Every finding on record at Alameda Care Hospice

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, observation, and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the patient's current medications were included in the medication review as part of the comprehensive assessment and updated on the drug profile. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 10/18/2023 with a terminal diagnosis of Alzheimer’s disease. During the home visit observation with the Registered Nurse (Staff 4), a medication review was completed comparing the hospice medication profile dated 01/31/2024 to the patient’s medications administered by the caregiver. The caregiver reported the patient is taking two tablets of Tylenol 500mg twice daily. The label on the medication bottle stated, Tylenol 500mg, take 2 tabs (1000mg) twice daily. The caregiver reported that the patient has been taking the scheduled Tylenol “at least a month or longer.” Tylenol was not included on the patient’s hospice medication profile. There was no documented evidence that the medication was included in the medication review as part of the comprehensive assessment. Clinical Record 3/Home Visit 2: The patient elected the hospice benefit on 12/11/2023 with a terminal diagnosis of cerebral atherosclerosis. During the home visit observation with the Hospice Aide, a medication review was completed comparing the hospice medication profile dated 01/31/2024 to the patient’s current medication bottles. The patient’s spouse was the primary caregiver and was knowledgeable of the patient’s medication regimen. The medication bottles presented by the spouse revealed the patient was receiving Atorvastatin 40mg once daily last filled 12/29/2023, Metoprolol 25mg, one-half tablet twice daily dated 10/12/2023 (spouse reported the patient only takes one-half tablet once daily as instructed by the physician), Omeprazole 20mg, once daily dated 10/30/2023, Lisinopril 5mg, two tablets daily last filled 01/09/2024 and Aspirin 81mg (spouse reported the patient takes one tablet daily). The Atorvastatin, Metoprolol, Omeprazole, Lisinopril, and Aspirin were not documented on the patient’s hospice medication profile. There was no documented evidence that the medications were included in the medication review as part of the comprehensive assessment. During a joint record review and interview on 02/01/2024, the Director of Nursing agreed there was no documented evidence that the medications were reviewed as part of the comprehensive assessment and updated to the drug profile.

It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure the individualized plan of care included measurable outcomes anticipated from implementing and coordinating care. Clinical Record 4: The patient elected the hospice benefit on 08/03/2023 with a terminal diagnosis of Alzheimer's disease. The plan of care dated 08/03/2023 through 01/31/2024 included a patient goal/outcome that stated, “pain will be reduced for patient comfort.” The goal was not measurable when it did not define what the pain level would be for patient comfort. Clinical Record 5: The patient elected the hospice benefit on 09/22/2023 with a terminal diagnosis of cerebral atherosclerosis. The plan of care dated 09/22/2023 included patient goals/outcomes that stated, “minimize pain” and “minimize bouts of dyspnea.” The goals on the plan of care were not measurable when they did not define what minimized pain and minimized dyspnea would be for the patient. Clinical Record 8: The patient elected the hospice benefit on 09/01/2023 with a terminal diagnosis of cerebral atherosclerosis. The plan of care dated 09/13/2023 included a patient goal/outcome that stated, “support needed for caregiver.” The goal on the plan of care was not measurable when it did not define the type of support needed for the caregiver. During a joint record review and interview on 02/01/2024, the Director of Nursing agreed there was no documented evidence that the plans of care goals/outcomes were individualized to the patient and family needs.

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; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; safe handling of soiled items in the patient’s care environment; other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, observation, and interview. In 1 of 3 (33%) home visit observations, the agency did not ensure that staff followed the agency’s hand hygiene policy. Agency policy, "Hand Hygiene, 9-009.1-9.009.2, stated in part, "Hand decontamination using an alcohol-based hand rub should be performed: before having direct contact with patients, after contact with non-intact skin and wound dressings, following moving from contaminated site of patient, after contact with inanimate/contaminated objects in the immediate vicinity of the patient.” Home Visit 1: During the home visit observation with the Registered Nurse (Staff 4), the nurse was observed to remove the soiled wound dressing from the patient’s lower back with a gloved hand, then removed the soiled gloves and performing hand hygiene. The nurse then removed clean gloves from the nursing bag and placed them on the patient’s bedding. The nurse washed her hands then put on the gloves from the bedding, picked up a used garbage bag that contained soiled wound supplies, and moved the garbage bag to the chair at the bedside. The nurse sprayed wound cleanser into the wound, placed calcium alginate in the wound, and covered it with a foam dressing. The Registered Nurse did not perform hand hygiene and don clean gloves after picking up the used garbage bag with soiled wound supplies before cleaning the patient’s wound and applying a clean dressing to the wound, as required by agency policy. During an interview on 02/01/2024, the Director of Nursing agreed the Registered Nurse did not follow the agency’s hand hygiene policy.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical records reviewed with aide services provided, the agency did not ensure the hospice aide provided services as ordered and included in the plan of care. Clinical Record 3: The patient elected the hospice benefit on 12/11/2023 with a terminal diagnosis of cerebral atherosclerosis. The hospice aide care plan dated 12/11/2023 assigned the aide the task of shower every visit. The hospice aide documented on the aide visit note dated 12/14/2023 that the patient was given a full bed bath. The hospice aide did not follow the aide care plan assigned task of providing a shower every visit. Clinical Record 5: The patient elected the hospice benefit on 09/22/2023 with a terminal diagnosis of cerebral atherosclerosis. The hospice aide care plan dated 09/22/2023 included orders for the aide frequency of visits twice a week. For the week of 10/08/2023 to 10/14/2023, the hospice aide documented one visit dated 10/11/2023. There was no documented evidence in the clinical record that the aide provided a second visit the week of 10/08/2023 to 10/14/2023 and no documentation of a reason for the missed visit. Clinical Record 14:The patient elected the hospice benefit on 05/15/2023 with a terminal diagnosis of Parkinson’s disease. The plan of care dated 08/18/2023 ordered hospice aide frequency of visits twice a week. Clinical record review revealed for the week of 08/20/2023 to 08/26/2023, the hospice aide documented a visit on 08/26/2023. During the week of 08/27/2023 to 09/02/2023, the hospice aide visit documented a visit on 08/31/2023. For the weeks of 08/22/2023 to 08/26/2023 and 08/27/2023 to 09/02/2023, the hospice aide provided one visit and the clinical record contained no documented evidence of a second aide visit and no documented reason for the missed visit. During the week of 09/03/2023 to 09/09/2023, the clinical record contained no documented evidence of hospice aide visits or reasons for missed visits. During a joint record review and interview on 02/01/2024, the Director of Nursing agreed there was no documented reason for the missed visits. Additionally, the Director of Nursing agreed there was no documented evidence the hospice aide provided the services as ordered.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed with aide services provided, the agency did not ensure the hospice aide reported changes in the patient's plan of care needs to the Registered Nurse. Clinical Record 3: The patient elected the hospice benefit on 12/11/2023 with a terminal diagnosis of cerebral atherosclerosis. The hospice aide documented on the aide visit note dated 12/19/2023, the patient “had a fall today at 4am trying to go to the bathroom.” There was no documented evidence in the clinical record that the hospice aide reported the patient’s fall to the Registered Nurse. During a joint record review and interview on 02/01/2024, the Director of Nursing agreed there was no documented evidence that the hospice aide reported the changes to the Registered Nurse.

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. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient live discharge, the agency did not ensure the hospice discharge summary was provided to the patient’s attending physician. Clinical Record 13: The patient elected the hospice benefit on 12/21/2023. The patient revoked the election of hospice benefit on 12/26/2023. The clinical record included a discharge note dated 12/26/2023 that documented a history and physical and medication list was sent to the emergency room, but there was no documented evidence that a discharge summary was completed and provided to the patient’s attending physician or receiving facility. Clinical Record 14: The patient elected the hospice benefit on 05/15/2023. The patient was discharged on 11/10/2023 with status of no longer terminally ill. The clinical record included a discharge note dated 11/10/2023 that documented a referral was sent to a home health agency, but there was no documented evidence that a discharge summary was completed and provided to the patient’s attending physician or receiving facility. During a joint record review and interview on 02/01/2024, the Director of Nursing stated, “I don’t see a discharge summary in the records, it wasn’t done.” The Director of Nursing agreed there was no documented evidence a discharge summary was provided to the patient’s attending physician or receiving facility.

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; 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 2 of 2 (100%) clinical records reviewed with patient live discharge, the agency did not ensure that the hospice discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, pain management, the patient’s current plan of care, and the patient’s latest physician orders. Clinical Record 13: The patient elected the hospice benefit on 12/21/2023. The patient revoked the election of hospice benefit on 12/26/2023. The clinical record included a discharge note dated 12/26/2023 that documented a history and physical and medication list was sent to the emergency room, but there was no documented evidence that a discharge summary was completed that included a summary of the patient’s hospice stay, including treatments, symptoms, pain management, and the patient’s current plan of care. Clinical Record 14: The patient elected the hospice benefit on 05/15/2023. The patient was discharged on 11/10/2023 with status of no longer terminally ill. The clinical record included a discharge note dated 11/10/2023 that documented a referral was sent to a home health agency, but there was no documented evidence that a discharge summary was completed that included a summary of the patient’s hospice stay, including treatments, symptoms, pain management, the patient’s current plan of care, and the patient’s latest physician orders. During a joint record review and interview on 02/01/2024, the Director of Nursing stated, “I don’t see a discharge summary in the records, it wasn’t done.” The Director of Nursing agreed there was no documented evidence that a discharge summary of the patient’s hospice stay, including treatments, symptoms, pain management, the patient’s current plan of care, and the patient’s latest physician orders was completed.