Every finding on record at Avera@Home Pipestone

Based on interview and document review the agency failed to complete a comprehensive medication review for 1 of 4 patients (P3) whos medications were reviewed. --- P3's plan of care dated 5/17/23, identified P3 had a diagnosis of neoplasm of unspecified behavior of brain, was seen by nursing once a week, and her medications included: diclofenic sodium 1% topical gel one application twice a day for pain acetaminophen 325 milligram (mg) tablet two tablets three times a day as needed for pain artificial tears ophthalmic eye dropperette one drop to each eye as needed for dry eyes Milk of Magnesia 400mg/5milliter (ML) give 15 ml daily as needed for constipation P3's hospice medication profile dated 6/6/23, indicated P3 had the following medications ordered: diclofenac sodium 1% topical gel one application twice a day for pain acetaminophen 325 mg tablet two tablets three times a day as needed for pain artificial tears ophthalmic eye dropperette 0.01% one drop to each eye as needed for dry eyes Milk of Magnesia 400mg/5 milliliter (ML) give 15 ml daily as needed for constipation P3's nursing facility medication orders dated 6/6/23, identified P3 had the following medications ordered: acetaminophen oral tablet give 650 mg by mouth every four hours as needed for pain or increased temperature artificial tears ophthalmic solution 1.4% instill two drops in both eyes every two hours as needed for dry eyes Milk of Magnesia oral suspension 1200 mg/15 ml give 30 ml by mouth every day as needed for constipation The nursing facility medication orders lacked an order for diclofenac sodium 1% gel twice daily for pain. During an interview on 6/7/23 at 9:25 a.m., registered nurse (RN)-C stated it varied how often medications were reconciled adding maybe once monthly. During an interview on 6/7/23 at 9:52 a.m., RN-B initially stated she would have to look at the policy regarding how often medications were reconciled and RN-B completed a medication review every two weeks during the comprehensive assessment. Medications were discussed at every visit. P3 had the diclofenic gel since hospice admission and stated the medication orders should match. RN-B would clarify the medications because it was important for patient safety and care to make sure what was ordered was what was being administered. During an interview on 6/7/23 at 10:55 a.m., the RN clinical coordinator CC-A stated she expected medications to be reconciled every visit. A policy, Medication Management Services dated 2/13/23, indicated the RN was responsible for implementation of medication management policies and procedures. Based on the nursing assessment, the RN would develop an individualized medication management plan consistent with current practice standards and guidelines. The RN would review client's medication record when setting up medications and at other appropriate times based on the client's needs.

Based on interview, and document review, the hospice failed to have individualized as needed (PRN) visit order frequencies for 2 of 14 patients (P1, P3) reviewed for plan of care. --- Findings include: P1's hospice plan of care (POC) dated 5/25/23, identified P1 had a diagnosis of hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. P1 was seen by the following disciplines and frequencies: nursing every week and had 10 PRN visit orders for pain, medication changes or decline, volunteers 20 PRN visits to provide socialization and support, social services twice a month for three months and 10 PRN to provide additional emotional support and education, home health aide (HHA) three times a week and 15 PRN visits for personal cares. P1's skilled nurse (SN) admission assessment dated 5/15/23, indicated P1 had progression of disease as documented by dyspnea (difficulty breathing) with increasing respiratory rate, edema, weakness and had a bilateral PleurX (a drain used to remove excess fluid) drain tubes in the right and left side of the chest. P1 SN PRN visit dated 5/19/23 indicated the facility called and reported P1 had shortness of breath and wanted the PleurX drained. During interview on 6/7/23 at 9:04 a.m., registered nurse (RN)-A stated when a patient was first admitted, their first certification period was about three months and stated she just adds 10 to 20 PRN visits in order to cover the period. P3's POC dated 5/17/23, indicated P3 had a diagnosis of neoplasm of unspecified behavior of brain. P3 was seen by the following disciplines and frequencies: nursing once a week for 12 weeks and 20 PRN visits for decline in status, symptoms management, and patient or family request, HHA 20 PRN visits for personal cares, patient support, volunteer 13 prn visits to provide support and socialization, and social services weekly and 10 PRN visits to provide emotional support and education. The POC identified P3 had a foley catheter that was changed PRN. During an interview on 6/7/23 at 9:52 a.m., RN-B stated they always added PRN visit orders but did not know why the PRN visit order frequencies were so high and stated she could not think of anyone who required that many PRN visits. During an interview on 6/7/23 at 10:17 a.m., RN -A and hospice manager (HM)-a verified PRN visit orders should be low ranges because the physician would need to be involved if an increase in PRN visits was noted and would then require an increase in scheduled visits. A policy, Hospice Plan of Care dated 8/16/22 indicated a written individualized patient and caregiver plan of care will be established and maintained for each individual admitted to the hospice program. It must state, in detail the scope and frequency of services needed to meet the patients and family/caregiver's needs and established patient goals and outcomes.

Based on observation, interview and document review the agency failed to ensure all services provided were included in the plan of care for 2 of 2 patients (P2, P9) reviewed who received nursing assistant (NA) services daily in the agency's residential hospice. --- P2's plan of care (POC) identified a start of care (SOC) dated 3/14/23. Diagnoses included malignant melanoma of trunk, secondary malignant neoplasm of brain, anxiety, and other cerebrovascular disease. Services ordered included skilled nurse (SN) two visits every week for 13 weeks, volunteer visits as needed (PRN), and social service (MSW) one visits every week for 13 weeks. P2's inpatient shift note dated 6/6/23, identified P2 received assistance with a bed bath, incontinence care, grooming, oral care, dressing and mobility. During interview on 6/7/23, the hospice manager (HM) stated nursing assistant (NA) services were included in patient's room and board when they resided in the residential hospice and were provided daily. P2's POC failed to identify NA services were being received and what tasks and duties were performed. P9's POC identified a SOC date 5/23/23. Diagnoses included abnormal weight loss, heart and kidney disease with heart failure, and diabetes mellitus. Services ordered included SN visits every week for 13 weeks, nursing assistant (NA) visits PRN, volunteer visits PRN, and MSW visits every week for 13 weeks. P9's inpatient shift note dated 6/5/23, indicated P9 had received assistance with a whirlpool bath, grooming, oral care, skin care, incontinence care, dressing and transfers. During interview on 6/8/23, P9 stated staff assist her with her bath, dress, grooming and transfers every day. During a joint interview on 6/7/23, with hospice manager (HM) and care coordinator (CC), the hospice manager indicated NA duties were part of the residential hospice room and board and provided daily so the frequency and duration did not need to be on the patient's POC. The CC stated aide duties and tasks should be on a patient's POC, even when it is patient's residing at the agency's residential hospice. The NA's charted daily and she was not sure why it had not pulled over and printed on the POC. It should have done so and it would be important to have the duties and tasks on the POC so the primary physician would be aware the patient was receiving NA services. The agency's policy Hospice Plan of Care dated 8/16/22, indicated the POC would identify the patient's needs and services to meet those needs. It must state in detail, the scope and frequency of services needed to meet the patient's and family needs and established patient goals and outcomes. The POC would be provided to both the attending primary care provider and the medical director for approval of verbal orders and certification of the terminal illness signatures.

Based on interview and document review, the agency failed to provide an assessment of the patient's spiritual needs, make efforts to facilitate visits by local clergy and advise the patient of this service for 1 of 14 patients (P9) reviewed for spiritual assessments. --- P9's plan of care (POC) identified a start of care (SOC) date 5/23/23. Diagnoses included abnormal weight loss, heart and kidney disease with heart failure, and diabetes mellitus. Services ordered included skilled nurse (SK) visits every week for 13 weeks, nursing assistant (NA) visits as needed (PRN) volunteer visits PRN, and social service (MSW) visits every week for 13 weeks. P9's admission SN visit note dated 5/23/23, indicated there were no immediate spiritual concerns. P9's MSW admission visit note dated 5/23/23, indicated P9 was protestant and no spiritual concerns were identified. During interview on 6/8/23, P9 stated she would like to have a visit from her chaplain but her church did not have one and she was unsure if the hospice agency offered any clergy visits. She would like to have an opportunity to talk about her spiritual beliefs with someone, if that were offered. She really missed her church visits. The medical record failed to identify a spiritual assessment for P9, or information to the patient of spiritual services offered by the hospice agency. When interviewed on 6/6/23, the hospice manager (HM) stated the agency did not have a pastor or clergy on staff. The MSW was doing the overall assessment on admission. If concerns were noted she would consult and/or refer to a pastor. She had not prioritized obtaining a chaplain on staff as she felt the MSW assessment was enough. During interview on 6/8/23, MSW stated she completed the spiritual assessment on admission. She kept the assessment pretty minimal at first because it was not really her area and she had not been trained for conducting a spiritual assessment. MSW usually just asked if they were a member of a church and how often they attended church. MSW asked if they wanted her to reach out to their pastor or if they would do so on their own; however, did not document this conversation. It was just not her area of expertise. The agency's policy Hospice Spiritual Assessment dated 9/7/21, indicated a spiritual assessment would be completed for each patient/family as part of the comprehensive assessment. On admission, the hospice registered nurse or designee would conduct an initial spiritual assessment. If applicable, the hospice chaplain or designee would contact the patient by a home visit or telephone, base on the patient's needs and acceptance of these services. The spiritual assessment would include religious and spiritual reactions to terminal illness, survivor risk factors, available religious support, coping styles and impact of illness on spirituality, anticipatory grief assessment and bereavement needs. The assessment would be documented in the patient's clinical record.

Based on interview and document review the hospice failed to ensure they had a copy of the patient's advanced directive for 5 of 14 patients (P1, P10, P3, P7, P6) reviewed for advanced directives. --- P1's hospice plan of care (POC) dated 5/25/23 indicated P1 had a diagnosis of hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. The POC indicated P1 had a healthcare power of attorney and did not want to be resuscitated under a heading: Advance Directives. The medical record was reviewed however, no advanced directives were located in P1 chart. During interview 6/5/23 at 3:00 p.m., social worker (SW)-B stated she was going to look for the advanced directives because she did not see anything scanned in the record. P10's hospice POC dated 4/6/23, indicated P10 had a diagnosis of unspecified protein-calorie malnutrition. The POC under the heading advance directives indicated P10 did not want resuscitation, however the medical record was reviewed and no advanced directives were located in P10's chart. During interview 6/7/23 at 10:51 a.m., registered nurse (RN)-F reviewed P10's medical record and could not locate the advanced directives. P3's POC dated 5/17/23, indicated P3 had a diagnosis of neoplasm of unspecified behavior of brain. The POC under the heading Advance Directives indicated P3 did not want to be resuscitated and had a healthcare power of attorney; however, the medical record was reviewed and no advanced directives were located in P3's chart. P3's SW progress note dated 4/17/23, indicated P3's nephew would provide a copy of the power of attorney paperwork at next visit. P3's SW progress note dated 4/18/23, indicated was reviewed, but lacked information regarding P3's advanced directive. P3's consent for hospice form indicated P3 was provided P3 was informed of the right to prepare advance directives and copies of the documents would be kept with the chart at the hospice office. During interview on 6/7/23 at 10:39 a.m., Rn-F and the hospice manager (HM) stated there were no advanced directives scanned in P3's chart. P6's POC dated 3/27/23, indicated P6 had a diagnosis of hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. The POC under the heading Advance Directives indicated P6 did not want resuscitation and had a healthcare power of attorney. P6's initial SW assessment dated 3/20/23 indicated a power of attorney was requested from the caregiver. The medical record was reviewed and no advanced directives were located in P6's chart. P7's record was reviewed however no advanced directive was scanned in the chart. During interview on 6/7/23 at 3:50 p.m., HM stated they went to the hospital chart to pull P7's advanced directives and stated the problem with the advanced directives not being in the hospice chart was that staff wouldn't have access to them. During interview on 6/8/23 at 9:32 a.m., SW-B stated she documents on admission the status of a power of attorney but needed to get better at following up with the advanced directives. SW-B stated it was important for advanced directives to be on the hospice chart because staff would know the patient's wishes and patient's family members needed to know and it was important to honor a patient's wishes. A policy, Advance Directives dated 5/18/23, indicated it was the policy to encourage individuals and their family/caregivers to participate in decisions regarding care and services. Upon admission the clinician provides information regarding a right to make decisions concerning health care which included the right to execute advance directives. If an advanced directive has been completed, the clinician will ask for a copy to be placed in the clinical record.

Based on interview and document review, the agency failed to ensure the interdisciplinary group (IDG) conferred with an individual with additional education in drug management to ensure the drugs and biologicals meet each patient's needs for 2 of 14 patients (P2, P9) reviewed for medications. --- P2's Palliative care encounter note dated 3/9/23, indicated P2 was being seen for a palliative care consultation. Medications included oxycodone (pain medication), Senna (laxative) and Lexapro (antidepressant), with recommendations to increase Lexapro to 20 milligrams (mg) daily and stop Crestor (cholesterol medication). P2's plan of care (POC) identified a start of care (SOC) of 3/14/23. Diagnoses included malignant melanoma of trunk, secondary malignant neoplasm of brain, anxiety, and other cerebrovascular disease. Medications included acetaminophen extra strength 500 mg 1 to 2 tablets every (q) four hours as needed (PRN), artificial tears 1 to 2 drops PRN, Keppra 10000 mg 1 table two time per day, Lexapro 10mg every day, Senna 8.6-50 mg 1 to 4 tablets up to three times per day PRN, acetaminophen 650 mg 1 suppository q 4 hours PRN, artificial saliva 1 application PRN, Bisacodyl 10 mg suppository daily PRN, dexamethasone 2 mg 1 tablet two times per day, levothyroxine 88 micrograms (MCG) q 2 hours PRN, morphine 100 mg/ 5 milliliters (ML) 0.5 to 2 ml q hour PRN, omeprazole 20 mg daily, ondansetron 4 mg 1 to two tablets q 4 hours PRN and solifenacin (a muscle relaxant) 10 mg every morning. P2's skilled nurse visit note dated 3/14/23, indicated P2 was admitted to hospice with various assessments completed. The visit documentation failed to identify if medications were reviewed with P2's physician or pharmacist and did not identify medication changes made or stopped at start of care. On 5/18/23 a verbal order was documented to stop P2's Keppra (an anticonvulsant) and dexamethasone (a steroid). A rationale was not indicated. P2's medical record lacked evidence that a physician or pharmacist reviewed P2's scheduled medications and/or made recommendations to discontinue or change P2's medication due to P2's terminal prognosis. The medical record lacked physician orders and rationale to discontinue P2's scheduled medications. The medical record lacked evidence P2 or her family was advised of the risks or benefits of discontinuing his prescribed scheduled medication. During interview with P2's primary physician (PP)-C on 6/8/23, PP-C stated she had not seen P2 since November 2022. PP-C received a telephone message P2's family wanted to stop her Keppra and dexamethasone. PP-C felt if the patient was unable to speak for herself and family felt the need to stop certain medications she was ok with trying that. She was not sent a medication list to review when P2 was admitted to hospice and risk and benefits of the medications were not discussed. PP-C stated she generally respected family wishes and trusted the hospice nurses would have had a discussion of risk vs benefits with family members and/or utilized their resources such as pharmacist input prior to contacting her with requests for medication changes. P9's discharge summary dated 5/17/23, indicated P9 had hospitalization for acute diastolic congestive heart failure. Discharge medications included furosemide 9a diuretic), potassium (supplement), magnesium (supplement), warfarin (a blood thinner), brimonidine-timolol eye drops, levothyroxine (thyroid medication), Actemra (to treat rheumatoid arthritis), nifedipine (to treat blood pressure), lisinopril (to treat blood pressure), prednisone (steroid), refresh eye drops, nasal moisturizing spray and Vitamin D3 (supplement). P9's POC identified a SOC date 5/23/23. Diagnoses included abnormal weight loss, heart and kidney disease with heart failure, and diabetes mellitus. Medications included Actemra (to treat rheumatoid arthritis), artificial tears, potassium, nasal moisturizing spray, refresh eye drops, Senna-S, acetaminophen, atenolol, bisacodyl, brimonidine-timolol eye drops, Vitamin D3, clotrimazole cream, diclofenac gel, furosemide, hyoscyamine, lorazepam, magnesium, melatonin, morphine, ondansetron, and prednisone. The medical record lacked evidence that a physician or pharmacist reviewed P9's scheduled medications and/or made recommendations to discontinue or change P9's medication. The medical record lacked physician orders and rationale to discontinue P9's nifedipine, lisinopril and warfarin. The medical record lacked evidence P9 or her family was advised of the risks or benefits of discontinuing her prescribed scheduled medication. During interview on 6/7/23, P9's primary physician (PP)-D stated they were contacted during the initial visit P9 was hypotensive with poor color and low oxygen saturation. PP-D did stop R9's nifedipine at that time but was pretty sure that was the only medication that she has discontinued. PP-B did not remember being contacted with a recommendation to stop P9's warfarin and did not know when the medication had been discontinued. The only medication PP-D remembered discontinuing was the nifedipine and she did not give orders to stop any other medications. When interviewed on 6/7/23, the hospice manager (HM) stated when P9 was first admitted she was not doing well or swallowing her medications. The family did not want to continue P9's warfarin. The nurse left the primary physician a message that the patient was refusing the medication. She was unable to find documentation risk and benefits of discontinuing P9's warfarin was discussed with P9 or her family, nor was physician review of medications documented and it should have been. During a joint interview with the hospice manager (HM) and registered nurse care coordinator (CC) on 6/7/23, the HM stated they had a contract with a pharmacy-A to review patient medications. When patients were admitted to hospice, the case manager would review the medications and consult with the patient and then consult with the primary care physician. The CC stated the medications were reconciled from the discharge summary or patient bottles, discussion with the patient and family or list in the home. The nurse would make a list from that at admission and fax to that list to the primary physician. Frequently the primary physician would indicate on that fax which meds he/she wished to continue and which ones were to be stopped or added. That list would then be put on the patients POC for physician signature. The agency did not scan the fax into the patient's medical record and did not document medications were reviewed with the primary physician. Family and patients were advised on risk and benefits of discontinuing certain medications, however was not documented in the patient's medical record. When interviewed on 6/6/23, pharmacist-E stated the pharmacy did not do regular business with the agency and she was not aware of a contract with the agency. The agency contract Pipestone County Hospice Pharmacy Services Agreement dated 2/18/21, indicated the pharmacy would review patient medications, making recommendations related to which medications were hospice appropriate, related to the terminal diagnosis and should be paid for hospice, which medications were not related to the patient's hospice diagnosis, but the patient should continue to take, and which medications should be discontinued, because they were not longer providing a benefit to the patient, any potential risks for side effects of medication interactions, alternative medications that would be generally just as effective, and other recommendations that would benefit the patient. The agency policy Requesting and Receiving Medication Prescriptions and Refills dated 2/13/23, identified purpose to ensure complete and up-to-date medication orders for each client are requested and received from an authorized prescriber in a timely basis. The registered nurse (RN) was responsible for assuring that current, authorized prescriber prescriptions for medications to be managed by the hospice staff were kept in the client's record and changes in orders were addressed in the client's care plan, service plan and medication administration record. The RN would be responsible for providing any needed information and education to the client, regarding any new medications, directions for use of medications, and side effects or other medications issues. the RN would document any education provided. The agency's policy Medication Profile/Medication Regimen Review dated 5/2020, indicated at the time of admission the registered nurse would check all medications a client may be taking. Changes in medication orders would be documented in the medical record with a physician's signature obtained by telephone or verbal orders.