Caritas Hospice

“It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, and document review which revealed the hospice: Failed to ensure that each patient had a written plan of care (POC) that was individualized, reflected patient and family goals, and identified planned interventions based on identified problems {HCPC.21. I/L545}; Failed to ensure each patient’s individualized plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care {HCPC21. I/L548}; Failed to ensure that the Interdisciplinary Group’s (IDG’s) revised plan of care included a record of the patient’s progress toward outcomes and goals specified in the plan of care {HCPC.21. I/L553}; and Failed to ensure he Interdisciplinary Group (IDG) reviewed and documented the individualized care plan as frequently as the patient’s condition required, including the patient’s death to review the Bereavement plan of care (POC) per agency policy {HCPC.21. I/L552}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56 IDG, Care Planning, Coordination of Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice clinical record containing past and current findings is maintained for each hospice patient. The clinical record must contain correct clinical information that is available to the patient’s attending physician and hospice staff. The clinical record may be maintained electronically. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure patients’ clinical records contained physician orders for all care and services provided {HSIM.3. I/L678}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.104: Clinical Records. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“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 each patient had a written plan of care (POC) that was individualized, reflected patient and family goals, and identified planned interventions based on identified problems. The agency’s policy titled, “Plan of Care Process” (01/26/2024) stated in part, “The POC includes but is not limited to: … Standing orders or routine orders must be individualized to address the specific patient’s needs…” Clinical Record 1: The initial nursing assessment dated 02/26/2024 identified the patient had dyspnea with exertion, constipation, and a high risk for falls. The initial POC effective on 02/26/2024 and updated on 02/28/2024 and 03/13/2024 identified routine and standard interventions including, “Teach comfort and symptom control, Teach Pt (Patient)/CG (caregiver) how to prevent injuries, and Monitor bowel status.” The initial and updated plans of care (POCs) also identified routine and standard goals including, “Cardiovascular and Respiratory Symptoms managed, Patient has improved respiratory status, Patient will remain free of injury, and Compliance with bowel regimen.” The initial POC and updated POCs did not contain documented evidence to support that the POC included individualized interventions, such as specific things to be done to manage this patient’s symptoms or specific needs associated with end-stage atherosclerotic heart disease, or reflected the patient’s goals associated with identified problems, including what the patient identified as managed or improved. The POCs did not include documented evidence to support a specific goal associated with the patient’s identified high risk for falls. Clinical Record 2: The initial nursing assessment dated 02/27/2024 identified the patient had dyspnea with exertion, constipation, and a high risk for falls. The initial POC effective on 02/27/2024 and updated on 02/28/2024 and 03/13/2024 identified routine and standard interventions including, “Teach comfort and symptom control, Teach Pt (Patient)/CG (caregiver) how to prevent injuries, and Monitor bowel status.” The initial and updated plans of care (POCs) also identified routine and standard goals including, “Cardiovascular and Respiratory Symptoms managed, Patient has improved respiratory status, Patient will remain free of injury, and Compliance with bowel regimen.” The initial POC and updated POCs did not contain documented evidence to support that the POC included individualized interventions, such as specific things to be done to manage this patient’s symptoms or specific needs associated with hypertensive heart disease, or reflected the patient’s goals associated with identified problems, including what the patient identified as managed or improved. The POCs did not include documented evidence to support a specific goal associated with the patient’s identified high risk for falls. The Chaplain completed the initial spiritual care assessment on 03/01/2024 and documented a plan to continue to provide one (1) to two (2) spiritual care and support visits per month. The POC updated and effective 03/13/2024 included a visit frequency for the chaplain of one visit per month and interventions to allow the patient the opportunity to express feelings and grief. The clinical record did not contain documented evidence to support that the spiritual plan of care reflected the patient and family’s individualized goals associated with identified spiritual needs. Clinical Record 3: The initial nursing assessment dated 02/28/2024 identified the patient had dyspnea with exertion, constipation, and a high risk for falls. The initial POC effective on 02/28/2024 and updated 03/13/2024 identified routine and standard interventions including, “Teach comfort and symptom control, Teach Pt (Patient)/CG (caregiver) how to prevent injuries, and Monitor bowel status.” The initial and updated plans of care (POCs) also identified routine and standard goals including, “Cardiovascular and Respiratory Symptoms managed, Patient has improved respiratory status, Patient will remain free of injury, and Compliance with bowel regimen.” The initial POC and updated POCs did not contain documented evidence to support that the POC included individualized interventions, such as specific things to be done to manage this patient’s symptoms or specific needs associated with heart failure, or reflected the patient’s goals associated with identified problems, including what the patient identified as managed or improved. The POCs did not include documented evidence to support a specific goal associated with the patient’s identified high risk for falls. The Chaplain completed the initial spiritual care assessment on 03/01/2024 and documented a plan to continue to provide one (1) to two (2) spiritual care and support visits per month. The POC updated and effective 03/13/2024 included an updated visit frequency for the chaplain of one visit per month; however, the written plan of care did not include individualized goals and interventions associated with identified spiritual care needs. Clinical Record 4: The initial nursing assessment dated 10/20/2023 identified the patient had pain, anxiety, dyspnea with exertion, constipation, and a high risk for falls. The initial POC effective on 10/20/2023 and updated on 10/21/2023 and 11/04/2023 identified routine and standard interventions including, “Monitor and control pain level, teach patient/caregiver on identified knowledge deficits, teach comfort and symptom control, Teach Pt (Patient)/CG (caregiver) how to prevent injuries, and Monitor bowel status.” The initial and updated plans of care (POCs) also identified routine and standard goals including, “Cardiovascular and Respiratory Symptoms managed, Patient has improved respiratory status, Patient will remain free of injury, and Compliance with bowel regimen.” The initial POC and updated POCs did not contain documented evidence to support that the POC included individualized interventions, such as specific things to be done to manage this patient’s symptoms or specific needs and education associated with malignant neoplasm of the uterus, or reflected the patient’s goals associated with identified problems, including what the patient identified as managed or improved. The POCs did not include documented evidence to support a specific goal associated with the patient’s identified high risk for falls. Clinical Record 5: The initial nursing assessment dated 01/08/2024 stated the patient with a FAST score of 7b, indicating end-stage Alzheimer’s disease. The initial plan of care effective 01/08/2024 and updated POC effective 01/09/2023 identified routine and standard interventions including, “Teach patient/caregiver on identified knowledge deficits and Teach comfort and symptom control.” Routine and standard interventions, including “symptoms of disease process will be managed, and symptoms of anxiety are decreased,” were also identified on the initial and updated POCs. The initial and updated POCs did not contain documented evidence to support that the POC included individualized interventions specific to managing this patient’s symptoms or care and educational needs associated with Alzheimer’s disease, or reflected the patient’s goals associated with identified problems, including what the patient and family identified as managed or improved. On 03/21/2024 joint clinical record reviews and interviews were conducted with the Administrator, Alternate Administrator, and Director of Nursing who confirmed that the clinical records identified did not include written plans of care that were individualized to meet each patient/family’s specific goals utilizing specific interventions and standing orders that had been individualized based on the patient’s specific needs.”

“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 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 5 of 5 (100%) clinical records reviewed revealed that the agency did not ensure each patient’s individualized plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The initial plan of care effective 02/26/2024 included the following outcomes: “Symptoms of disease process will be managed, Patient)/CG (Caregiver) will proceed through grief process with support of IDT (interdisciplinary team), Patient)/CG will find comfort through psychosocial/spiritual support, and Patient will experience a comfortable death.” The initial POC and the POC updated on 02/28/2024 and 03/13/2024 did not include how the outcomes created during the implementation and coordination of the POC would be measured to determine the patient’s progress toward care goals. Clinical Record 2: The initial plan of care effective 02/27/2024 included the following outcomes: “Symptoms of disease process will be managed, Patient)/CG will proceed through grief process with support of IDT, Patient)/CG will find comfort through psychosocial/spiritual support, and Patient will experience a comfortable death.” The initial POC and the POC updated on 02/28/2024 and 03/13/2024 did not include how the outcomes created during the implementation and coordination of the POC would be measured to determine the patient’s progress toward care goals. Clinical Record 3: The initial plan of care effective 02/28/2024 included the following outcomes: “Symptoms of disease process will be managed, Patient)/CG will proceed through grief process with support of IDT, Patient/CG will find comfort through psychosocial/spiritual support, and Patient will experience a comfortable death.” The initial POC and the POC updated on 03/13/2024 did not include how the outcomes created during the implementation and coordination of the POC would be measured to determine the patient’s progress toward care goals. Clinical Record 4: The initial plan of care effective 10/20/2024 included the following outcomes: “Symptoms of disease process will be managed, Patient)/CG will proceed through grief process with support of IDT, Patient/CG will find comfort through psychosocial/spiritual support, and Patient will experience a comfortable death.” The initial POC and the POC updated on 11/04/2023 did not include how the outcomes created during the implementation and coordination of the POC would be measured to determine the patient’s progress toward care goals. Clinical Record 5: The initial plan of care effective 01/08/2024 included the following outcomes: “Symptoms of disease process will be managed, Patient)/CG will proceed through grief process with support of IDT, Patient/CG will find comfort through psychosocial/spiritual support, and Patient will experience a comfortable death.” The initial POC and the POC updated on 01/09/2024 did not include how the outcomes created during the implementation and coordination of the POC would be measured to determine the patient’s progress toward care goals. On 03/21/2024 joint record reviews and interviews were conducted with the Administrator, Alternate Administrator, and Director of Nursing who confirmed that the plans of care for the clinical records identified did not include measurable outcomes. The Leaders reported that they were under the impression that the clinical forms provided by a hospice consulting group included all aspects required for the plan of care and did not need additional information.”

“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, document review and interview. In 2 of 5 (40%) clinical records reviewed revealed that the agency did not ensure the Interdisciplinary Group (IDG) reviewed and documented the individualized care plan as frequently as the patient’s condition required, including the patient’s death to review the Bereavement plan of care (POC) per agency policy. The agency’s policy titled, “Bereavement,” (11/01/2021) stated in part, “After the death of the patient: The Bereavement Coordinator will complete a follow-up assessment and develop a POC for bereavement services… This POC will be discussed at the next IDG/IDT meeting. Clinical Record 4: The IDG meetings held on 10/21/2023 and 11/04/2023 documented the review and revision of the patient’s care plan, including the plan to increase the frequency of hospice aide visits. The patient died on 11/06/2023, and a bereavement plan of care (POC) was initiated to start on 11/07/2023. The clinical record did not contain documented evidence to support that the IDG reviewed the bereavement POC per the agency’s policy. Clinical Record 5: The IDG meetings held on 01/09/2023 and 01/23/2024 documented the review and revision of the patient’s care plan, including the plan to increase the frequency of hospice aide visits. The patient died on 01/23/2024, and a bereavement plan of care (POC) was initiated to start on 01/24/2024. The clinical record did not contain documented evidence to support that the IDG reviewed the bereavement POC per the agency’s policy. On 03/21/2024 joint record reviews and interviews were conducted with the Administrator, Alternate Administrator, and Director of Nursing who confirmed that the clinical records identified did not contain documentation of an IDG review of the identified caregiver’s bereavement POC. The leaders confirmed that they did not collaborate after the death of the patient.”

“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. A revised plan of care includes a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed revealed that the agency did not ensure that the Interdisciplinary Group’s (IDG’s) revised plan of care included a record of the patient’s progress toward outcomes and goals specified in the plan of care. Clinical Record 1: The initial plan of care was created on 02/26/2024 after the completion of the initial nursing assessment. Goals implemented on the updated plan of care effective 02/28/2024 and associated with the identified problems, high risk for falls and constipation, during the initial nursing assessment included that the patient would remain free from injury and symptoms would be managed. The clinical record did not contain documented evidence to support that the IDG’s revision of the POC on 03/13/2024 included a record of the patient’s progress toward the outcomes and goals identified in the plan of care. Clinical Record 2: The initial plan of care was created on 02/27/2024 after the completion of the initial nursing assessment. Goals implemented on the updated plan of care effective 02/28/2024 and associated with the identified problems, high risk for falls and constipation, during the initial nursing assessment included that the patient would remain free from injury and symptoms would be managed. The clinical record did not contain documented evidence to support that the IDG’s revision of the POC on 03/13/2024 included a record of the patient’s progress toward the outcomes and goals identified in the plan of care. Clinical Record 3: The initial plan of care was created on 02/28/2024 after the completion of the initial nursing assessment. Goals implemented on the plan of care effective 02/28/2024 and associated with the identified problems, high risk for falls and constipation, during the initial nursing assessment included that the patient would remain free from injury and symptoms would be managed. The clinical record did not contain documented evidence to support that the IDG’s revision of the POC on 03/13/2024 included a record of the patient’s progress toward the outcomes and goals identified in the plan of care. Clinical Record 4: The IDG meetings held on 10/21/2023 and 11/04/2023 documented the review and revision of the patient’s care plan, including the plan to increase the frequency of hospice aide visits. The initial plan of care was created on 10/20/2023 after the completion of the initial nursing assessment. Goals implemented on the updated plan of care effective 10/21/2023 and associated with the identified problem, high risk for falls, during the initial nursing assessment included that the patient would remain free from injury. The clinical record did not contain documented evidence to support that the IDG’s revision of the POC on 11/04/2023 included a record of the patient’s progress toward the outcomes and goals identified in the plan of care. Clinical Record 5: The initial plan of care was created on 01/08/2024 after the completion of the initial nursing assessment. Goals implemented on the updated plan of care effective 01/09/2024 and associated with the identified problem, high risk for falls, during the initial nursing assessment included that the patient would remain free from injury. The clinical record did not contain documented evidence to support that the IDG’s revision of the POC on 01/23/2024 included a record of the patient’s progress toward the outcomes and goals identified in the plan of care. On 03/21/2024 joint record reviews and interviews were conducted with the Administrator, Alternate Administrator, and Director of Nursing who confirmed that the clinical records identified did not contain documentation of patients’ progress toward goals associated with falls and constipation.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) clinical records reviewed, in which bereavement services were provided, revealed that the agency did not ensure the bereavement plan of care (POC) included the frequency of services to be delivered. The agency’s policy titled, “Bereavement” (11/01/2021), stated in part, “The bereavement POC will include delineation of services and frequency to be provided…” Clinical Record 4: The patient died on 11/06/2023, and a post-death bereavement risk assessment was documented by the Registered Nurse on 11/06/2023. Bereavement services were initiated on 11/07/2023 for the caregiver and included a plan for a sympathy phone call and a sympathy card. The bereavement plan of care effective 11/07/2023 did not include a frequency for delivering these identified bereavement services. Clinical Record 5: The patient died on 01/23/2024, and a post-death bereavement risk assessment was documented by the Registered Nurse on 01/23/2024 Bereavement services were initiated on 01/24/2024 for the caregiver and included a plan for a sympathy phone call and sympathy card. The bereavement plan of care effective 01/24/2024 did not include a frequency for delivering these identified bereavement services. On 03/21/2024 joint record reviews and interviews were conducted with the Administrator, Alternate Administrator, and Director of Nursing, who confirmed that the Bereavement POC did not include a frequency for when the sympathy phone call and sympathy card mailing. The Alternate Administrator stated that he kept a “log” that included this information to ensure the POC was followed; however, the frequencies documented on the log were not included in the POC.”

“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 physician orders. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records reviewed revealed that the agency did not ensure patients’ clinical records contained physician orders for all care and services provided. Clinical Record 1/Home Visit 1: The election of hospice benefit was 02/26/2024 with a diagnosis of End-stage atherosclerosis of native coronary artery. The initial nursing assessment dated 02/26/2024 stated that the caregiver was checking and managing the patient’s blood sugar as well as a medication regime that included instructions to hold the blood pressure (BP) medication if the BP was less than 100/50. During the home visit (Home Visit 1) on 03/20/2024 with the registered nurse (RN) (Personnel Record 1), the patient’s caregiver confirmed that the patient’s BP was being checked daily. The nurse, during the interview, confirmed that the caregiver checked the patient’s blood sugar as needed for signs or symptoms of hypoglycemia or hyperglycemia. The clinical record did not contain physician orders for the patient’s blood sugar to be checked, including the frequency or delineation of responsibility, or an order delineating the responsibility of the daily BP checks. Clinical Record 2: The election of hospice benefit was 02/27/2024 with a diagnosis of Hypertensive cardiac disease. The initial nursing assessment dated 02/27/2024 included documentation that the patient was taking Tylenol daily as needed for pain, and the medication profile detailing the medications to be covered by hospice included Tylenol 500mg every eight (8) hours as needed for pain or fever greater than 101 degrees. The initial plan of care (POC) dated 02/27/2024 included signed physician orders for the medications taken by the patient; however, the POC did not include an order for Tylenol. Clinical Record 3: The election of hospice was 02/28/2024 with a diagnosis of Heart failure. The initial nursing assessment dated 02/28/2024 stated, “yes,” regarding whether a blood sugar check was performed as part of the initial assessment, followed by a note stating, “Blood sugar managed by daughter.” The updated plans of care dated 02/28/2024 and 03/13/2024 included an intervention to teach the use of the glucometer. The clinical record did not contain physician orders for the patient’s blood sugar to be checked, including the frequency or delineation of responsibility for the blood sugar checks. Clinical Record 5: The election of hospice benefit was 01/08/2024 with a diagnosis of Alzheimer’s Disease. The Medical Social Worker (MSW) completed the initial psychosocial visit and assessment on 01/10/2024 and documented, “daughter declined SW (social worker) services. The initial plan of care was effective 01/08/2024 and updated on 01/09/2024 and 01/23/2024 to include a visit frequency of one (1) visit per benefit period for the MSW. The clinical record did not contain a physician’s order to discontinue MSW services per the daughter’s request on 01/10/2023 or documented evidence to support that the daughter had requested the services resume after the MSW visited. On 03/21/2024 joint clinical record reviews and interviews were conducted with the Administrator, Alternate Administrator, and Director of Nursing who confirmed the clinical records identified did not include physician orders for blood sugar checks, Tylenol, delineation of responsibility for performing daily BP checks, or discontinuation of MSW services as requested on initial MSW visit. Leadership also confirmed there was no documentation regarding the daughter requesting MSW services.”