Every finding on record at Advocate Hospice Care, LLC

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 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 3 of 19 (16%) clinical records reviewed and home visits observed, the agency did not ensure the patient's drug profile was updated during each comprehensive assessment and/or when new medication was added or changes were made to existing medications. Clinical Record 1/Home Visit 1: During the home visit on 12/10/2024 with the Registered Nurse (RN) (Personnel Record 7), the hospice medication profile was compared to the patient's medications. A bottle of Furosemide dated 11/14/2024 take 40mg daily was with the patient's current medications and in the ‘med minder’ daily, confirmed by the daughter. The hospice medication profile reviewed on 12/09/2024 included Furosemide 20mg daily. The hospice medication profile did not include the 40mg daily. Clinical Record 10/Home Visit 2: During the home visit on 12/11/2024 with the Hospice Aide (Personnel Record 10), the hospice medication profile was compared to the facility medication list. The facility medication list included Vitamin B12 500mcg and Levetiracetam 1250mg twice a day. The hospice medication profile reviewed on 12/11/2024 included Diclofenac 1% gel as needed, Aspirin daily, and Levetiracetam 1,000mg twice a day. The hospice medication profile did not include Vitamin B12 500mcg and Levetiracetam 1,250mg twice a day. Clinical Record 2/Home Visit 3: During the home visit on 12/11/2024 with the Chaplain (Personnel Record 9), the hospice medication profile was compared to the patient's medications. The patient presented her current medications, which included a bottle of Morphine dated 11/26/2024, take 0.25ml every 4 hours as needed for pain, and Trelegy 100mcg/62.5mcg/25mcg inhaler daily. The hospice medication profile reviewed on 12/10/2024 did not include Trelegy or Morphine. During a joint record review and interview on 12/11/2024, the Director of Operations agreed that the patient's medication profile was not updated with the current medications. Additionally, the Director of Operations stated that we have a lot of new nurses and will be providing more education on visualizing the medications at the visits.

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: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the plan of care included drugs and treatment necessary to meet the needs of the patient. Clinical Record 1/Home Visit 1: During the home visit on 12/10/2024 with the Registered Nurse (RN) (Personnel Record 7), the hospice medication profile was compared to the patient's medications. A bottle of Furosemide dated 11/14/2024, take 40mg daily, was with the patient's current medications and in the med minder daily, confirmed by the daughter. The hospice medication profile reviewed on 12/10/2024 included Furosemide 20mg daily. It did not include the 40mg daily. The hospice plan of care reviewed on 12/10/2024 did not include the Furosemide. Clinical Record 2/Clinical Record 10: During the home visit on 12/11/2024 with the Chaplain (Personnel Record 9), the hospice medication profile was compared to the patient's medications. The patient presented her current medications, which included a bottle of Morphine dated 11/26/2024, take 0.25ml every 4 hours as needed for pain, and Trelegy 100mcg/62.5mcg/25mcg inhaler daily. The hospice plan of care reviewed on 12/11/2024 did not include Trelegy or Morphine. Clinical Record 10: During the home visit on 12/11/2024 with the HHA, the hospice medication profile was compared to the facility medication list. The facility medication list included Vitamin B12 500mcg and Levetiracetam 1250mg twice a day. The hospice medication profile reviewed on 12/11/2024 included Diclofenac 1% gel as needed, Aspirin daily, and Levetiracetam 1,000mg twice a day. It did not include Vitamin B12 500mcg and Levetiracetam 1,250mg twice a day. The hospice plan of care reviewed on 12/11/2024 did not include Levetiracetam 1250mg twice a day and Vitamin B12 500mcg. During a joint record review and interview on 12/11/2024, the Director of Operations agreed that the plan of care did not include the medications identified.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met, as evidenced by document review, interview, and observation. In 2 of 4 (50%) home visit observations, the agency did not ensure the staff followed the hand hygiene policy. Agency Policy, Hand Hygiene Policy No. 7-011, stated in part, "Hand decontamination with an alcohol-based hand rub should be performed after contact with body fluids, or excretions, non-intact skin, wound dressings, after contact with inanimate objects in the immediate vicinity of the patient and after removing gloves. Hand washing with soap: Wash hands for at least fifteen (15) seconds, rinse with warm water, use a disposable towel to turn off faucet." Home Visit 1: During the home visit on 12/10/2024 with the Registered Nurse (RN) (Personnel Record 7), the RN washed their hands with an alcohol-based hand rub, donned gloves, cut off kerlix gauze, removed gloves, donned new gloves, cleansed the wound, removed the dressing, put calcium alginate on the wound, secured with tape, put an ABD pad on wound and wrapped with kerlix, removed gloves, donned new gloves, and then dated the tape on the wound. The RN did not perform hand hygiene between the glove changes. Home Visit 2: During the home visit on 12/11/2024 with the Hospice Aide (Personnel Record 10), the aide washed their hands with soap and water, turned the faucet off with their hand, donned gloves, pulled phone from pocket, took picture of the coccyx, placed the phone on the recliner beside the patient's bed, applied barrier cream. The aide did not turn the faucet off with a disposable towel, did not wash hands between glove changes, and did not wash their hands after touching the cell phone before touching the wound. During an interview on 12/12/2024, the Director of Clinical Operations confirmed the finding and the agency policy that hands should be cleansed between glove changes after touching inanimate objects, and the faucet should be turned off with a disposable towel.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group; Included in the plan of care. This standard was not met, as evidenced by clinical record review, interview, and observation. In 2 of 15 (13%) clinical records reviewed of patients who accepted hospice aide services, it was revealed that the agency did not ensure the hospice aide provided services as ordered and included in the plan of care. Clinical Record 5: The hospice aide plan of care dated 08/29/2023 ordered bathing (shower) three times a week. The patient was seen four times during the week of 09/04/2023, and a shower was documented as given each time. The patient was seen four times during the week of 09/25/2023 and was documented as receiving a shower each time. The patient was seen five times during the week of 10/02/2023, and a shower was documented as given each visit. Clinical Record 10/Home Visit 2: The hospice aide (Personnel Record 10) was observed during the visit, to the nursing facility, on 12/11/2024 transferring the patient from a high back wheelchair to the bath chair using a Hoyer lift and sling, showering the patient in the shower room, using an electric shaver to shave /trim eyebrows, electric nose hair trimmer, shaved face with razor. The hospice aide plan of care dated 10/19/2024 did not order the high back wheelchair or Hoyer lift using a sling, shower the patient in the shower room, use an electric shaver to shave /trim eyebrows, electric nose hair trimmer, or shave face with a razor. During a joint record review and interview on 12/11/2024, the Director of Operations agreed the hospice aide did not follow the plan of care as ordered. Additionally, the Director of Operations stated, more education is needed with the aides on following the plan of 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. 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; 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 agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Hospice Volunteer Requirement Report reviewed for 01/01/2024 through 12/11/2024 revealed a volunteer cost savings of 2.82%. During a review of the Hospice Volunteer Requirement Report and interview on 12/12/2024, the Manager of Accreditation and Regulatory Compliance agreed that the agency did not meet the minimum five percent cost savings requirement 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; 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 in which the patient was discharged due to moving out of the service area or is no longer terminally ill revealed that the agency did not ensure that the discharge summary was forwarded to the patient's attending physician. Clinical Record 15: The patient elected the hospice benefit on 03/12/2024, and was discharged on 07/04/2024 (no longer terminally ill). There was no documented evidence that the discharge summary was provided to the patient’s attending physician. During a joint record review and interview on 12/12/2024, the Director of Patient Care Services agreed there was no documented evidence that the discharge summary was sent to the patient’s attending physician. Additionally, the Director of Operations stated, we need to educate the person responsible for sending them.

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, document review and interview. In 4 of 4 (100%) clinical records reviewed, the agency did not ensure the Interdisciplinary Group (IDG) completed the initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Agency Policy #1-015, "Comprehensive Assessment at Admission (Dated: 1/2023)", stated in part, "Policy: A comprehensive patient assessment will be performed by the interdisciplinary group no later than five (5) calendar days after the election of hospice care in consultation with Attending Physician." Clinical Record 1: The patient elected the hospice benefit on 6/1/23. The clinical record lacked evidence of the Social Worker's and the Chaplain's initial assessments being documented within five (5) calendar days after the patient's election of hospice care. There was no documented evidence that the patient had refused the Social Worker and the Chaplain. Clinical Record 2: The patient elected the hospice benefit on 6/1/23. The clinical record lacked evidence of the Social Worker's and the Chaplain's initial assessments being documented within five (5) calendar days after the patient's election of hospice care. There was no documented evidence that the patient had refused the Social Worker and the Chaplain. Clinical Record 3: The patient elected the hospice benefit on 5/31/23. The clinical record lacked evidence of the Social Worker's and the Chaplain's initial assessments being completed within five (5) calendar days after the patient's election of hospice care. There was no documented evidence that the patient had refused the Social Worker and the Chaplain. Clinical Record 4: The patient elected the hospice benefit on 5/31/23. The clinical record lacked evidence of the Social Worker's and the Chaplain's initial assessments being completed within five (5) calendar days after the patient's election of hospice care. There was no documented evidence that the patient had refused the Social Worker and the Chaplain. During an interview on 6/12/23, the Administrator/Director of Patient Care Services (DCPS) and the Alternate Administrator/Alternate DPCS reviewed and agreed the agency did not ensure the Social Worker and Chaplain completed an initial assessment no later than five (5) calendar days after the election of hospice care and agreed the record lacked documentation that the patients had refused both the Social Worker and the Chaplain.

It is required that each patient’s individualized written plan of care: reflects patient and family goals, and 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, document review and interview. In 2 of 4 (50%) clinical records reviewed, the agency did not ensure the patient's individualized written plan of care (POC) identified goals and interventions based on problems identified in the initial and updated comprehensive assessments. Agency Policy #9-017, "The Interdisciplinary Plan of Care (Dated: 1/2023)", stated in part, "Policy: The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group . . . This plan will focus on identified problems, goals, and interventions." Clinical Record 2: The patient elected the hospice benefit on 6/1/23. The Plan of Care (POC) dated 6/1/23 documented a wound care order that stated, "Facility wound nurse to perform wound care to left ankle wound, injury due to hitting on bed utilizing clean technique cleanse with wound cleanser, apply Santyl, cover with 4x4 Telfa, secure with Kling/tape, change every week and prn if soiled or dislodged Instruct caregiver in wound care." The agency did not ensure wound care goal(s) and intervention(s) were included on the patient's individualized written POC. Clinical Record 3: The patient elected the hospice benefit on 5/31/23. The Registered Nurse documented in the initial assessment dated 5/31/23: "Pt has PEG Tube with Jevity 1.5 running at 80/ml/min for 1000 ml nightly. Peg tube site intact with 20 French, 7-10 ml bulb. Medium condom cath (catheter) intact draining clear yellow urine." The agency did not ensure the Percutaneous Endoscopic Gastrostomy (PEG) Tube and the condom catheter goals and interventions were included on the patient's individualized written POC. During an interview on 6/12/23, the Administrator/Director of Patient Care Services (DPCS) and the Alternate Administrator/Alternate DPCS, reviewed and agreed the agency did not ensure the plan of care included the goals and interventions based on problems identified in the initial comprehensive assessments.

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 document review, clinical records review, and interview. 1 of 5 (20%) records reviewed, the agency failed to document all disciplines accepted completed a comprehensive assessment in 5 calendar days after the election of hospice care. Record #70263: Hospice benefit signed for election on 05/20/2021, with the acceptance of social worker services. An initial Plan of Care dated 05/20/2021 documented orders for “Social Work to evaluate by 5/25/2021.” No documented visit or communication from social work was evidenced by documentation until 06/01/2021. This is seven (7) days late. In an interview with the Administrator/RN (Staff ID: #17691) on 1/19/2022 and 1/21/2022, who reviewed the records, stated that the LMSW had been unable to enter information into the EHR at the time. The policy titled, "Comprehensive Assessment -Timing: (PC.C50) (revised 2019), read in part, "...The comprehensive assessment of the patient is completed by designated members of the IDG, in consultation with the attending physician, no later than five (5) calendar days after the patient elects the hospice benefit."

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; [and] 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 document review, record review, and interview. 1 of 1 (100%) of a patient who had been on Oxygen therapy, the agency failed to ensure that the current practice of prescription and administration of oxygen therapy as a medication was documented. Record #99092: For the 1st certification and start of care being from 12/20/2021 through 3/20/2022, 70-year-old admitted to hospice with a diagnosis of COPD (chronic obstructive pulmonary disease), Pneumonia, Muscle Weakness, Respiratory distress with Hypoxia and Oxygen-dependent at 3 Liters per Nasal Cannula (NC). The RN, during the initial assessment, dated 12/20/2021, documented O2 in place at 3. L via NC. The Oxygen was not recorded on the Medication Profile. In an interview with the Administrator/RN (Staff ID: #17691) on 1/19/2022 and 1/21/2022, who reviewed the records, stated that the Electronic Health Record did not provide this capacity on the medication profile. The policy titled, "Comprehensive Assessment -Content (PC.C55) (revised 2019), read in part. "...The comprehensive assessment must include: Drug profile, including prescriptions, over-the-counter-drugs, herbal remedies, and alternative treatments."

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 a review of documents, clinical records, and interview. 1 of 5 (20%) records reviewed failed to document complete measurable goals. Record #70263: A patient medical history of Dementia and Heart disease. Upon admission on 05/20/2021, with the acceptance of social worker services. MSW's initial comprehensive assessment was not completed until 6/01/2021. There was no documented evidence of establishing MSW goals to the plan of care listed in the assessment. In an interview on 1/19/2022 and 1/21/2022, the Administrator/RN (Staff ID: #17691), who reviewed the patient records, stated that the EHR presented challenges and the electronic record software for stating accurate compliance by staff continues to require additional training and oversight. The policy titled "Comprehensive Assessment -Patient Outcome Measures (PC.C65) (revised 2019) read in part, "...The comprehensive assessment includes data elements that allow for the measurement of patient outcomes. Members of the IDG document data elements that measure patient outcomes in the same manner for each patient. The data elements take into consideration aspects of care related to hospice and palliation. The data elements are an integral part of the comprehensive assessment and the reassessment tool and are documented in a systematic and retrievable way from each patient. Data elements are used for each patient in individual care planning and the coordination of services."

It is required that Hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a Registered Nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by a review of agency documents, clinical records, and interview, which revealed in 2 of 4 (50%) records of patients receiving Hospice Aide services revealed documented evidence that hospice aide services failed to report changes in the patient's vital signs as ordered by the Registered Nurse. Record #45191: For the 1st certification beginning 12/20/2021 through 3/20/2022, the patient was admitted for Alzheimer’s and abnormal weight loss. The "Hospice Care Note and Care Plan" dated 12/20/2021, the RN assigned "Report V/S of BP > 160/90 or <90/60 P>100 or <60 R >24 or <14 T >101 or <94. The Aide documented BP at 176/80 on 1/4/2022 and 165/75 on 1/6/2022. The record lacked evidence of why the aide had not notified the RNCM on 1/04/2022 and 1/06/2022 of the Systolic Blood Pressure being a value above 160 when the B/P had been taken, as ordered on the Aide Plan of Care. The “Comments/Special Instructions” entry that should have documented the anomaly was left blank. Record #59417: For the 1st certification beginning 12/20/2021 through 3/20/2022, the patient was admitted for Dementia and Heart Disease. The "Hospice Care Note and Care Plan" dated 12/21/2021, assignment "Report V/S of BP > 160/90 or <90/60 P>100 or <60 R >24 or <14 T >101 or <94. The Aide note dated 12/28/2021 documented BP on 12/28/2021 at 185/95, and on 12/30/2021, documented BP at 176/75. The section titled "Comments/Special Instructions: Notified supervisor” was blank. The record lacked evidence of why the aide had not notified the RNCM on 12/28/2021 of the Systolic Blood Pressure above 160 and the Diastolic above 90 as ordered and on 12/30/2021. In an interview on 1/19/2022 and 1/21/2022, the Administrator/RN (Staff ID: #17691), who reviewed the aide records, stated that the aide had called the RNCM but challenges with the use of the electronic record software for stating accurate compliance by staff continues to require additional training and oversight. The policy titled "Hospice Aide Assignments and Duties” (PC.H25), (revised, 2019), read in part, "...Hospice aides must report changes in the patient's medical condition, when observed, to a Registered Nurse, as the changes are related to the plan of care."

It is required that the Interdisciplinary Group (IDG) determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. The plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. If the patient and/or family cannot administer drugs or biologicals, it is noted in the plan of care, as well as how it is addressed by the IDG. This standard was not met as evidenced by a review of clinical records and interview. 3 of 3 (100%) records reviewed of home patients who self-administered their medications revealed that the agency had failed to ensure documented evidence validating that the patient and/or family had been assessed for their ability to administer drugs or biologicals to the patient in the home. Record #45191: For the 1st benefit period beginning 12/20/2021 through 3/20/2021, for a patient whose diagnosis included Alzheimer's and abnormal weight loss, there was no documented evidence on the plan of care, during IDG meetings, or on the medication profile regarding safe self-administration and/or family capacity for the administration of drugs and biologicals. Record #99092: For the 1st benefit period beginning 12/20/2021 through 3/20/2021, a patient whose diagnosis included COPD and Respiratory Failure. There was no documented evidence on the plan of care, during IDG meetings, or on the medication profile regarding safe self-administration and/or family capacity to administer drugs and biologicals. Record #59417: For the 1st benefit period beginning 12/20/2021 through 3/20/2021, a patient whose diagnosis included Dementia and Heart Disease. There was no documented evidence on the plan of care, during IDG meetings, or on the medication profile regarding safe self-administration and/or family capacity to administer drugs and biologicals. In an interview with the Administrator/RN (Staff ID: #17691) on 1/19/2022 and 1/21/2022, who reviewed the records, stated that the Electronic Health Record did not provide this capacity on the updated plan of care during the IDG meetings or on the medication profile. In addition, it was determined this item set is not a part of their electronic medical record.

It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies. Instruction is documented in the patient record. The patient, family, and/or other caregivers must be able to demonstrate the appropriate use of the DME to the satisfaction of the IDG. The IDG documents that the patient, family, and/or caregivers can demonstrate appropriate use. This standard was not met as evidenced by observation during home visits on 12/01/2021, clinical record review, and interviews. 1 of 1 (100%) observation during home visits of patients utilizing oxygen failed to have an oxygen safety sign posted. Record #99092: During a home visit on 1/20/2022, it was observed with Administrator/RN [Staff ID: 17691], a 70 year-old male patient wearing continuous oxygen with a primary diagnosis of COPD (chronic obstructive pulmonary disease), Pneumonia, muscle weakness, Respiratory distress with Hypoxia and Oxygen dependent at 3 Liters per NC. There was no Oxygen safety sign posted in the home. Interview on 1/20/2022 and 1/21/2022, with the Administrator/RN (Staff ID: #17691), who accompanied the home visit, stated that a laminated oxygen safety signs will be posted in the home.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by a review of contracts and interview. A review of the contracts revealed that the Therapy (PT/OT/ST) contracts failed to include the clause, in writing, between the contractor/contractee, for the provision that requires criminal background checks. An interview was conducted on 1/20/2022 and 1/21/2022 with the Administrator/RN (Staff ID: #17691), who stated that this agency would provide an addendum to ensure compliance.