Primrose Hospice, Inc.

“Based on interview and medical record review, it was determined the agency did not follow an individualized written plan of care as established by the interdisciplinary group. Specifically, there were missing aide, chaplain, social worker and skilled nursing visits for 7 of 14 sampled patients. (Identifier numbers: 1, 2, 3 9, 10, 11 and 12.) Findings include: 1. Patient 1 was admitted to the agency on 6/22/2022 with a terminal diagnosis of Alzheimer’s disease, unspecified dementia, dystonia and type 2 diabetes mellitus. Patient 1’s medical record was reviewed on 4/9/2024. The IDG team meeting notes that were completed on 2/8/2024, 2/22/2024, 3/7/2024, 3/21/2024 and 4/4/2024 were reviewed. All meetings notes had that a Medical Social Worker (MSW), was to visit the patient 1-2 times a month for 8 weeks, a hospice aide was to visit 1 time a week for 8 weeks and the Chaplain was to visit 1-4 times a month for 8 weeks. There was no psychological or spiritual care plans developed. Additionally, there was no aide visits the week of 2/18/2024, 3/3/2024, 3/10/2024, 3/24/2024 and 3/31/2024 In an e-mail to the Operations Manager (OM), dated 4/9/2024 at 2:58 PM, he stated that it was documented that a social worker was there for “emotional support, counseling” and that the chaplain was there for “spiritual support.” The care plans did not have measurable interventions or goals. 2. Patient 2 was admitted to the agency on 2/22/2023 with a terminal diagnosis of heart failure. Patient 2’s medical record was reviewed on 4/10/2024. The IDG team meetings for 2/8/2024, 2/22/2024, 3/7/2024, 3/21/2024 and 4/4/2024 were reviewed. It was documented that MSW was to see patient 2 1-2 times a month for 8 weeks for counseling and education and a chaplain was to visit the patient 1-2 times a month for 8 weeks. However it was further documented that patient 2 had declined chaplain services. A care plan for the MSW did not have interventions or goals documented. In an e-mail to the OM, dated 4/9/2024 at 4:47 PM, the OM documented that he though the emotional support and education was the MSW care plan. He further stated that the chaplain put the orders in the computer in error. 3. Patient 3 was admitted to the agency on 9/10/2023 with a terminal diagnosis of unspecified dementia with behavioral disturbances. Patient 3’s medical record was reviewed on 4/10/2024. The IDG team notes, dated 4/4/2024 was reviewed. The chaplain was to see patient 3 1-4 times a month for 2 months for spiritual support and counselling. Interventions and goals were not documented. 4. Patient 9 was admitted to the hospice agency on 3/14/2024, with a terminal diagnosis of acute myeloid leukemia with multilineage dysplasia. Patient 9s medical record was reviewed on 4/9/2024. Review of the plan of care (POC) developed for patient 9 on 3/15/2024, indicated that a hospice aide was to assist with activities of daily living 5 to 7 times per week. Documented evidence showed that patient 9 was only receiving hospice aide visits 4 times per week. On 4/9/2024 at 12:30 PM, an email was sent to the Operations Manager asking for information on the missed visits. On 4/9/2024 at 3:54 PM an email was received from the Operations Manager that stated, we initially scheduled 5 visits per week for him, but he decided that he did not want visits on Thursdays. We must have forgotten to update his care plan after that change. Thank you for catching that. We have educated the nurse that it was missing from the patient record, and it has been corrected. 5. Patient 10 was admitted to the hospice agency on 12/15/2023, with a terminal diagnosis of Alzheimer’s disease unspecified. Patient 10s medical record was reviewed on 4/9/2024. Documented evidence showed that upon admission patient 10 had declined chaplain visits. A review of the POC developed for patient 10 on 3/15/2024, indicated that the chaplain was to visit for spiritual support and counseling 1 to 2 times per month. Additionally, there was no psychological or spiritual care plans developed. On 4/9/2024 at 3:04 PM, an email was sent to the Operations Manager asking for information on the discrepancy. 04/9/2024 at 3:54 PM, an email was received from the Operations Manager that stated, “;Our chaplain put this into the plan of care incorrectly. He said he thought he still needed to put a frequency of 1-2 in in case they decided they wanted visits later. Weve educated him on the correct way to enter and change frequencies and will correct this moving forward.” 6. Patient 11 was admitted to the hospice agency on 7/6/2023, with a terminal diagnosis of unspecified dementia. Patient 11s medical record was reviewed on 4/9/2024. A review of the POC developed for patient 11 on 11/15/2023, 11/30/2023, 12/14/2023 and 12/20/2023 indicated that the chaplain was to visit for spiritual support and counseling 1 to 2 times per quarter. Additionally, there was no psychological or spiritual care plans developed. Documented evidence showed no visit occurred with patient 11 and the chaplain. On 4/9/2024 at 5:11 PM, an email was sent to the Operations Manager asking for information on the discrepancy. 7. Patient 12 was admitted to the hospice agency on 1/16/24, with a terminal diagnosis of senile degeneration of the brain, not elsewhere classified. Patient 12s medical record was reviewed on 4/10/2024. A review of the plan of care (POC) developed for patient 12 on 2/27/2024 indicated that a skilled nurse (SN) was to visit 3 to 5 times per week. Documented evidence showed that patient 12 was only receiving skilled nursing visits 2 times per week. On 4/10/2024 at 8:44 AM, an email was sent to the Operations Manager asking for information on the discrepancy. On 4/10/2024 at 9:24 AM, an email was received from the Operations Manager that stated, patient 12s nurse said that the aide frequency must have accidentally been added for nurse. She further stated that the nursing visit frequency should have been 1-3 times per week.”

“Based on interview and record review, it was determined the hospice agency did not ensure that an individualized written plan of care for each patient was developed that included patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments for all services provided. Specifically, goals and interventions were not included in the plan of care (POC) for the social worker (SW) and chaplain for 14 of 14 sampled patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14). Findings include: A review of 14 patients medical records was completed from 4/8/2024 through 4/11/2024. There was no documented evidence that goals or interventions had been added to the POC by the social worker (SW) or the chaplain. On 4/9/2024 at 5:11 PM, an email was sent to the clinical director requesting information on why the POC did not include goals or interventions completed by the SW and Chaplain. On 4/10/2024 at 12:28 PM, and email was received from the clinical director, he stated we thought that brief section with the description of care in conjunction with the initial assessment covered us for the SW and chaplains care plan, but it sounds like we need to provide more education on how to input goals and interventions and make the care plan more thorough.”

“Based on interview and observation, it was determined the agency did not provide care to include all necessary services for the palliation and management of the terminal illness and related conditions, including drugs and treatment necessary to meet the needs of the patient. Specifically, there was a delay in treatment when a patient was diagnosed with a urinary tract infection. (Patient identifier: 2) Patient 2 was admitted to the agency on 2/22/2023 with a terminal diagnosis of heart failure. A review of patient 2’s medical record was completed on 4/11/2024. An order was received on 2/15/2024 to obtained a urinalysis with a culture and sensitivity; and patient 2 was started on Levaquin 500 mg a day for 14 days. There was no further documentation in patient 2’s medical record regarding the orders. A request for the agency to obtain a copy of the laboratory results were made on 4/10/2024 at 11:59. The laboratory results were received and reviewed at 12:51 PM. The urinalysis returned negative, but the culture and sensitivity returned positive for Aerococcus urinae which was susceptible to Levofloxacin. In an interview with the Director of Nursing (DON), dated 4/11/2024., the DON was asked about the delay in treatment related to patient 2’s urinary tract infection. The DON stated that he called the laboratory and was verbally told the urinalysis was negative. Since it was negative, he did not follow up with the culture and sensitivity. He stated that the primary care physician then went on vacation. When the physician returned, the Levaquin 500 mg a day for 14 days. The DON did not update the plan of care.”

“Based on interview and record review, it was determined the agency did not revise the plan of care to include information from the patient’s updated comprehensive assessment and did not note the patient’s progress toward the outcomes and goals for 1 of 14 sampled patients. Specifically, the care plan was not updated when a patient was diagnosed with a urinary tract infection. (Patient identifier: 2) Findings include: Patient 2 was admitted to the agency on 2/22/2023 with a terminal diagnosis of heart failure. A review of patient 2’s medical record was completed on 4/11/2024. An order was received on 2/15/2024 to obtained a urinalysis with a culture and sensitivity; and patient 2 was started on Levaquin 500 mg a day for 14 days. There was no further documentation in patient 2’s medical record regarding the orders. A request for the agency to obtain a copy of the laboratory results were made on 4/10/2024 at 11:59. The laboratory results were received and reviewed at 12:51 PM. The urinalysis returned negative, but the culture and sensitivity returned positive for Aerococcus urinae which was susceptible to Levofloxacin. There was no documentation that patient 2’s plan of care was updated to include the diagnosis of a urinary tract infection or that Levaquin was initiated. In an interview with the Director of Nursing (DON), dated 4/11/2024., the DON was asked about the delay in treatment related to patient 2’s urinary tract infection. The DON stated that he called the laboratory and was verbally told the urinalysis was negative. Since it was negative, he did not follow up with the culture and sensitivity. He stated that the primary care physician then went on vacation. When the physician returned, the Levaquin 500 mg a day for 14 days.”