Every finding on record at Bethany Hospice and Palliative Care, LLC

Based on record reviews and staff interview, it was determined the hospice governing body failed to assume responsibility for the management of the hospice and the provision of all hospice services including failing to forward a discharge summary to the patients attending physician and failing to complete a discharge summary to assist in post-discharge continuity of care for one patient (P) (P#4) of two discharged patients sampled. --- Findings include: Record review reveals patient P#4 was admitted to hospice on 10/17/2024 with a diagnosis of metastatic colon cancer (cancer that has spread to other parts of the body). Patient was discharged from hospice on 10/20/2024. Review of Visit Note Report dated 10/20/2024 reveals P#4 had a pain level of 10 out of 10 when discharged. A review of the Hospice Certification and Plan of Care dated 10/17/2024 revealed P#4 was prescribed 15mg of long-acting morphine (used to treat moderate to severe pain) twice a day, 20 mg of oxycodone (used to treat moderate to severe pain),every six hours as needed, Xanax (antianxiety agent) 1mg three times a day, and oxygen to manage symptoms related to the terminal illness. Review of document titled ";Discharge-Transfer Summary Report" reveals P#4 was discharged to ";home or self-care" on 10/20/2024. Further review of the document failed to reveal documentation of the overall status of the patient at discharge or continuing pain and symptom management needs, specifically pain and pain management or dyspnea. The document failed to reveal that P#4s physician received a copy of the discharge summary. An interview on 1/13/2024 at approximately 3:00 p.m. was conducted at the hospice agency with the Executive Director (ED). The ED revealed that she believed P#4s physician was called regarding the discharge but did not provide documentation of the call or evidence the patients discharge summary was forwarded to the physician. The ED confirmed that all documentation for P#4 had been provided.

Based on review of agency policy ";Discharge Summary," and staff and family physician interview, it was determined the agency failed to ensure continuation of care as evidence of not forwarding a discharge summary or clinical record to patients Primary Physician for one patient (P) (P#4) of two sampled live discharged patients. --- Findings include: Review of policy titled ";Discharge Summary" Policy No 4-077.2 revised November 2018 reveals the following:5. A copy of the discharge summary will be provided to the patients attending physician. If requested the clinical records will be provided. An interview was conducted on 1/15/2024 at 10:15 a.m. at the Hospice agency with the Executive Director (ED) who admitted the agency failed to forward a discharge summary or clinical record to patients (P#4) Primary Physician. A phone interview was conducted on 1/14/2024 at 5:00 p.m. with the patients (P#4) Primary Physician who acknowledged she never received any documentation or phone calls regarding the patients (P#4) discharge from the Hospice agency.

Based on a review of agency policies ";Discharge Summary" and ";Discharge from Hospice Program," clinical record review, and staff interview, it was determined that the agency failed to complete a discharge summary including documentation to assist in post-discharge continuity of care for one patient (P) (P#4) of two sampled discharged patients. --- Findings include: Review of policy titled ";Discharge Summary," Policy No. 4-077.1, revised November 2018 reveals the following:Policy All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record. Procedure 1.Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include, as appropriate:K. Continuing pain and symptom management needs.L. The overall status of the patient at discharge. Review of policy titled ";Discharge from Hospice Program," Policy No. 4-076.1, revised November 2018 reveals the following:Procedure 3. When a patient is discharged, transferred, or referred to another organization, relevant information will include:G. Continuing symptom management needs, e.g. pain, nausea, dyspnea. 4. Documentation will be filed in the clinical record. Information will be documented on a discharge/transfer form, which is to be completed within 72 hours. Record review reveals patient P#4 was admitted to hospice on 10/17/2024 with a diagnosis of metastatic colon cancer (cancer that has spread to other parts of the body). Review of Visit Note Report dated 10/20/2024 reveals P#4 had a pain level of 10 out of 10 when discharged. A review of the Hospice Certification and Plan of Care dated 10/17/2024 revealed P#4 was prescribed 15mg of long-acting morphine twice a day, 20 mg of oxycodone every six hours as needed, Xanax 1mg three times a day, and oxygen. Review of document titled ";Discharge-Transfer Summary Report" reveals P#4 was discharged to ";home or self care" on 10/20/2024. Further review of the document failed to reveal documentation of the overall status of the patient at discharge or continuing pain and symptom management needs, specifically pain and pain management or dyspnea. An interview on 1/13/2024 at approximately 3:00 p.m. was conducted at the hospice agency with the Executive Director (ED). The ED confirmed that all documentation for P#4 had been provided.

Based on home visit observation, clinical record review and staff interview, it was determined that the agency failed to ensure that patient medication profiles were updated to reflect current medications at the time of the comprehensive assessment for one of 13 patients (P) (P#3). The findings include: 1. A home visit was conducted on at 10:40 a.m., on 1/19/22, at the residence of Patient #3 with Registered Nurse (RN) #BB. The patient was admitted to hospice on 9/25/20, with the diagnosis of dementia with Lewy bodies. The clinical record was reviewed for certification period 11/19/21 to 1/17/22. During the home visit the surveyor compared P#3's current medication list in the agency's electronic medical record (EMR) to the medications in P#3's home. P#3 had the following medications listed in the agency EMR but not present in the home: a. Isosorbide mononitrate ER, a medication used to treat high pressure b. Aspirin, a medication used to prevent blood clots c. Midodrine HCl, a medication used to treat low blood pressure d. Mirabegron, a medication used to treat overactive bladder e. Pravastatin, a medication used to treat high cholesterol f. Geodon, a medication used to treat agitation While reviewing medications in the home with RN #BB, RN #BB verbalized understanding of the requirement to reconcile all medications in the home with medications listed in the agency EMR during every comprehensive nursing assessment visit. During interview at the agency at 11:30 a.m. on 1/20/22, the Administrator was made aware the medication profile was not updated to reflect current medications at the time of the comprehensive assessment.

Based on clinical record review it was determined that the interdisciplinary group failed to ensure that the plan of care included patient specific orders for frequency of services to be provided by the hospice aide for two of 13 patient (P) clinical records reviewed (P#10 and P#12) The findings include: 1. Patient #10 was admitted to hospice on 6/16/21, with the diagnosis senile degeneration of the brain. The clinical record for P#10 was reviewed for the certification period 6/16/21 to 9/13/21. The clinical record revealed the plan of care lacked a specific detailed statement for the scope and frequency of the hospice aide services ordered by the physician on 8/4/21. The physician's order stated, "Aid (sic) visits multiple times per week". The physician's order lacked a frequency and duration for the required service. Review of the clinical record revealed P#10 received no hospice aide visits by the agency. 2. Patient#12 was admitted to hospice on 5/4/21, with the diagnosis of malignant neoplasm of the brain. The clinical record for P#12 was reviewed for the certification period 5/4/21 to 8/1/21. The clinical record revealed the plan of care lacked a specific detailed statement for the scope and frequency of the hospice aide services ordered by the physician on 5/25/21. The physician's order stated, "Start hospice aid (sic) service". The physician's order lacked a frequency and duration for the required service. Review of the clinical record revealed P#12 was visited by the hospice aide on 7/13/21 and 7/14/21. During interview at the agency at 11:30 a.m. on 1/20/22, the Administrator was made aware that the plan of cares for two of 13 clinical records reviewed (P#10 and P#12) did not contain specific orders for frequency of services needed to provide palliation of the hospice terminal diagnosis.

Based on clinical record review, it was determined that the agency failed to ensure services were provided in accordance with the plan of care for three of 13 patients (P) (P#6, P#10 and P#12). The findings include: 1. Patient #6 was admitted to hospice on 11/16/18, with the diagnosis of Alzheimer's disease. The clinical record was reviewed for the certification period 12/30/21 to 2/27/22. The clinical record contained a physician's order dated 3/31/21, for hospice aide services to be provided two times per week. However, there were no hospice aide visits documented in the clinical record during the certification period reviewed. The clinical record also lacked documentation of notification to the physician of the missed visits and approval by the physician for to modify P#6's plan of care. 2. Patient #10 was admitted to hospice on 6/16/21, with the diagnosis senile degeneration of the brain. The clinical record for P#10 was reviewed for the certification period 6/16/21 to 9/13/21. The clinical record contained a physician's order for hospice aide services dated 8/4/21. The physician's order stated, "Aid (sic) visits multiple times per week". However, there were no hospice aide visits documented in the clinical record during the certification period reviewed. The clinical record also lacked documentation of notification to the physician of the missed visits and approval by the physician to modify P#10's plan of care. 3. Patient #12 was admitted to hospice on 5/4/21, with the diagnosis of malignant neoplasm of the brain. The clinical record for P#12 was reviewed for the certification period 5/4/21 to 8/1/21. The clinical record contained a physician's order for hospice aide services 5/25/21. The physician's order stated, "Start hospice aid (sic) service". P#12 received hospice aide services on 7/13/21 and 7/14/21. However, there were no other hospice aide visits documented in the clinical record during the certification period reviewed. The clinical record also lacked documentation of notification to the physician of the missed visits and approval by the physician to modify P#12's plan of care. During interview at the agency at 11:30 a.m. on 1/20/22, the Administrator was made aware that services were not provide in accordance with the plan of care for three of 13 clinical records reviewed (P#6, P#10 and P#12).