Southern Grace Hospice LLC

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the Interdisciplinary Group completed the initial comprehensive assessment no later than five calendar days after the election of the hospice benefit. Clinical Record 6: A clinical record review revealed that the patient elected the hospice benefit on 08/27/2024. The Skilled Nurse (SN) documented the comprehensive nursing assessment on 08/27/2024, the Spiritual Counselor (SC) documented the spiritual assessment on 08/29/2024, and the Medical Social Worker (MSW) documented the psychosocial assessment on 09/02/2024, six days after the hospice election. The Administrator (Personnel Record 1) was interviewed on 11/14/2024 and stated, “The family requested the MSW assessment on 09/02/2024, but the MSW did not document the family’s request.””

“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 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 and interview. In 2 of 14 (14%) medical records reviewed, the agency did not ensure that the medications were reviewed to identify duplicate drug therapy. Clinical Record 1: A clinical record review revealed that the patient’s current medication list included two orders for Tylenol. “Tylenol 650mg, 1 suppository rectally every four hours as needed for fever/temp,” was added to the care plan on 07/15/2024 with the initial comprehensive assessment. On 09/27/2024, an order was entered for “Tylenol 500mg two tabs orally every six hours as needed for pain/fever.” The order did not include parameters for when the patient should take Tylenol orally or rectally. There were subsequent documented comprehensive assessments on 09/18/2024, 10/02/2024, 10/16/2024, and 10/30/2024, where the duplicate medication was not reconciled. There was no documentation in the clinical record of communication of the duplicate medication with the attending physician. The Administrator was interviewed on 11/13/2024 and stated, “The Tylenol suppository is part of the patient’s comfort kit, so the nurses add the medication when the kit is ordered. The nurse should have provided instructions on when the patient should use the suppository or the oral tablets to prevent the patient from taking too much.” Clinical Record 6: A clinical record review revealed that the care plan dated 10/26/2024 included two orders for Tylenol: “Tylenol 325mg, 2 caps orally as needed for pain” and “Tylenol #3 300/30mg, 1 tablet every 6 hours as needed for pain.” A comprehensive assessment was documented on 10/30/2024, but it did not include reconciliation documentation or clarification of the duplicate medication. There was no documentation in the clinical record of communication of the duplicate medication with the attending physician. The Administrator was interviewed on 11/14/2024 and stated, “The nurse case manager should have added parameters in the medication order to clarify when the patient should take Tylenol and when to take Tylenol #3.””

“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 a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure the plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family need. Clinical Record 6: The initial comprehensive assessment completed on 08/27/2024 included documentation that the Spiritual Counselor (SC) and Medical Social Worker (MSW) services were needed. A review of the plan of care dated 08/27/2024 included visit frequency orders for Skilled Nursing (SN) and Hospice Aide (HA) services, however it did not include a visit frequency for the SC or MSW. SC visits were documented on 08/29/2024 and 09/03/2024, and an MSW visit was documented on 09/02/2024 without orders on the plan of care. On 10/03/2024, an interim order was documented and signed by the physician for SC visits “monthly and prn” and MSW visits “monthly and prn.” Subsequent SC visits were documented on 10/17/2024 and 11/04/2024, and an MSW visit was documented on 10/27/2024. The Administrator was interviewed on 11/14/2024 and stated, “The visit frequency for MSW and SC was missed on the care plan.””

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, including drugs and treatment necessary to meet the needs of the patient’ This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the plan of care included orders based on problems identified in the comprehensive assessment. Clinical Record 2: A clinical record review revealed that the plan of care dated 09/28/2024 included orders for “Insert 14 Fr Foley catheter and change PRN. Instruct in irrigation. Instruct in routine care and function of catheter. Instruct in the use of Texas catheter.” The documentation in the genitourinary section of the comprehensive assessments dated 09/28/2024, 10/02/2024, 10/16/2024, and 10/30/2024 did not indicate that the patient had any urinary problems requiring a catheter nor did the documentation show that the patient had a catheter inserted. All subsequent nursing visit notes did not include documentation that the patient had a Foley catheter. A Texas catheter was not documented as being used by this patient (this was a female patient). The Administrator was interviewed and stated, “These are standard referral orders that are added to every patient in case they need a catheter at some point during care.””

“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. This standard was not met as evidenced by document review and interview. A review of the volunteer cost savings report revealed the agency did not provide volunteer hours equal to at least five percent of the total patient care hours of all paid hospice employees and contract staff. The volunteer cost savings report, dated 01/01/2024 through 11/14/2024, documented 56.3 non-direct care volunteer hours, which equals 3% of the total patient care hours of all paid hospice employees and contract staff. The Volunteer Coordinator (VC) and the Alternate Administrator were interviewed on 11/14/2024. The Alternate Administrator stated, “The current VC was the only volunteer we had this year. Three additional volunteers are currently in onboarding, so volunteer hours will increase with the added volunteers. They will also be oriented to volunteer for patients.” The agency did not provide volunteer hours equal to at least five percent of the total patient care hours of all paid hospice employees and contract staff.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed where the patient was transferred to a facility, the agency did not ensure that the receiving facility was provided the discharge summary. Clinical Record 12: A review of the clinical record revealed that the patient elected the hospice benefit on 09/05/2024. On 11/06/2024, the patient was transferred to the hospital and revoked hospice. Further review showed that a discharge summary was created for the patient at revocation, but the record did not include documentation that the discharge summary was provided to the receiving facility. The Administrator was interviewed on 11/14/2024 and stated, “The hospital only requested a list of the patient’s medications, which was sent. But a discharge summary was not sent to the hospital.””

“It is required that each patient’s individualized written plan of care: Reflects patient and family goals; Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, including measurable outcomes anticipated from implementing and coordinating the plan of care. The documentation in the patient’s record is in accordance with the hospice’s policies and procedure. 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 plans of care were individualized to include measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected hospice care on 05/04/2023. Review of the plan of care (POC) identified the problem “spiritual grief” 05/04/2023. The plan of care documented, “Deficit related to care management.” Goal. Patient/caregiver will understand and deliver care needed to maintain safety.” The POC did not include a measurable outcome for the goal. Clinical Record 2: The patient elected hospice care on 01/192024. Review of the plan of care (POC) identified the problem “Deficit related to infection” on 01/19/2024. The plan of care documented, Goal...Patient’s infection will be contained, comfort will be promoted, further infection will be prevented.”, The POC did not include a measurable outcome for the goal. Clinical Record 3: The patient elected hospice care on 12/20/2023. Review of the plan of care (POC) identified “physical comfort alteration. “ 12/20/2023. Goal. “Patient will achieve and maintain optimal physical comfort.” The POC did not include a measurable outcome for the goal. Clinical Record 4: The patient elected hospice care on 01/11/2024. Review of the plan of care (POC) identified “circulatory function and fluid volume alteration. “ 01/11/2024. Goal. “Patient/caregiver will maintain adequate cardiac circulatory function and fluid volume as long as possible.” The POC did not include a measurable outcome for the goal. Clinical Record 5: The patient elected hospice care on 06/18/2023. Review of the plan of care (POC) identified “physical comfort alteration. “ 06/18/2023. Goal. “Patient will achieve and maintain optimal physical comfort.” The POC did not include a measurable outcome for the goal. The Director of Clinical Services was interviewed on 04/01/2024 and confirmed the goals did not include outcomes that were measurable.”