need for emotional support, advance directives, and caregiver support. The clinical record lacked evidence that goals and interventions to address psychosocial problems identified in the comprehensive assessment were included in the plan of care effective 2/23/2023. Clinical Record 4: The social worker comprehensive assessment was completed on 10/30/2023. The Medical Social Worker (MSW) documentation identified the need for emotional support and end-of-life arrangements. The clinical record lacked evidence that goals and interventions to address psychosocial problems identified in the comprehensive assessment were included in the plan of care effective 11/2/2023. Clinical Record 5: The social worker comprehensive assessment was completed on 10/27/2023. The Medical Social Worker (MSW) documentation identified need for emotional support and end of life arrangements. The clinical record lacked evidence that goals and interventions to address psychosocial problems identified in the comprehensive assessment were included in the plan of care effective 11/2/2023. During a joint record review and interview on 3/6/2024, the Director of Clinical Implementation confirmed findings and stated in part “We have been working with this social worker on her documentation.””

“It is required that a hospice aide provide services that are included in the plan of care. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 5 (20%) clinical records reviewed that received hospice aide services revealed that the agency did not ensure that the hospice aide provided services that were included in the plan of care. Policy PC.6 Plan of Care Process revised 5/1/2019 stated in part “All hospice care and services furnished to patient and their families will follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician if any, the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patient’s needs.” Policy PC.7 Implementing Care and Treatment revised 8/1/2015 stated in part “The aide will provide with written instructions for patient care prepared by an RN and/or therapist.” Clinical Record 3/Home Visit 3: During home visit with the hospice aide, (Personnel Record 7) on 3/6/2024, the aide was observed preparing to shower the patient. The clinical record lacked evidence that the hospice aide plan of care initiated on 2/15/2024 and revised on 3/6/2024 included interventions for bathing. During an interview with aide during the home visit, the aide stated in part “I follow the plan of care, sometimes the patient gets showered and when too weak will do bed bath, but I always let the nurse know what I did.” During an interview and joint record review on 3/6/2024, the Director of Clinical Implementation confirmed findings and stated in part “I don’t see interventions for bathing listed on the hospice aide plan of care.””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record contains at a minimum physician orders. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 2 of 5 (40%) clinical records reviewed revealed that the agency did not ensure that physician orders were obtained to discontinue medications a patient refused or was no longer taking. Policy IM.6 Medical Record Content revised 10/1/2011 stated in part “Agency will initiate and maintain an individual and accurate medical record for each patient receiving care in compliance with all federal and state laws and regulations. Each medical record will contain the following: Updated orders as obtained.” Clinical Record 1/Home Visit 1: During the home visit with the registered nurse (RN) (Personnel Record 10) on 3/6/2024, the medications were reviewed. The hospice medication profile included pregabalin 75mg by mouth three times daily. The medication was not in the patient’s home and the RN sated, “I think that medication was discontinued because he is refusing the medication, I will check on that.” The clinical record lacked evidence that a physician order was obtained to discontinue pregabalin. During an interview on 3/6/2024, the Director of Clinical Implementation confirmed findings and stated in part “There is no order to discontinue pregabalin. If the patient is refusing a medication, it should be discontinued.” Clinical Record 2/Home Visit 2: During the home visit with the RN (Personnel Record 2) on 3/6/2024, the medications were reviewed the hospice medication profile included Haloperidol 0.5mg tablet daily. The medication Haloperidol was not in the patient’s home. The clinical record lacked evidence that a physician order was obtained to discontinue Haloperidol. Additionally, a medication bottle of hydroxyzine 25 mg by mouth every 6 hours as needed was present in the home. The clinical record lacked evidence that hydroxyzine was listed on the hospice medication profile or that a physician order was obtained for the medication. During an interview on 3/7/2024, the Director of Clinical Services/Registered Nurse confirmed findings for clinical record 2 and stated in part “The owner at the care home does not have these medications and the patient has not been taking the medications.””

“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 1 of 1 (100%) clinical record reviewed that revocated the election of hospice care revealed that the agency did not ensure that a discharge summary was completed and forwarded to the patient’s attending physician. Policy PE.4 Patient Discharge revised 9/1/2019 “If a patient revokes the election of hospice care, or is discharged from hospice, the hospice must forward to the patient’s attending physician, a copy of the hospice discharge summary and the patient’s clinical record, if requested.” Clinical Record 5: The patient revocated hospice services on 11/9/2023 to seek aggressive treatment. The clinical record lacked evidence that a discharge summary was completed and forwarded to the attending physician.”