Generations Hospice and Palliative Care

“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 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, interview and observation. In 1 of 3 (33%) clinical record reviews and home visit observations revealed the agency did not ensure that the comprehensive assessment drug profile contained all of the patient’s prescription and over-the-counter medications and medication reviews were completed. Document 1: The agency’s policy read it part, “The hospice will develop a medication profile, upon admission, with all the medications the patient is taking, including over-the-counter and herbal medications, and obtain a physician order. Update the Medication Profile with each physician order including new medications, changes in medications, and discontinued medications”. (Medication Management) (JCC 013115) Clinical Record 1/Home Visit 1: A home visit (Home Visit 1) was conducted on 11/20/2024 with the Registered Nurse (RN) Personnel Record 1). A review of the patient’s medications and the comprehensive medication profile revealed Senna Plus (bottle label dated 11/12/2024 and instructions to take three (3) tablets twice daily), Hyoscyamine 0.125mg (with a bottle label dated 02/24/2024 every four hours as needed), and Lorazepam (bottle label dated 11/12/2024) 0.5mg twice daily (medication profile instruction was one tablet every two (2) hours as needed for anxiety) were not included in the Plan of Care for the certification period of 09/30/2024 to 12/29/2024. As a result, the medication review that included all medications was not performed. The caregiver confirmed that the medications and instructions were not new, and the label dates were for refills. In an interview with the RN, the RN stated she would have to check with the patient’s pharmacy about the medications and instructions. In an interview with the Director of Clinical Services (DCS) on 11/21/2024, the DCS stated that the medication profile was updated but that the nurse had not reconciled the medications.”

“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 duration noted in Item 2. This standard was not met as evidenced by document review and interview revealed the agency did not ensure the Volunteer cost savings equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff was achieved through volunteer services. Document: Agency Volunteer cost savings report revealed that the agency was tracking volunteer hours but was unable to produce evidence that the 5% requirement was met for the total patient care hours of all paid hospice employees and contract staff through volunteer services. In an interview with the Administrator/Volunteer Coordinator (VC), the VC stated she was utilizing a spreadsheet with a formula that was no longer working and therefore was unable to provide evidence of the 5% requirement. A review of the volunteer cost savings report revealed that the agency was tracking volunteer hours but was unable to produce evidence that the 5% requirement was met for the total patient care hours of all paid hospice employees and contract staff through volunteer services.”

“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 2 of 2 (100%) clinical records for patients who revoked hospice services revealed the agency did not ensure that the discharge summaries were forwarded to the attending physician. Clinical Record 4: The patient was admitted to hospice services on 04/27/2024 with diagnoses of Intrahepatic Bile Duct Carcinoma, Alcoholic Cirrhosis of the liver with ascites, and Myelofibrosis. On 05/01/2024, the patient revoked services seeking aggressive treatment. There was no documented evidence that the discharge summary was sent to the attending physician. Clinical Record 6: The patient was admitted to hospice services on 07/01/2024 with diagnoses of Hypertensive Heart Disease with Heart Failure, Alcoholic Liver Cirrhosis without Ascites, Viral Hepatitis C, Seizure Disorder, Late Effects of CVA, Esophageal Varices, and Gastrointestinal bleeding. On 09/06/2024, the patient revoked services seeking aggressive treatment. There was no documented evidence that the discharge summary was sent to the attending physician. In an interview with the Administrator and the Director of Clinical Services (DCS) on 11/21/2024, the DCS stated that she believed the summaries were sent but the administrator and DCS were unable to provide evidence that the summaries were sent.”

“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 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 with the which revealed the hospice: Failed to ensure that the clinical record included updated plans of care {HSIM.3. I/L672}; Failed to ensure the entries in the patient records were appropriately authenticated by the person performing the care or service {HSIM.4. I/ L679} and Failed to ensure that the plan of care was individualized, reviewed, or revised as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days {HCPC.22. 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 418.104: 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 the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes. history of pain and its treatment, both pharmacological and non-pharmacological, use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status; characteristics of the pain, including location, frequency, and intensity. How pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping), and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. 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 the pain assessment included location, characteristics, duration, frequency or how it impacts the patient’s function. Clinical Record 2: The patient elected the hospice benefit on 07/01/2024 with a diagnosis of Hypertensive Heart Disease. The initial certificate of terminal illness written by the medical director on 07/02/2024 stated “pain requiring the use of opioids.” In the initial RN assessment dated 07/01/2024 the RN documented “patient pain goals is to be pain free and comfortable.” She documented “yes, pain is an active problem for the patient.” The RN did not document a thorough pain assessment that included location, character, duration, frequency, what relieves/worsens pain, and effect on function and quality of life. On the RN assessment dated 07/17/2024 the patient reported mild pain (1-3). The RN did not document location, character, duration, frequency, or effect on function or quality of life. Home visit (home visit 2) with the Chaplain (Personnel Record 1), the patient was awake and sitting up on her couch. She engaged in meaningful conversation and answered questions appropriately. In an interview with the Director of Clinical she stated that the RN did not get the details of pain due to the patient’s cognition, however the RN documented the patient was alert and oriented times 1. When the surveyor visited (home visit 2) the patient with the Chaplain (Personnel Record 1), she was awake and sitting up on her couch. She engaged in meaningful conversation and answered questions appropriately.”

“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, 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 2 of 5 (40%) clinical records reviewed revealed that the agency did not ensure that the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: Patient elected hospice benefit on 06/14/2024 with a diagnosis of Alzheimer’s Disease. On the initial RN assessment, the RN documented “shortness of breath with minimal exertion.” and “generalized pain that is dull on a daily basis. Patient is being treated with Tylenol 325mg by mouth as needed.” On the plan of care dated 06/28/2024 there were no measurable outcomes anticipated from implementing and coordinating the plan of care. A problem of decreased endurance was identified, interventions were “monitor respiratory status and teach methods for increasing exercise tolerance”. Outcomes were “symptoms managed”. The patient has an active problem of generalized pain documented on the initial RN assessment dated 06/14/2024. Pain was also documented on RN assessment dated 06/20/2024 as mild (1-3), 06/26/2024 as mild (1-3). On the plan of care dated 06/28/2024 pain average and location were not addressed. Interventions included “Monitor pain control, teach diversion/relaxation techniques, teach med regimen to control pain, teach comfort measures”. Outcomes documented were “Pain goal with no goal listed, compliance of pain med regiment, and symptoms managed”. The same was documented on IDT plans of care dated 07/12/2024, 07/26/2024, 08/09/2024, and 08/2023. Clinical Record 3: The patient elected the hospice benefit on 07/02/2024 with a diagnosis of End Stage Renal Disease. On the initial RN comprehensive assessment dated 07/02/2024, the RN documented that the patient had constant pain in bilateral lower extremities that the patient rated 2 out of 10, the same was documented by the RN on the assessment dated 07/09/2024. The RN documented that pain was an active problem for the patient. On the plan of care dated 07/12/2024, physical comfort and pain were listed as a problem for the patient interventions included monitor pain control, teach diversion/relaxation techniques, teach medication regimen to control pain, teach comfort measures. Outcomes were listed as pain control with no goal filled in, symptoms measured with explanation how the symptoms would be measured. The same was documented on plan of care updates dated 07/26/2024, 08/09/2024, and 08/23/2024. In an interview with the director of nursing she agreed that the outcomes were not measurable, and conversation was had about developing measurable outcomes.”

“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 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that the plan of care was individualized, reviewed, or revised as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. Clinical Record 2: The patient elected hospice services on 07/01//2024. IDG care plan updates dated 07/12/2024, 07/26/2024, 08/09/2024, and 08/23/2024 were all photocopied with no changes made to any of the care plans. However, there was no evidence of the IDT’s review or revision of the plan of cares. This was evident by 100% of matching verbiage, identical blanks on plan of care, and identical narrative notes. There was no evidence that the IDT team was reviewing the plan of care or documenting record of the patients progress toward goals no less than every 15 days. In an interview with the director of nursing and administrator there was no explanation why these notes were photocopied. The DON stated that the nurses email them the notes and they put them in the chart. She did not realize the notes had been photocopied.”

“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. Updated plans of care. 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 the clinical record included updated plans of care. Clinical Record 2: The patient elected hospice services on 07/01/2024. IDG care plan updates dated 07/12/2024, 07/26/2024, 08/09/2024, and 08/23/2024 were all photocopied with no changes made to any of the care plans. This was evident by 100% of matching verbiage, identical blanks on plan of care, and identical narrative notes. There was no evidence that the IDT reviewed the plan of care, updated the care plans, and documented the patients progress toward goals in the clinical record. In an interview with the director of nursing and administrator there was no explanation why these notes were photocopied. A visit was made by the RN on 07/24/2024 and documented on the clinical visit notes. A visit made on 08/21/2024 was a photocopy of the 07/24/2024 visit note, only the date and time had been changed. A visit was also made on 07/31/2024 and documented on clinical visit notes. The documentation on 08/28/2024 was a photocopy of the visit made on 07/31/2024 with only the date and time changed. In an interview with the Director of Nursing she stated that the nurses email them the notes and they put them in the chart. She did not realize the notes had been photocopied.”

“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. 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 the entries in the patient records were appropriately authenticated by the person performing the care or service. Clinical Record 2: The patient elected the hospice benefit on 07/01/2024. A visit was made by the Registered Nurse (RN) on 07/24/2024 and documented on the appropriate forms. A visit made on 08/21/2024 was a photocopy of the 07/24/2024 visit only the date and time had been changed. A visit was also made on 07/31/2024 and documented on correct forms. The documentation on 08/28/2024 was a photocopy of the visit made on 07/31/2024 with only the date and time changed. Clinical Record 2: During review of the clinical record, it was found that IDT meeting notes were photocopied for the dates of 07/12/2024, 07/26/2024, 08/09/2024, and 08/23/2024. All 4 of the date’s documentation were exactly the same including evidence of white out used in areas of dates and times. In an interview with the director of nursing on 09/05/2024 she reviewed the documents in question. The RN assessments and the IDG care plans. She did not have any explanation as to why the documents were photocopied and only said that the RN are responsible for emailing the completed documents to her to put the patients record.”