Moments Hospice of Madison

“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 following: 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, document review, and observation. Agency policy #2-004 “Medication Profile” (no date) stated in part, “The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.” In 2 of 14 (14%) clinical records reviewed and home visits observed, the agency did not ensure the patient’s drug profile included all current prescription and over-the-counter medications. Clinical Record 1/Home Visit 1: The patient elected hospice care on 09/22/2023. The IDG (interdisciplinary group) plan of care dated 02/02/2024 ordered oxygen at 2 liters continuously. During the home visit on 03/19/2024, the patient was observed using oxygen at 2 liters. The drug profile effective from 02/02/2024 to present did not document oxygen. Clinical Record 10: The patient elected hospice care on 05/12/2023. The Registered Nurse (RN) comprehensive assessment dated 02/29/2024 documented, “Patient noted to have SOB (shortness of breath) at rest and has been using rescue inhaler and nebulizer as needed.” The drug profile effective 05/15/2023 did not document a nebulizer medication/treatment. On 03/20/2024 the Team Director reported that a call was made to the RN case manager who confirmed the patient had been using nebulizer treatments “since sometime in January.” During an interview, on 03/21/2024, the Team Director confirmed these drug profiles had not been updated when the new medications were added, nor was the discrepancy identified during the weekly medication reconciliations.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The assessment update is completed: as frequently as the condition of the patient requires; [and] no less frequently than every 15 days. 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 the comprehensive assessment was completed no less frequently than every 15 days. Clinical Record 11: The patient elected the hospice benefit on 05/03/2023 with a diagnosis of malignant neoplasm of the thyroid gland. Effective July 2023 the nursing visit frequency was once every 14 days. The comprehensive assessment visit was documented by the Registered Nurse (RN) on 07/18/2023. There were no other nursing visits completed between 07/18/2023 and the date of discharge 08/10/2023 (the discharge visit was coded as a “non-visit”), with 17 days outstanding. Between July 18, 2023, and the date of discharge the patient was seen by music therapy, massage therapy, and the chaplain. On 08/04/2023 the RN documented the reason for the missed visit was “the daughter has not signed the discharge paperwork.” On 03/21/2024, the Team Director confirmed that the nurse should have made an additional visit, stating, “There was a lot of communication between us and the daughter trying to complete the discharge process, and it was missed.””

“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. 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 the plan of care included specific interventions related to the problems identified in the comprehensive assessments. Clinical Record 4: The patient elected the hospice benefit on 09/29/2023 with a diagnosis of Alzheimer’s disease. During the comprehensive assessment, dated 03/03/2024, the RN documented, “Patient continues to have hallucinations. These do not seem to bother her. She has times of anxiety and or agitation where she will strike out at staff.” The drug profile included an order dated 10/09/2023 for Lorazepam 0.5 mg tablet every 4 hours as needed for anxiety/agitation/restlessness. The plan of care included a diagnosis of generalized anxiety disorder with an effective date of 09/29/2023. The plan of care effective from 9/29/2023 to the present did not include problems, goals, or interventions related to anxiety, agitation, or hallucinations. On 03/20/2024, the Team Director reviewed the record and confirmed that the plan of care did not include any goals or interventions related to the hallucinations, anxiety or agitation and said, “They have been added now.””

“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. A revised plan of care includes information from the patient’s updated comprehensive assessment. 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 the plan of care was revised when problems, goals, and/or interventions were resolved. Clinical Record 9: The patient elected the hospice benefit on 01/03/2023 with a diagnosis of Myasthenia Gravis. A nursing visit on 01/13/2023 documented a wound “left forearm, trauma, superficial wound,” with wound care orders obtained. The plan of care documented the problems, “Need for skilled teaching related to decubitus care-hospice,” “Need for decubitus wound care,” and the goal “Patient verbalized tolerance to decubitus care.” The plan of care documented several interventions related to performing wound care and education on wound care. The problems, goals, and interventions had an initiation date of 01/13/2023. The nursing visit note dated 02/07/2023 documented that no skin issues were identified, and according to subsequent assessments, the wound was no longer present. The plan of care was not updated to discontinue the wound care problems, goals, and interventions. On 03/20/2024, the Team Director was interviewed and agreed that the wound had healed and that the wound care problems, goals, and interventions should have been discontinued. 42702 SOC 01/03/2023 BP 02/07/2024 Myasthenia Gravis with exacerbation (home) RN, SW, CH, HA, massage (vol at start of care)”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed in which volunteer services were accepted, the agency did not ensure the volunteer services were documented per the plan of care orders. Clinical Record 6: The patient elected hospice care on 02/02/2024. On 02/19/2024 the physician ordered “Volunteer service request 1-3 visits per month, start February 2024.” A review of the clinical record revealed no evidence of volunteer visits documented for February. One (1) volunteer visit was documented for March, dated 03/19/2024. Clinical Record 7: The patient elected hospice care on 01/26/2024. On 01/26/2024 the physician ordered “Volunteer service request 1-3 visits per month, start February 2024.” A review of the clinical record revealed no evidence of volunteer visits documented for February. One (1) volunteer visit was documented for March, dated 03/06/2024. During an interview on 03/21/2024, the Team Director and the Volunteer Coordinator reported, “The volunteer assigned said he made or attempted to make all his visits in February and had sent in the documentation.” The Volunteer Coordinator said there had been some computer issue and could not locate any documentation showing that the visits were made, per the plan or care orders, for these two patients.”

“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: physician orders. 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 the clinical record included physician orders for all prescribed medications. Clinical Record 10: The patient elected hospice care on 05/12/2023. The Registered Nurse (RN) comprehensive assessment dated 02/29/2024 documented, “Patient noted to have SOB (shortness of breath) at rest and has been using rescue inhaler and nebulizer as needed.” The drug profile effective 05/15/2023 did not document a nebulizer medication/treatment. On 03/20/2024, the Team Director reported that a call was made to the RN case manager, who confirmed the patient had been using nebulizer treatments “Since sometime in January.” An order was entered into the clinical record on 03/21/2024 for “DuoNeb treatment; give one vial via inhalation/nebulizer every 8 hours for SOB/wheezing.” The Team Director confirmed that there was no order for the nebulizer treatments before 03/21/2024.”