Every finding on record at Bethesda Hospice

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 and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that the initial comprehensive assessment was completed within five (5) calendar days after the election of hospice care. Clinical Record 9: The election of hospice care was dated 01/19/2024. The initial chaplain assessment was dated 01/25/2024, six (6) calendar days after the election of hospice care. On 07/10/2024, the Director of Hospice reviewed the record and confirmed the finding.

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 effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and 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, document review and interview. In 5 of 14 (36%) clinical records reviewed it was revealed that the agency did not ensure that the drug profile included all of the patient's current medications. Document 1: Agency Policy PC.M60 titled, Medications-Profile, dated 08/2023 read in part, "A patient-specific medication profile is maintained for each patient and reviewed, at a minimum, every fifteen days. When a patient is admitted to hospice, a medication profile is initiated to document all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy". Clinical Record 2: The initial nursing assessment dated 06/20/2024 read in part, "Client is oxygen dependent". The drug profile dated 06/20/2024 did not include oxygen. Clinical Record 3: The initial nursing assessment dated 10/25/2023 read in part, "Client wears oxygen at 2Liters at bedtime". The drug profile dated 10/25/2023 did not include oxygen. Clinical Record 9: The initial nursing assessment dated 01/19/2024 read in part, "Patient is on continuous oxygen". The drug profile dated 01/19/2024 did not include oxygen. Clinical Record 12: The initial nursing assessment dated 05/14/2024 read in part, "Patient is on continuous oxygen at 4Liters". The drug profile dated 05/14/2024 did not include oxygen. Clinical Record 14: The initial nursing assessment dated 06/14/2024 read in part, "Patient is on oxygen at 5Liters continuously." The drug profile dated 06/14/2024 did not include oxygen. In an interview on 07/09/2024, the Director of Hospice reviewed the records and stated, "Oxygen is not documented on these drug profiles but it should have been."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 11 (36%) clinical records reviewed of patients that received aide services it was revealed that the agency did not ensure that all patient care instructions were included in the aide care plan. Clinical Record 1: The aide visits dated 06/20/2024 and 07/03/2024 read in part, "Patient's fingernails were cleaned and filed. RN was notified". The current aide care plan dated 06/18/2024 lacked instructions related to nail care. Clinical Record 3: The record revealed an initial nursing assessment dated 10/25/2023 that read in part "Client wears oxygen at 2L at bedtime.". The aide care plan dated 10/25/2023 lacked instructions related to care of the patient receiving oxygen. Clinical Record 5: The record revealed an initial nursing assessment dated 12/22/2023 that read in part "Patient has an 18fr foley catheter in place". The aide care plan dated 12/22/2023 lacked instructions for care of an indwelling catheter. Clinical Record 9: The record revealed an initial nursing assessment dated 01/19/2024 that read in part, "Patient is on continuous oxygen". The aide care plan dated 01/19/2024 lacked instructions related to care for the patient receiving oxygen. In an interview on 07/09/2024, the Director of Hospice reviewed the records and stated, "There should have been instructions for nail care, catheter care and oxygen on these aide care plans but there isn't".

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 physician orders. This standard was not met as evidenced by clinical record review and interview. In 7 of 14 (50%) clinical records reviewed it was revealed that the agency did not ensure that all physician's orders were included in the patient's clinical record. Clinical Record 2: The initial nursing assessment dated 06/20/2024 read in part, "Client is oxygen dependent.". The initial plan of care dated 06/20/2024-09/18/2024 read in part, "Administer oxygen per physician's orders.". The record lacked specific physician's orders for oxygen. Clinical Record 3: The initial nursing assessment dated 10/25/2023 read in part "Client wears oxygen at 2Liters at bedtime.". The initial plan of care dated 10/25/2023-01/22/2024 read in part, "Administer oxygen per physician's orders.". The record lacked specific physician's orders for oxygen. Clinical Record 5: The initial nursing assessment dated 12/22/2023 read in part "Patient has an 18fr foley catheter in place.". The initial plan of care dated 12/22/2023-03/20/2024 read in part, "Maintain foley catheter as ordered by physician". The record lacked specific physician's orders for the foley catheter. Clinical Record 9: The initial nursing assessment dated 01/19/2024 read in part, "Patient is on continuous oxygen". The initial plan of care dated 01/19/2024-04/16/2024 read in part, "Administer oxygen per physician's orders.". The record lacked specific physician's orders for oxygen. Clinical Record 12: The initial nursing assessment dated 05/14/2024 read in part, "Patient on continuous oxygen at 4Liters. Patient has an 18Fr Foley catheter in place". The initial plan of care dated 05/14/2024-08/12/2024 read in part, "Administer oxygen per physician's orders. Maintain foley catheter as ordered by physician". The record lacked specific physician's orders for oxygen and the foley catheter. Clinical Record 13: The initial nursing assessment dated 10/10/2023 read in part, "Patient has a foley catheter in place that the facility manages.". The initial plan of care dated 10/10/2023-01/08/2024 read in part, "Maintain foley catheter as ordered by physician". The record lacked specific physician's orders for the foley catheter. Clinical Record 14: The initial nursing assessment dated 06/14/2024 read in part "Patient is on oxygen at 5Liters continuously. Patient has an 18Fr Foley catheter in place". The initial plan of care dated 06/14/2024-09/12/2024 read in part, "Administer oxygen per physician's orders. Maintain foley catheter as ordered by physician". The record lacked specific physician's orders for the foley catheter and oxygen. In an interview on 07/10/2024, the Director of Hospice reviewed the records and stated, "There are no specific physician's orders in these charts for a foley catheter or oxygen".

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). The Interdisciplinary Group discusses the policies and procedures in a language and manner that the patient and family or patient’s legal representative understand; ensures that the safe use and disposal of controlled drugs is understood; documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 11 (9%) discharged clinical records reviewed revealed that the agency did not ensure that disposal of controlled medications was documented per agency policy. Document 1: Agency Policy PC.M70 "Medications-Use and Disposal of Controlled Substances" dated 08/2023 read in part "Controlled drugs no longer needed by the patient are disposed of in compliance with State and Federal regulations and disposal instructions and activities are documented which includes: the type of controlled substance, dosage, route, quantity, as well as the date and time of the disposal.". Clinical Record 11: The plan of care dated 02/15/2024-05/13/2024 read in part, "Fentanyl 12mcg patch, apply to skin Q72 hours; hydromorphone 1mg/ml solution, give 1mg every 2 hours as needed for pain; hydromorphone 1mg tablets, give 1 tablet every 4 hours as needed for pain; morphine 20mg/ml solution, give 5mg every 2 hours as needed for pain or shortness of breath". The record revealed a nursing death visit note dated 02/23/2024. The nursing death visit note lacked documentation of disposal of the fentanyl patches, hydromorphone solution, hydromorphone tablets and morphine solution by the facility. In an interview on 07/10/2024, the Director of Hospice reviewed the record and stated, "The facility disposed of the medications per their policy, but it was not documented in the nursing note.".