Every finding on record at Alliance Healing Hospice & Palliative Care LLC

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 1 of 18 (6%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure the aide provided services as ordered by the Interdisciplinary Group and included in the plan of care. Clinical Record 12: The plan of care, effective 03/08/2024 through 05/06/2024, included a frequency of visits for the aide of two (2) visits per week. The hospice aide care plan, last updated 11/04/2023, instructed the aide to provide the patient a shower one (1) time per week and a bed bath one (1) time per week. The aide completed visits on 03/13/2024, 03/15/2024, 03/20/2024, and 03/22/2024 and documented in the visit summary for each visit that the aide had placed the patient in the facility's whirlpool, and once clean and dry, applied powder to all skin folds. The clinical record did not contain documented evidence that the aide's care plan was updated to include a whirlpool bath and powder application to skin folds or that the Registered Nurse provided verbal instructions to the aide to perform the identified tasks. On 04/25/2024 joint clinical record reviews and interviews were conducted with the Vice President of Clinical Operations, Director of Clinical Services, Administrator, and Chief Executive Officer who confirmed that the aide’s care plan did not include instructions for the aide to perform a whirlpool bath or to apply powder to the patient’s skin folds and that the clinical record did not contain evidence that the RN had provided verbal instructions to provide tasks not included on the aide’s care plan.

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, document review and interview. In 2 of 19 (11%) clinical records reviewed it was revealed that the agency did not ensure the clinical record included physician orders for all care and services provided. Document 5: The agency’s policy titled, “PC.M50 Medication – Orders (Copyright 2021),” stated in part, “Verbal and signed orders for medications are documented in the patient’s clinical record and the medication profile is updated accordingly. Clinical Record 2: The plan of care for the current benefit period wad dated 04/02/2024 through 06/30/2024. On 04/24/2024, Home Visit 2 (two) was completed with the Chaplain (Staff 4). A copy of the assisted living facility's "Physician's Order report was compared to the hospice plan of care and current medication profile. The hospice plan of care and medication profile did not contain physician orders for the following scheduled and as needed medications: Loratadine 10MG tablet, Ensure Vanilla, Bisacodyl enteric coded 5MG tablets, Chlorhexidine Gluc oral rinse, Docusate sodium 100mg capsule, and Lidocaine patch 5% (five percent). Clinical Record 3: The plan of care for the current benefit period was dated 02/25/2024 through 05/24/2024. On 04/24/2024, Home Visit 3 (three) was completed with the Medical Social Worker (Staff 3), and a copy of the skilled nursing facility's "Order Summary" report was compared to the hospice plan of care and current medication profile. The medication profile did not contain updated physician orders for the dosage and frequency of administration for the following scheduled and as needed medications: ipratropium-albuterol 0.5MG-2.5MG/3ML inhalation, naloxone hydrochloride 2MG/2ML intramuscular, melatonin 3mg oral tablet, and the discontinuation of lorazepam 0.5MG oral tablet dated 11/27/2023. On 04/25/2024 joint clinical record reviews and interviews were conducted with the Vice President of Clinical Operations, Director of Clinical Services, Administrator, and Chief Executive Officer who confirmed that the clinical records identified did not contain physician orders for all medications provided.

Based on document review, policy review and interviews, the hospice IDG failed to maintain an integrated system of communication to ensure the coordination and supervision of the Plan of Care and services provided patients at discharge, the hospice IDG failed to supervise professional staff to ensure documented visit notes of services, medications and information provided at discharge were documented by staff completing the assessment, and the hospice IDG failed to ensure orders for discharge were obtained and documented, prior to or at the time of discharge from the hospice services for one of three patients reviewed (Patient 2). The cumulative effects of the Hospice Agency's failure to maintain an integrated system of communication to ensure coordination and supervision of the Plan of Care and services delivered, has the potential to place patients at risk for unmet care needs, services and information, when no longer directly receiving services from the hospice, at discharge. Findings Include: 1. The hospice failed to maintain a system of communication and integration to ensure the IDG maintained the responsibility for coordinating and supervising the care and services provided to patients at discharge from hospice services. Refer to L554.

Based on document review, policy review and interviews, the Hospice IDG failed to 1. Maintain an integrated system of communication to ensure the coordination and supervision of the Plan of Care and services provided, for one of three patients that required coordinated hospice services at discharge (Patient 2); 2. Supervise professional staff to ensure documented visit notes of services, medications and information provided at discharge, were documented by staff completing the assessment at the time of discharge, for one of three patients that required coordinated hospice services at discharge (Patient 2); and 3. Ensure orders for discharge were obtained and documented, prior to or at the time of discharge from the hospice services, for one of three patients that required coordinated hospice services at discharge (Patient 2).This deficient practice has the potential to place patients at risk for unmet care needs, services and information, when no longer receiving services from the hospice, at discharge. Findings Include: Review of a hospice policy titled, "PC.D20 Discharge From Hospice, Copyright 2021, showed prior to discharge, the hospice IDG consults with the hospice physician and the RN obtains a discharge order from the patient's attending physician. The interaction with the physician(s) will be documented in the patient record. The hospice nurse consults with the patient's attending physician regarding the need for other health care services and obtains appropriate discharge and referral orders. 1. Review of Patient 2's medical record showed the patient was 22 years old, admitted on 08/16/22 and later readmitted 08/26/22, for administrative purposes after the hospice's initial Medicare certification. The patient was admitted with a primary diagnosis of Severe Protein Calorie Malnutrition and lived in her home with her primary caregiver. Review of the Hospice Plan of Care dated and signed by the hospice IDG on 08/26/21 for the Certification Period of 08/26/21 -11/23/21, showed Patient 2 had a history of Major Depressive Disorder, Anxiety Disorder, Nausea, Low back pain, Post-traumatic Stress Disorder and Borderline Personality Disorder. Medications ordered on the hospice Plan of Care included injectable Medications for treatment of nausea, anxiety and pain by way of a Central Venous Line (IV access through an implanted port in the chest) and Fentanyl transdermal (through the skin) patch for pain. The Hospice Plan of Care, effective 08/26/21 did not list any oral (PO) solutions or medications for Patient 2 to utilize for the treatment of pain ,anxiety and nausea. Review of documentation provided by the hospice pharmacy showed Patient 2 was ordered 08/16/21, by the Medical Director, to have the following PO (Oral Medications): Lorazepam 2 mg/mL oral concentrate 0.25-1 mL every hour as needed prn (anxiety); Ondansetron 4 mg disintegrating tablet: 4 mg PO every 6 hours PRN (Nausea); Morphine Concentrate Oral Solution, 100 mg/5 mL (20 mg/mL): 0.25 -1 mL every hour as needed PRN (pain). The Plan of Care on admission (08/26/21) did not contain the ordered oral medications the patient had supplied in the home for use in addition to the injectable medication. Review of the Hospice Plan(s) of Care dated and signed by the hospice Interdisciplinary Group (IDG) showed the IDG did not update the Plan of Care to include the oral medications Lorazepam 2 mg/mL oral concentrate 0.25-1 mL every hour as needed prn (anxiety) (effective 08/16/21); Ondansetron 4 mg disintegrating tablet: 4 mg PO every 6 hours PRN (Nausea) (Eff 08/16/21); Morphine Concentrate Oral Solution 100 mg/5 mL (20 mg/mL): 0.25 -1 mL every hour as needed PRN (pain) (Eff 08/16/21) as ordered by the IDG and supplied in the home for the oral treatment of nausea and pain, in addition to injectable medications for the following consecutive IDG Meeting Dates: 1. 08/31/21 for the IDG Period of 08/18/21 - 08/31/21 (Admission IDG), 2. 09/14/21 for the IDG Period of 09/01/21 - 09/14/21, 3. 09/28/21 for the IDG Period of 09/15/21 - 09/28/21, 4. 10/12/21 for the IDG Period of 09/29/21 - 10/12/21, 5. 10/26/21 for the IDG Period of 10/13/21 - 10/26/21, 6. 11/09/21 for the IDG Period of 10/27/21 - 11/09/21, and 7. 11/23/21 for the IDG Period of 11/10/21 - 11/23/21 (Post-Discharge IDG) During an interview on 03/24/22 at 12:51 PM, Staff A, RN, Director of Clinical Services (DCS), confirmed Patient 2 had oral medications for pain, anxiety and nausea ordered by the medical director at the time of admission, but that additional intervention was required because the patient could not tolerate oral medications. She confirmed that because the patient was no longer taking the oral medication, the updated Plan of Care omitted the oral medication that remained in the home, from the medication profile. The IDG failed to ensure the Plan of Care was updated prior to and at the time of discharge to include an accurate Medication Profile for patient use in the home. 2. Review of the hospice Discharge Visit note for Patient 2, completed by Staff B, RN (former Executive Director) and Staff C, RN Case Manager on 11/15/21, and documented by Staff A, RN Nursing Director (not present at visit), showed Staff B, RN (former Executive Director) and Staff C, RN Case Manager reviewed medications with patient and caregiver at the time of the home visit. Staff A documented, Staff B, RN (former Executive Director) and Staff C, RN visualized the patient still had Morphine and Ativan (oral medication) for anxiety and pain present. The document showed the Medication Profile was provided to the patient at discharge. The Medication Profile provided did not include the Oral medications ordered by the IDG on Admission and intended for use in the home, after discontinuation of the Injectable IV pain and anti- nausea medications (that remained on the discharged Medication Profile). Review of hospice documentation from Staff A, Nursing Director, showed Staff B, RN (former Executive Director) and Staff C, RN did not document the actual completion of the discharge visit within the patient's record, to confirm the provision of services and education, including medication information, provided to the patient directly by each clinician present at discharge. During an interview on 03/24/22 at 2:20 PM, Staff C, RN, confirmed she, Staff C, RN, was present at the discharge visit on 11/15/21, by request of Staff B, RN to assist with any discharge needs. She confirmed that Staff B, RN conducted the discharge assessment and was responsible for the discharge visit documentation. During an interview on 03/23/22 at 3:05 PM, Staff A, RN, Director of Clinical Services (DCS), confirmed Staff A, RN did not conduct the onsite visit to complete the discharge visit, instead was directed by Staff B, RN (former Executive Director) to complete the visit discharge summary. Staff A, RN confirmed the discharge visit was conducted on 11/15/21 by Staff B, RN (former Executive Director) and Staff C, RN and that a visit note was not documented by Staff B, RN nor Staff C, RN at the time of discharge of Patient 2's from Hospice. The hospice IDG failed to supervise professional staff to ensure documented visit notes of services provided, medications and information provided at the time of Patient 2's discharge from hospice were completed by the staff conducting the visits and included within the hospice record. 3. Review of documentation for Patient 2, showed there were no physician orders for discharge obtained by Staff B, RN (former Executive Director), prior to or at the time of Patient 2's discharge from services on 11/15/21. Review of untitled documentation from Staff D, Medical Director, showed the hospice discussed a plan to potentially discharge the patient from hospice, during a meeting conducted on 11/09/21. The document showed the IDG discussed the patient's potential discharge for an extended prognosis of greater than 6 months with lack of clinical decline, following completion of lab work to be drawn on 11/10/21. The IDG failed to ensure orders for discharge were obtained and documented in the record, following the completion of the lab, prior to or at the time of Patient 2's discharge from the hospice on 11/15/21.