Quality Plus Hospice LLC

“Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. The agency does not have evidence of the ability to provide general inpatient level of care. They did not obtain a GIP contract. Upon personnel record review, 4 of 12 (Personnel #3,#4,#5,#8) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel #3, #4, #5, #8: No evidence of a withholding W-2/W4 statement to validate employment.”

“Upon patient record review, 4 of 6 (Patient #1, #2, #3, #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: Med profile does not include routes for med administration, and found Montelukast 10 mg BID in home (order was for 100mg), ASA 81mg PO QD, no evidence on the medication profile for these two medications. Patient #2: On HV found p.t is taking Synthroid 50 mcg one PO QD, Oxybutynin chloride 5mg PO one Q HS, Pilocarpine HCL Op sol. 1%- one drop each eye TID, Dorzolamide 2% Opth. sol one drop each eye BID, Novolin u100 SQ to scale TID (no scale provided), none of these meds are on med profile. On the profile and no longer taking is Glipizide 10mg 1 tab PO BID and Januvia 100mg PO QD- both dc’d in Dec.2023. Lanoxin 0.125mg dc’d many months ago per daughter. Patient #3: SN initial assess included the note: Hydrocodone 5ml Q 8 hrs prn pain via Peg tube (no dosage m per 5ml). During HV this medication was found in home, also Pantoprazole 40mg PO one QD via Peg tube, and Lisinopril 5 mg via peg tube 1 x day (medication profile had Lisinopril as 10mg in error). There was no evidence on the medication profile for these three medications. Patient #4: On nurse’s notes day of death 9/21/2023 “O2 in home”. No evidence in med. profile for O2.”

“Upon patient record review, 3 of 6 (Patient #3,#4,#5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patients #3,#4,#5, No evidence of a bereavement assessment at SOC within 5 days.”

“Upon patient record review, 2 of 6 (Patient #4,#5) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #4: SOC 6/28/2023- SN 1x week, no evidence of SN visits from 7/28/2023-8/14/2023 (17 days), or 8/14/2023-9/20/2023 (37 days), no update to the comprehensive assessment during these dates. Patient #5: SN visits 5/6/2022 and 5/22/2022 (16 days), no evidence of a a comprehensive assessment no less frequently than 15 days.”

“Upon patient record review, 3 of 6 (Patient #3, #4,#6) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #3: Pt is identified on SOC (12/10/2023) assessment as having a peg tube, and receiving Isomil 1.5cal 1 can Q 4 hrs.. There is no mention of the peg tube feedings in the POC. Patient #4: SOC 6/28/2023, Dr orders and brief SOC POC. No POC in record after SOC. On Death note documented O2 in home, no evidence of order for or inclusion of O2 on POC. No evidence of problems, goals, and interventions to address fall risk, fluid overload, shortness of breath, pain or comfort measures. Patient #6: SOC orders for 7/24/2022 included SN 1x week, order same day for dressings changes to be done daily. No evidence of problems, goals, and interventions to address wounds or skin care.”

“Upon patient record review, 4 of 6 (Patient #1,#2,#3,#4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: During HV medication reconciliation found Montelukast 10 mg BID in home (order was for 100mg), ASA 81mg PO QD, evidence of orders for these two medications. Patient #2: During HV medication reconciliation found pt is taking Synthroid 50 mcg one PO QD, Oxybutynin chloride 5mg PO one Q HS, Pilocarpine HCL Op sol. 1%- one drop each eye TID, Dorzolamide Opth. sol one drop each eye BID, Novolin u100 SQ to scale TID (no scale provided), none of these meds have Dr. orders. Patient #3: The SOC SN initial assess included: Hydrocodone 5ml Q 8 hrs prn pain via Peg tube. During HV this medication was found in home, also Pantoprazole 40mg PO one QD via Peg tube, and Lisinopril 5 mg via peg tube 1 x day. There was no evidence of orders for these three medications. Pt is identified on SOC assessment as having a peg tube, and receiving Isomil 1.5cal 1 can Q 4 hrs. There is no evidence of orders for the tube feedings. Patient #4: On nurse’s note on day of death 9/21/2023 “O2 in home”. No evidence of orders for O2.”

“Upon client record review, 2 of 6 (Patient #4, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: SN ordered 1x week, no evidence of SN visits from 7/28/2023-8/14/2023, or 8/14/2023-9/2023. SW ordered 1x Month, no evidence of any SW visits, SC ordered 1x M, no evidence of any SC visits. Patient #6: SOC orders for 7/24/2022 included SN 1x week, order same day for dressings changes to be done daily, no designation of who is to perform these dressing changes. SN visited 7/24, 7/25, 7/26/2022 without orders for daily visits. Visits then resumed at 1x week with no clear order.”

“Upon personnel record review, 1 of 12 (Personnel #7) did not have evidence that Hospice Aide Services are provided by a qualified individual in accordance with the appropriate state’s regulations, the hospice’s policies and procedures and/or job descriptions and the ACHC Glossary of Personnel Qualifications as defined by the Medicare Conditions of Participation. Personnel #7: There was no evidence the aide completed A training program and competency evaluation as specified in CFR 418.76(b) and 418.76(c), A competency evaluation program that meets the requirements of CFR 418.76(c), A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 and is currently listed in good standing on the state nurse aide registry or A state licensure program. The aide has not be utilized in patient care.”

“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The agency administrator and governing body did not provide agency oversight to ensure all core services can be provided to include general inpatient level of care. No evidence that employment of all core staff could be verified through withholding statements. Alternate Medical Director contract was not in place until during the survey. Emergency Preparedness plan was not complete in order for the agency to be prepared to handle emergencies. No evidence of a qualified aide to provide aide services.”

“Upon patient client record review, 1 of 6 (Patient #1) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: On SOC assessment DNR is marked “no”, on MSW initial assessment DNR is marked “yes”, then a note is documented within same record “Not ready to sign OOH DNR at this time. On initial Dr. orders dated 8/3/2023 Dr. has marked an order for DNR. No evidence of clear entries.”