Touching Hearts Hospice LLC

“It is required that the patient has a right to receive information about the services covered under the hospice benefit. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed revealed that the agency did not ensure that the drugs and biologicals related to the palliation and management of terminal illness and related conditions were identified in the plan of care. Clinical Record 1: The Medication Profile dated 04/28/2024 lacked the identification of related or non-related medications. Clinical Record 2: The Medication Profile dated 04/01/2023 lacked the identification of related or non-related medications. Clinical Record 5: The Medication Profile dated 04/01/2023 lacked the identification of related or non-related medications. During a joint record review and interview on 05/08/2024, the Administrator/Director of Nursing confirmed that the drugs and biologicals related to the palliation and management of terminal illness and related conditions were not identified on the medication profile.”

“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, 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, 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 and interview. In 1 of 3 (33%) clinical records reviewed revealed the organization did not ensure a medication reconciliation was completed and medications updated to the medication profile. Home Visit 1: The date of election was 04/27/2024. The Medication Profile (Clinical Record 2) dated 04/27/2024 revealed Amlodipine 10mg po daily, Aspirin 25mg po daily, Coreg 12.5mg po HS (at bedtime), Losartan 50mg po daily, Hydralazine 50mg po TID (three times daily), Finasteride 5mg po daily, Tylenol #3 30/300mg po Q6H PRN (every 6 hours as needed), Plavix 75mg po daily, Trazodone 25mg po HS, Senna 8.6mg po daily, and oxygen 3L N/C PRN. During the home visit (Home Visit 1) (Personnel Record 5), the medications bottles in the home revealed Amlodipine 5mg po daily dated 4/23/2024, Coreg 12.5mg po BID (twice daily) dated 4/23/2024, Losartan 100mg po daily dated 4/23/2024, Donepezil 5mg po HS dated 4/16/2024, and Prozac 20mg po daily dated 4/16/2024. During a joint record review and interview on 05/08/2024, the Administrator/Director of Nursing confirmed that there was no documented evidence the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that an update of the comprehensive assessment was completed as frequently as the condition of the patient requires and no less frequently than every 15 days. Clinical Record 5: The date of election per the Informed Consent and Election of Benefits was 04/01/2023. The Initial Nursing Assessment was dated 04/01/2023 and had a time in at 1300 and a time out at 1430. A Nursing Clinical Progress Note with a start of care (SOC) of 03/31/2023 was dated 04/01/2023, with a time in at 1100 and a time out at 1200. There was another Nursing Clinical Progress Note documented by (Personnel Record 2) was not dated or timed. The record lacked evidence of a comprehensive assessment no less than every 15 days. During a joint record review and interview on 05/08/2024, the Administrator/Director of Nursing confirmed that an update of the comprehensive assessment was not completed as frequently as the condition of the patient requires and no less frequently than every 15 days.”

“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 as frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed revealed the agency did not ensure the individualized plan of care was reviewed and documented by the IDG no less frequently than every 15 calendar days. Clinical Record 4: The date of election was 03/22/2023. The “Plan of Care - Update” document dated 04/05/2023 lacked signatures from the interdisciplinary team. Clinical Record 5: The date of election per the “Informed Consent and Election of Benefits” was 04/01/2023. The Initial Plan of Care was dated 03/31/2023. The record lacked “Plan of Care - Update” documents. The record lacked evidence that the individualized plan of care was reviewed and documented by the IDG no less frequently than every 15 calendar days. During a joint clinical record review and interview on 05/08/2024, the Administrator/Director of Nursing confirmed that the individualized plan of care was not reviewed and documented by the IDG no less frequently than every 15 calendar days.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that nursing care and services were provided per the patient plan of care. Clinical Record 5: The election of the hospice benefit was dated 04/01/2023. The initial nursing assessment was dated 04/01/2023. A nursing clinical progress note with a start of care (SOC) of 03/31/2023 was dated 04/01/2023. Another nursing clinical progress note documented by Personnel Record 2 was not dated or timed. The plan of care effective 04/01/2024 included a skilled nurse frequency order for one time a week (1xw). There was no documented evidence of a skilled nurse visit for the weeks of 04/03/2023-04/09/2023, 04/10/2023-04/16/2023, 04/17/2023-04/23/2023, 04/24/2023-04/30/2023, 05/01/2023-05/07/2023, 05/08/2023-05/13/2023. During a joint record review and interview on 05/08/2024, the Administrator/Director of Nursing confirmed that the nursing care and services were not provided per the patient plan of care.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records that had aide services reviewed revealed that the agency did not that the registered nurse did not make an on-site supervisory visit to the patient’s home no less frequently than every 14 days. Clinical Record 4: The date of election was 03/22/2023. The hospice aide services started on 03/23/2023. The patient revoked services on 04/07/2023. The record lacked evidence that a registered nurse made an on-site supervisory visit. Clinical Record 5: The date of election was 04/01/2023. The hospice aide services started on 04/04/2023. The aide made visits twice a week through 05/13/2023. The patient revoked services on 05/13/2023. The record lacked evidence that a registered nurse made an on-site supervisory visit. During a joint clinical record review and interview on 05/08/2024, the Administrator/Director of Nursing confirmed that the registered nurse did not make on-site supervisory visits.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, and estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Upon reviewing the volunteer program, the documentation lacked evidence identifying each position occupied by a volunteer and the work time spent by volunteers occupying those positions. The documentation included a copied list of “Volunteer monthly Administrative Hours,” including filing papers, delivering supplies, phone calls, payroll, office work, and sending/mailing letters. The “Volunteer monthly Administrative Hours” documents included the months of January 2024, March 2024, and April 2024, revealing “8 hrs.” for the total hours for each month. For February 2024, the “Volunteer monthly Administrative Hours” document did not include any hours listed. They were not indicating the date, time, or what the volunteer was doing for January 2024, March 2024, and April 2024. During a joint document review and interview on 05/09/2024, the Administrator/Director of Nursing/Volunteer Coordinator confirmed that the volunteer program documentation did not identify each position occupied by a volunteer and the work time spent by volunteers occupying those positions Upon reviewing the volunteer program, the documentation lacked evidence identifying each position occupied by a volunteer and the work time spent by volunteers occupying those positions. The documentation included a copied list of “Volunteer monthly Administrative Hours,” including filing papers, delivering supplies, phone calls, payroll, office work, and sending/mailing letters. The “Volunteer monthly Administrative Hours” documents included the months of January 2024, March 2024, and April 2024, revealing “8 hrs” for the total hours for each month. For February 2024, the “Volunteer monthly Administrative Hours” document did not include any hours listed. In May 2023, the “Volunteer monthly Administrative Hours” document had check marks beside delivering supplies and office work for the “8 hrs” the volunteer worked.”

“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 includes, at a minimum, the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes, including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure each patient’s record included updated comprehensive assessments and clinical notes, including the care and services provided. Clinical Record 5: The election of the hospice benefit was dated 04/01/2023. The initial nursing assessment was dated 04/01/2023. A nursing clinical progress note with a start of care (SOC) of 03/31/2023 was dated 04/01/2023. Another nursing clinical progress note documented by Personnel Record 2 was not dated or timed. The plan of care effective 04/01/2024 included a skilled nurse frequency order for one time a week (1xw). There was no documented evidence of a skilled nurse visit for the weeks of 04/03/2023-04/09/2023, 04/10/2023-04/16/2023, 04/17/2023-04/23/2023, 04/24/2023-04/30/2023, 05/01/2023-05/07/2023, 05/08/2023-05/13/2023. During a joint clinical record review and interview on 05/08/2024, the Administrator/Director of Nursing confirmed that the record lacked evidence of updated comprehensive assessments and clinical notes, including the care and services provided.”

“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. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed revealed that the agency did not ensure that the patient record entries were 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. Clinical Record 2: The Informed Consent and Election of Benefits was signed on 04/27/2024 with an effective date of 04/26/2023 through 07/24/2023. The Initial Orders, Initial Plan of Care, and the Initial Nursing Assessment were dated 04/27/2024. The Certificate of Terminal Illness had a benefit period of 04/28/2024-07/26/2024. Clinical Record 5: The date of election per the Informed Consent and Election of Benefits was 04/01/2023. The Initial Nursing Assessment was dated 04/01/2023 and had a time in at 1300 and a time out at 1430. A Nursing Clinical Progress Note with a start of care (SOC) of 03/31/2023 was dated 04/01/2023, with a time in at 1100 and a time out at 1200. The Another Nursing Clinical Progress Note documented by Staff 2 was not dated or timed. During a joint clinical record review and interview on 05/08/2024, the Administrator/Director of Nursing confirmed that the documents were dated incorrectly.”

“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 and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 5: The discharge summary dated 05/13/2023 lacks documentation that the discharge summary was forwarded to the patient’s attending physician. During a joint record review and interview on 05/08/2024, the Administrator/Director of Nursing confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s 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; and 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 and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to 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; and 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. Clinical Record 5: The date of the revocation was 05/13/2023. The Discharge Summary lacked the patient’s current plan of care; the patient’s latest physician orders; and 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. There were boxes to indicate if these were attached to the discharge summary but were left unchecked. During a joint record review and interview on 05/08/2024, the Administrator/Director of Nursing confirmed that the record lacked evidence of a completed discharge summary that included 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; and 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.”