Every finding on record at Advanced Home Health and Hospice, Inc.

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 following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, 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 and interview. In 1 of 3 (33%) home visit observations, the organization did not ensure a medication review was completed, and the medication profile was updated. Home Visit 3: The patient elected the hospice benefit on 09/16/2024. During the home visit observation with the Hospice Aide (HA) (Personnel Record 9), a medication review was completed by comparing the patient’s home medications to the hospice medication profile. The patient’s home medications included Aripiprazole 2mg po [by mouth] daily started on 09/03/2024 per the facility's administrator. The hospice medication profile did not include Aripiprazole. During a joint record review and interview on 10/10/2024, the Regional Director/ Registered Nurse/ Bereavement Coordinator/ Volunteer Coordinator confirmed the medication review had not included Aripiprazole, and the medication was not included in the patient’s medication profile.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by, the hospice IDG [interdisciplinary group] in collaboration with the attending physician (if any), the patient or patient representative if any of them so desire, the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed with spiritual counseling services provided, the agency did not ensure the spiritual counselor provided services as ordered on the plan of care. Clinical Record 2: The patient elected the hospice benefit on 05/06/2024. The plans of care dated 05/06/2024 to 08/03/2024 and 08/04/2024 to 11/01/2024 included an order for "Chaplain frequency 1/month duration 90/day 3 PRN [as needed] spiritual needs." The clinical record contained documentation of a missed visit in June that stated, "Scheduled visit rescheduled chaplain's unavailability." The missed visit in August stated, "Please assign to Chaplain [name]" and the missed visit in September stated, "No answer to phone call. Rescheduled." There was no documented evidence in the clinical record that the Chaplain attempted to reschedule the spiritual counseling visits ordered once a month. During a joint clinical record review and an interview on 10/10/2024, the Regional Director/ Registered Nurse/ Bereavement Coordinator/ Volunteer Coordinator confirmed that there was no documented evidence that spiritual counseling services were provided during the times identified.

It is required that 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 durations noted in Item 2. This standard was not met as evidenced by document review and interview. The hospice did not ensure cost savings achieved through volunteers was documented. Review of the agency’s volunteer program revealed the agency did not document the number of volunteer hours and the cost savings the hospice would have incurred if paid employees occupied the positions from January 2024 through September 2024. During an interview on 10/10/2024, the Regional Director/ Registered Nurse/ Bereavement Coordinator/ Volunteer Coordinator confirmed the agency did not have documentation of volunteer hours from January 2024 through September 2024. Upon reviewing the volunteer program, the documentation lacked evidence of the number of volunteer hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from January 2024 through September 2024. There were no documented volunteer hours for 2024.

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 1 of 2 (50%) clinical records reviewed for patients with live discharge, the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 11: The patient elected the hospice benefit on 12/12/2023 and was discharged for no longer terminally ill on 06/08/2024. The clinical record contained no documented evidence that the discharge summary was forwarded to the patient’s attending physician. During a joint record review and interview on 10/10/2024, the Regional Director/ Registered Nurse/ Bereavement Coordinator/ Volunteer Coordinator confirmed that the record did not include documentation that the discharge summary was forwarded to the patient’s attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following, a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients with live discharge, the agency did not ensure the discharge summary included required elements. Clinical Record 11: The patient elected the hospice benefit on 12/12/2023 and was discharged for no longer terminally ill on 06/08/2024. The clinical record contained no documented evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. During a joint record review and interview on 10/10/2024, the Regional Director/ Registered Nurse/ Bereavement Coordinator/ Volunteer Coordinator confirmed that the record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician.

Observed in Record Review. In 2 of 2 applicable patient records reviewed, the comprehensive assessment was not updated and/or collaboration did not occur by the Interdisciplinary Group (IDG) every 15 days as required. According to organizational policy Comprehensive Assessment No. 2-030, the comprehensive assessment will be updated every 15 days at a minimum and according to organizational policy Interdisciplinary Group Meeting (IDG) No. 2-050, the IDG will meet to discuss patient and family/caregiver changes, progress, and updates to the plan of care. Upon review of RR#1, it was noted on review of IDG documentation in the record over the last two certification periods, multiple notes did not include specific updates to the patient’s condition or indicate no changes were required with some notes including a statement as follows, “Discussed in IDG, continues to meet hospice requirements”. On review of IDG documentation, the documentation did not consistently reflect collaboration from all disciplines regarding the patient’s condition and plan of care. For example, on review of a social worker visit note, the documentation indicated the frequency of visits was to be changed to as needed and “MSW to discuss at upcoming weekly IDG meeting”; however, on review of IDG documentation following this visit, there was no documentation to validate this was discussed with the team. On review of the most current plan of care, there were no routine and/or as needed social worker or chaplain visit frequencies included and on review of IDG documentation, there was no documentation to validate the change in visit frequencies was discussed with the team. Upon review of RR#3 and IDG documentation, the documentation did not consistently reflect collaboration from all disciplines regarding the patient’s condition and plan of care. For example, on review of social worker visit notes, there was extensive documentation regarding trying to locate family members, discussing the patient’s care with the facility staff, and discussing a possible transition to live with his sister if appropriate; however, on review of IDG documentation following these visits, there was no documentation to validate this information was discussed with the team. This was reviewed and validated with the new Executive Director and current Interim Executive Director. Observed in Record Review. In 1 of 3 patient records reviewed, the update of the comprehensive assessment did not include specific information about the patient's progress toward desired outcomes. According to organizational policy Ongoing Comprehensive Assessments No. 2-031, the assessments will address progress towards hospice goals. Upon review of Interdisciplinary Group (IDG) update documentation for RR#1, progress towards goals was not consistently addressed. Progress was documented as a percentage or either as “improving or declining”; however, there was no documentation to support how the patient was improving or declining related to those goals. On review of goals established for emotional support and caregiver resources, there was no IDG documentation to validate these goals were addressed and progress, or lack thereof, was discussed. This was reviewed and validated with the new Executive Director and current Interim Executive Director.

Observed in Record Review. In 2 of 3 patient records reviewed with aide services, complete written patient care instructions were not prepared by the RN. Upon review of RR#1, it was noted the patient had oxygen therapy ordered continuously. On review of the aide plan of care, the aide was assigned to perform a complete shower for the patient; however, there were no specific instructions provided to the aide regarding oxygen precautions nor whether the patient was to be on oxygen during bathing or while the aide performed other assigned tasks. The patient had a walker and a wheelchair and on review of the aide plan of care, the aide was assigned to assist with ambulation; however, there were no instructions provided to the aide regarding the type of equipment to be used to assist with ambulation. Upon review of RR#3, it was noted the patient had oxygen therapy ordered continuously. On review of the aide plan of care, the aide was assigned to perform a partial bath/shower for the patient; however, there were no specific instructions provided to the aide regarding oxygen precautions nor whether the patient was to be on oxygen during bathing or while the aide performed other assigned tasks. This was reviewed and validated with the new Executive Director and current interim Executive Director.

Observed in Record Review. In 1 of 3 patient records reviewed, the patient record contained inaccurate information. Upon review of RR#3, it was noted the chaplain had completed three visits including the initial spiritual assessment and on review of the narrative section of each note, the information documented on the routine visit notes was identical to the information documented on the initial assessment. This was reviewed and validated with the new Executive Director and current interim Executive Director.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization had not provided emergency preparedness training to staff, volunteers, and individuals providing on-site services under arrangement at the following intervals: initial training; at least every two years. The Medical Director's HR file did not contain any documentation that any initial training had occurred as confirmed with the HR Manager.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization had not assessed potential medication-related problems, including duplicate drug therapy. In the chart for HV#2, the patient was on 5 prn medications for constipation. The patient was also on 4 different prn pain medications, including Ibuprofen, Hydromorphone, Tramadol and Norco. Hydromorphone was the only medication which addressed different amounts to take based on the severity of the patient's pain. In the chart for HV#3, the original oxygen order on the plan of care stated oxygen 2LNC, frequency continuous, prn - lacking clarity if the oxygen was continuous or as needed. In the chart for RR#4, the patient had 4 medications ordered prn for constipation. This was discussed with the DPCS.

Observed in Record Review. In 1 of 3 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment and reassessment that identified the patient’s need for hospice care and services. In the chart for RR#6, there was no assessment of bereavement risk documented in the chart. This was discussed with the DPCS. Observed in Record Review. In 1 of 10 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment and reassessment that identified the patient’s need for hospice care and services. In the chart for RR#5, there was no assessment of bereavement risk documented in the chart. This was discussed with the DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the update of the comprehensive assessment was not based on changes that had taken place since the initial assessment and did not include information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. Progress toward goals was either missing, or where present, not objectively measurable so as to not be meaningful to the group to determine the course of care, in the charts for RR#3, RR#6, RR#7 as confirmed with the DPCS. Observed in Record Review. In 10 of 10 patient records reviewed, the update of the comprehensive assessment was not based on changes that had taken place since the initial assessment and did not include information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. Progress toward goals was either missing, or in the few instances it was addressed as a percentage, not meaningful to the group in determining actual progress and course of care in the charts for RR#1, RR#2, RR#4, RR#5, RR#8, RR#9, RR#10, HV#1, HV#2 and HV#3 as confirmed with the DPCS. Observed in Record Review. In 1 of 3 patient records reviewed, the hospice’s interdisciplinary group did not update the comprehensive assessment in collaboration with the patient’s attending physician, if any, as frequently as the patient’s condition requires, but no less than every 15 days. In the charts for RR#7, the IDG meetings/updates were more than 21 days apart in the previous benefit period. This was discussed with the DPCS. Observed in Record Review. In 2 of 10 patient records reviewed, the hospice’s interdisciplinary group did not update the comprehensive assessment in collaboration with the patient’s attending physician, if any, as frequently as the patient’s condition requires, but no less than every 15 days. In the charts for HV#1and HV#2, the IDG meetings/updates were more than 21 days apart in the previous benefit period. This was discussed with the DPCS.

Observed in Record Review. In 10 of 10 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. This applied to all charts reviewed. Examples - In the chart for HV#1, the goals of care were not individualized nor appropriate as they all had the anticipated achievement date of By the time of death/discharge, even Patient/Caregiver will demonstrate appropriate interventions and strategies to reduce anxiety. and Patient will be pain free or verbalize an acceptable pain level with current pain management regimen. In the chart for HV#2, all goal target dates, except for hospice aide will promote safe personal care and hygiene which was within 1 certification period are by the time of death/discharge including Patient and/or caregiver will verbalize an understanding of the signs and symptoms of COVID-19, necessary precautions and when to get immediate medical attention. and Caregiver will demonstrate ability to maintain wound dressing to prevent further complications and/or infection. In the charts for RR#1 and HV#3 (same patient), some goals were not measurable such as patient will demonstrate optimal respiratory status within disease limitations and will maintain adapted lifestyle that minimizes distress and complications and were not individualized in that all goals except one (knowledge of COVID precautions/when to seek tx) were anticipated to be met by the time of death/discharge including Caregiver will demonstrate ability to maintain wound dressing to prevent further complications and/or infection. In the chart for RR#8, a pediatric patient, the pain goal was not appropriate/measurable/individualized - Patient will demonstrate optimal pain control and symptom management as disease process allows by time of death/discharge. This was discussed with the DPCS. Observed in Record Review. In 3 of 3 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. This applied to RR#3, RR#6 and RR#7. Example - In the charts for RR#3 and RR#7, most of the goals of care were not individualized nor appropriate as they almost all had the anticipated achievement date of By the time of death/discharge, even Patient will be pain free or verbalize an acceptable pain level with current pain management regimen. This was discussed with the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including a statement of the scope and frequency of the services necessary to meet the specific patient and family needs. In the chart for RR#9, the aide was scheduled 2/week for the entire benefit period yet only 3 visits were actually made, mostly due to refusal of the patient and PCG. The POC was not updated to reflect this change in need. This was discussed with the DPCS.

Observed in Record Review. In 1 of 3 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for RR#6, there were no physician orders for wound care, PICC line dressing changes. The wound care intervention on the POC did not include a frequency. The POC was updated with interventions, however no signed physician orders were found for these treatments. The RN documented the patient uses nutritional supplements twice daily; these were not on the POC. This was discussed with the DPCS. Observed in Record Review. In 3 of 10 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for HV#1, medications begun at the admission were not on the initial plan of care, including Miralax, Acetaminophen, Levothyroxine, Carbidopa-Levidopa. The patient was also taking Boost supplements daily which was not on the Plan of Care (POC). In the chart for HV#3, the patient was using Ensure daily which was not on the POC. While BiPAP and CPAP were noted on the plan of care and in the nursing assessment, there were no further orders for BiPAP settings/frequency on the POC. In the charts for HV#1, and HV#2 the patients had home oxygen, however there were no potential problems related to safety nor any goals on the plans of care. This was discussed with the DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medical supplies and appliances necessary to meet the patient’s need. In the chart for RR#2, the original POC did not contain any DME or supplies. The patient had wounds as well as oxygen, urinary catheter, and adaptive equipment. This was confirmed with the DPCS.

Observed in Record Review. In 1 of 3 patient records reviewed, the hospice aide had not provided services that were ordered by the physician or allowed practitioner in the plan of care. In the chart for RR#3, the aide was ordered three times weekly. In the first week of the current benefit period no visits were provided. In week 2, one visit was performed. In week 3, there is one missed visit documented; the other two scheduled visits have no documentation started. In week 4, three visits are on the schedule, however there is no documentation to support care was provided. This was discussed with the DPCS. Observed in Record Review. In 1 of 10 patient records reviewed, the hospice aide had not provided services that were ordered by the physician or allowed practitioner in the plan of care. In the chart for RR#5, aide services were ordered twice weekly, then three time weekly. Nail care was ordered weekly; the aide was providing this service at every visit. This was discussed with the DPCS.

Observed in Record Review. In 2 of 10 patient records reviewed, all disciplines that provide care, treatment or services to the patient did not collaborate in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. In the chart for HV#2, the Admission RN noted that the patient had a wound, however the patient and PCG refused care to it at that visit. The RN indicated that there were orders, however there were none documented and there was no indication the physician was contacted about the wound. At the next RN visit, the RN indicated the primary caregivers told her that the physician no longer wanted treatment for the wound, however, again, no communication with the provider was documented; no order written. In the chart for RR#5, the nurse assessed the patient to be at high nutritional risk; the assessment document indicated the clinician was to collaborate with the IDT to discuss treatment options. There was no documentation that occurred; no documentation that nutritional treatment/goals were discussed with patient/PCG either. This was discussed with the DPCS.

Observed in Data Session. The hospice nurse surveyor noted and it was confirmed by leadership that the organization's written infection prevention and control goals did not include limiting the spread of infections associated with the use of medical equipment, devices and supplies as discussed with the DPCS. Observed in Data Session. The hospice nurse surveyor noted and it was confirmed by leadership that the organization's written infection prevention and control goals did not include how it would address prioritized risks. Prioritized risks included COVID-19 infection as highest risk with UTI, wound/incisions and catheter/bloodstream infections, yet there were no infection control goals related to any risks. Observed in Data Session. The hospice nurse surveyor noted and it was confirmed by leadership that the organization's written infection prevention and control goals did not include limiting the spread of infections associated with procedures as discussed with the DPCS.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization had not documented orientation of staff on the following: relevant policies and procedures including those related to infection prevention and control. There was no documentation of any orientation in the file for the Medical Director as confirmed with the HR Manager.

Observed in Record Review. In 2 of 2 patient records reviewed, the hospice had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. There was no written bereavement plan of care in the charts for BR#1 nor BR#2, though assessments had been documented and contacts documented, there was no plan developed which specified the type of services to be offered nor the frequency of service delivery. This was confirmed with the Bereavement Counselor and bereavement specific plans of care do not exist in the current EMR.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100, §418.54, §418.56 §418.60, §418.64 as discussed with the organizational leadership team.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization had not documented orientation of staff on the following: specific job duties, including those related to infection prevention and control and assessing and managing pain. There was no documentation of any orientation in the file for the Medical Director as confirmed with the HR Manager.

Observed in HR File Review. In 4 of 8 HR files reviewed, the organization had not defined the competencies it requires of its staff who provide patient care, treatment, or services. In the files for the RN, LVN, Bereavement Counselor and Medical Director, there were no competencies marked as required on the documentation, though many had been completed. This requirement was present for the MSW, Aide and confirmed with the HR Manager.

Observed in Record Review. In 1 of 3 patient records reviewed, the patient record did not contain accurate information. In the chart for RR#3, the RN documented in a narrative note in the current benefit period that the patient is a 99 yo Hispanic male. The patient is less than 90 years old and female. This was discussed with the DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, the patient record did not contain information that reflected the patient's care, treatment, or services. In the chart for HV#1 the current medication profile included Norvasc which had been marked as discontinued on the medication profile in the patient's home. The PCG and RN at the visit confirmed that the Norvasc had been discontinued almost 3 weeks prior to this visit and the patient was less wobbly as a result. This was discussed with the DPCS. Observed in Record Review. In 1 of 10 patient records reviewed, the patient record did not contain the following clinical information: any medications administered, including dose. In the chart for RR#5, the LVN documented she administered Haldol, however did not include dose nor route. This was discussed with the DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, in which a discharge alive occurred, the hospice did not inform the attending physician of the availability of a discharge summary. In the charts for RR#1, RR#9 and RR#10 there were no discharge summaries in the chart as confirmed with the DPCS.

Observed in Document Review. In 1 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include all required elements. The pharmacy contract did not include a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with the CEO and DPCS.

Observed in HR File Review. In 1 of 8 HR files reviewed, criminal background checks were not obtained within three months of the date of employment for the states that the individual has lived in or worked in during the past three years. The Medical Director's criminal background check was performed more than 3 months post hire as confirmed with the HR Manager.