Every finding on record at Bridgeway Hospice, LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient's date of election was 04/28/2023. The primary hospice diagnosis was atherosclerotic heart disease of the native coronary artery with unstable angina pectoris. The registered nurse (RN) Recertification visit dated 06/11/2024 documented that the patient had 2+ pitting edema to both lower extremities, was a fall risk assessment of 7/10 with a score of 4 or greater is considered at risk for falling and had a co-morbidity of diabetes mellitus type 2. The RN Recertification visit dated 08/07/2024 documented that the patient had 1+ pitting edema to both lower extremities, was a fall risk assessment of 7/10 with a score of 4 or greater is considered at risk for falling and had a co-morbidity of diabetes mellitus type 2. The medications listed on the Plan of Care dated 06/30/2024 for the benefit period 06/21/2024-08/19/2024 documented the patient was receiving Lasix 20mg daily for edema and Metformin 1000mg twice daily for DM-II. The Plan of Cares dated 06/21/2024-08/19/2024 and 08/20/2024-10/28/2024 lacked problems, interventions, and goals for fall risk, edema, hypoglycemia, and hyperglycemia. Clinical Record 5: The patient's date of election was 09/25/2024. The primary hospice diagnosis was neurocognitive disorder with Lewy bodies. The RN Initial Assessment visit dated 09/25/2024, the RN - Skilled Nursing Visit dated 10/02/2024, and the RN Comprehensive Visit dated 10/09/2024 documented that the patient had shortness of breath/dyspnea with moderate exertion, a productive cough, dizziness, and bladder and bowel incontinence. The Plan of Cares dated 09/25/2024-10/04/2024 and 10/05/2024-12/03/2024 lacked problems, interventions, and goals for altered respiratory status and risk for skin impairment. During a joint review of the record and an interview on 10/16/2024, the Director of Nursing confirmed that there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the assessments.

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. This standard was not met as evidenced by document review, interview and observation. In 1 of 4 (25%) home visit observations revealed the organization did not ensure the staff followed the hand hygiene policy. Document 1: Agency policy, “Hand Hygiene IC.15,” dated 12/15/2022, stated in part, “Hand Hygiene with Soap and Water. Staff will identify and gather appropriate supplies. Staff will wet hands and wrists with water using temperature that is comfortable. Staff will apply the amount of product recommended by the manufacturer to hands and rub hands together vigorously for at least 15 seconds (with the recommendation of 20 seconds, but either time is acceptable), covering all surfaces of the hands and fingers. Staff will rinse hands and wrists thoroughly with water. With hands held upright, staff will dry hands and wrists thoroughly with a clean paper towel. They will use a paper towel to turn off the faucet. Hand Hygiene with an Alcohol-based Hand Rub. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: after removing gloves." Home Visit 3: During the home visit (Clinical Record 3) on 10/15/2024 with the Home Health Aide (Personnel Record 8), the aide was observed to wash the hands with soap and water. After rinsing the hands, the aide turned off the water with wet hands and then dried them with a clean, dry cloth. The aide donned gloves shaved the patients and removed the gloves. The aide then donned a new pair of gloves without decontaminating the hands. The aide was observed to have removed the gloves two more times during the visit without decontaminating the hands before donning a new pair of gloves. The aide did not perform hand hygiene after removing gloves. During a joint document review and interview on 10/16/2024, the Director of Nursing agreed the staff did not follow the hand hygiene policy.

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 3 of 16 (19%) clinical records reviewed of patients receiving hospice aide services revealed the hospice did not ensure that the hospice aide care plan provided specific instructions to the aide. Clinical Record 3: The patient’s date of election was 06/24/2024. The primary hospice diagnosis was diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter. The hospice aide care plans dated 06/24/2024 and 09/17/2024 assigned the hospice aide the tasks, "Complete Bed Bath offer each visit and Partial Bath/Shower offer each visit." The care plan did not provide clear instructions to the hospice aide regarding the type of bath. Clinical Record 5: The patient’s date of election was 09/25/2024. The primary hospice diagnosis was neurocognitive disorder with Lewy bodies. The hospice aide care plan dated 06/25/2024 assigned the hospice aide the tasks, "Complete Bed Bath offer each visit, Partial Bath/Shower offer each visit, and Complete Shower offer each week." The care plan did not provide clear instructions to the hospice aide regarding the type of bath. Clinical Record 8: The patient’s date of election was 07/30/2024. The primary hospice diagnosis was senile degeneration of the brain. The hospice aide care plan dated 07/30/2024 assigned the hospice aide the tasks, "Complete Bed Bath offer each visit, Partial Bath/Shower offer each visit, and Complete Shower offer each week." The care plan did not provide clear instructions to the hospice aide regarding the type of bath. During a joint review of the record and an interview on 10/16/2024, the Director of Nursing agreed the instructions on the hospice aide care plan were not specific.

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, signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure the patient's signed consents included the date of election. Clinical Record 6: The patient elected the hospice benefit on 11/08/2023. The consent forms, signed and dated 11/07/2023, had a space for the date of election, but the space and box were left blank. Clinical Record 13: The patient elected the hospice benefit on 06/03/2024. The Consent for Primary Caregiver, the Consent for the use of Telecommunications Technology, and the Authorization for the Release of Information were signed and dated 06/03/2024. The RN Initial Assessment visit was dated 06/03/2024. The Consent for Election of Medicare Hospice Benefit and the Admission Consent forms were signed but not dated. The Consent for Election of Medicare Hospice Benefit form had a space for the date of election, but the space and box were left blank. During a joint record review and interview on 10/17/2024, the Director of Nursing confirmed that the patient's signed consent lacked the hospice date of election.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. Clinical Record 16: The patient's care was transferred to another Hospice provider on 08/08/2024. The record lacked evidence that the discharge summary was forwarded to the receiving hospice. During a joint record review and interview on 10/16/2024, the Director of Nursing confirmed that the record lacked evidence that the discharge summary was sent to the receiving Medicare/Medicaid-certified facility.

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 and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 15: The discharge summary dated 10/21/2023 lacks documentation that the discharge summary was forwarded to the patient's attending physician. During a joint record review and interview on 10/16/2024, the Director of Nursing confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.

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; and 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 for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded 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; and 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. Clinical Record 15: The date of the discharge was 10/21/2023. The record lacked evidence of a completed discharge summary that included 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; and 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. Clinical Record 16: The date of the transfer was 08/08/2024. The record lacked evidence of a completed discharge summary that included 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; and 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. During a joint record review and interview on 10/16/2024, the Director of Nursing confirmed that the record lacked evidence of a completed discharge summary that included 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; and 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.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. 4 of 9 (44%) records that received hospice services for greater than 15 days were reviewed revealed that the IDG did not review or revise the individualized plan of care no less frequently than every fifteen days. Record #11522: The patient was admitted on 9/25/21. The first IDG note was completed on 10/11/21. Record #10721: The patient was admitted on 9/3/21. The first IDG note was completed on 10/11/21. Record #23521: The patient was admitted on 9/16/21. The first IDG note was completed on 10/11/21 Record #97728: The patient was admitted on 9/21/21. The first IDG note was completed on 10/11/21. The Director of Nurses was interviewed on 11/24/21 and agreed that the initial review of the Plan of Care was not completed in collaboration with the IDG within the first fifteen days.