Every finding on record at Bristol Hospice - Miami Dade, LLC

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, and other alternative treatments that could affect drug therapy. 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, observation, and interview. Agency policy #2-004 "Medication Profile" (revised May 2020) sub-section seven (7) stated in part, "A drug regimen review will be performed at the time of the initial and the comprehensive assessment when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication." In 3 of 4 (75%) home visits observed, the hospice agency did not ensure that the comprehensive assessment included a review of the patient's current medication regimen. Home Visit 1/Clinical Record 1: The patient elected hospice care on 11/9/2022 and resided at a Skilled Nursing Facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 7] and the Director of Clinical Patient Care Services (DCPCS) on 10/17/2023, a medication reconciliation was performed comparing the hospice agency's medication profile to the patient's SNF medication profile. The SNF medication profile dated 10/17/2023 documented in part, "Levothyroxine,88mg, take one (1) tablet by mouth daily." The hospice agency's medication profile did not document the medication Levothyroxine. There was no evidence that the comprehensive assessment included a review of the patient's current medication regimen. Home Visit 2/Clinical Record 2: The patient elected hospice care on 1/31/2023. During the home visit with the Chaplain [Personnel Record 8] and the DCPCS on 10/17/2023, a medication reconciliation was performed comparing the hospice agency's medication profile to the patient's medication regimen. The caregiver confirmed the patient currently takes Lasix 20 mg.one tablet by mouth every day. The hospice agency medication profile did not document the medication Lasix. There was no evidence that the comprehensive assessment included a review of the patient's current medication regimen. Home Visit 4/Clinical Record 3: The patient elected hospice care on 4/27/2022. During the home visit with the Social Worker [Personnel Record 9] and the DCPCS on 10/17/2023, a medication reconciliation was performed comparing the hospice agency's medication profile to the patient's medication regimen. The patient's caregiver reviewed the medications the patient is currently taking. The caregiver confirmed the patient takes Aspirin 81 mg. one (1) tablet by mouth daily, Probiotic tablet 500 million colony forming units (CFU) one (1) tablet daily, Vitamin D3 125 mcg one (1) tablet daily. The hospice agency medication profile did not document the medications Aspirin, Probiotic, and Vitamin D3. There was no evidence that the comprehensive assessment included a review of the patient's current medication regimen During a joint record review and an interview on 10/17/2023, the DCPCS confirmed the hospice agency medication profile did not match the patient's current medication regimen.

It is required that each patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy# 9-017 "Plan of Care" (revised November 2021) sub-section four (4), stated in part, "The Plan of Care will identify the patient's needs and services to meet those needs." Sub-section twelve (12) stated in part, "The written plan of care will contain, but will not be limited to the following: (s) Drugs and treatments." In 3 of 19 (16%) clinical records reviewed, the hospice agency did not ensure all drugs needed for the palliation and management of the patient were listed on the care plan. Clinical Record 1/Home Visit 1: The patient elected hospice care on 11/9/2022 and resided at a Skilled Nursing Facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 7] and the Director of Clinical Patient Care Services (DCPCS) on 10/17/2023, a medication reconciliation was performed comparing the hospice agency's medication profile to the patient's SNF medication profile. The SNF medication profile dated 10/17/2023 documented in part, "Levothyroxine,88mg, take one (1) tablet by mouth daily." The hospice plan of care dated 10/17/2023 did not include documentation of the medication Levothyroxine. Clinical Record 2/Home Visit 2: The patient elected hospice care on 1/31/2023. During the home visit with the Chaplain [Personnel Record 8] and the DCPCS on 10/17/2023, a medication reconciliation was performed comparing the hospice agency's medication profile to the patient's medication regimen. The caregiver confirmed the patient currently takes Lasix 20 mg.one tablet by mouth every day. The hospice plan of care dated 10/17/2023 did not include documentation of the medication Lasix. Clinical Record 3/Home Visit 4: The patient elected hospice care on 4/27/2022. During the home visit with the Social Worker [Personnel Record 9] and the DCPCS on 10/17/2023, a medication reconciliation was performed comparing the hospice agency's medication profile to the patient's medication regimen. The patient's caregiver reviewed the medications the patient is currently taking. The caregiver confirmed the patient takes Aspirin 81 mg. one (1) tablet by mouth daily, Probiotic tablet 500 million colony forming units (CFU) one (1) tablet daily, Vitamin D3 125 mcg one (1) tablet daily. The hospice plan of care dated 10/17/2023 did not include documentation of the medications Aspirin, Probiotic, and Vitamin D3. During a joint record review and an interview on 10/17/2023, the DCPCS confirmed the plans of care did not contain all of the patients' current medications.

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, observation. document review, and interview. Agency policy #1-035 "Interdisciplinary Group Coordination of Care" (revised June 2022) sub-section four (4), stated in part, "Personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communication will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note." Agency policy# 9-017,"The Plan of Care" (revised June 2022) sub-section fifteen (15), stated in part, "Care provided to the patient will be in accordance with the plan of care." In 1 of 4 (25%) home visits observed of patients receiving hospice aide services, the hospice agency did not ensure all services provided by the hospice aide were ordered by the Interdisciplinary Group and included in the plan of care. Home Visit 3/ Clinical Record 4: The patient elected hospice care on 4/13/2023. The patient received hospice aide services five (5) times weekly. A review of the clinical record revealed the Aide care plans dated 4/13/2023 through 7/11/2023, 7/12/2023 through 10/9/2023, and 10/10/2023 through 12/8/2023 documented the hospice aide's task as a, "Bed Bath." During the home visit with the hospice aide (HA/CNA) [Personnel Record 5] and the Director of Clinical Patient Care Services (DCPCS) on 10/17/2023, the hospice aide reported they have always showered the patient, since the start of care on 4/13/2023. The hospice aide stated the patient "has always received a shower." For the week of 10/9/2023, the patient received hospice aide visits: 10/9/2023, 10/10/2023,10/11/2023, 10/12/2023, and 10/13/2023. The hospice aide documented they performed a complete bed bath during each of the visits. There was no evidence the hospice aide had communicated with the Registered Nurse (RN) the change in the type of bath. During a joint record review and interview on 10/17/2023, the DCPCS confirmed the hospice aide had completed a shower at multiple hospice aide visits, and the hospice aide care plan ordered a bed bath. The hospice RN added a late quick note entry on 10/17/2023 for the date of 4/18/2023 that stated, "CNA report that caregiver request transfer patient to the shower. MD notified and approved."

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: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 4 (25%) home visits observed of patients receiving hospice aide services, the hospice agency did not ensure the hospice aide visit notes included documentation of the care and services provided. Home Visit 3/Clinical Record 4: The patient elected hospice care on 4/13/2023. The patient received hospice aide services five (5) times weekly. A review of the clinical record revealed the Aide care plans dated 4/13/2023 through 7/11/2023, 7/12/2023 through 10/9/2023, and 10/10/2023 through 12/8/2023 documented the hospice aide's task as a, "Bed Bath." During the home visit with the hospice aide (HA/CNA) [Personnel Record 5] and the Director of Clinical Patient Care Services (DCPCS) on 10/17/2023, the hospice aide reported they have always showered the patient, since the start of care on 4/13/2023. The hospice aide stated the patient "has always received a shower." For the week of 10/9/2023, the patient received hospice aide visits: 10/9/2023, 10/10/2023,10/11/2023, 10/12/2023, and 10/13/2023. The hospice aide documented they performed a complete bed bath during each of the visits. During a joint record review and interview on 10/17/2023, the DCPCS confirmed the hospice aide had completed a shower at multiple hospice aide visits, and the hospice aide care plan ordered a bed bath. In addition, the DCPCS confirmed the hospice aide did not document correctly, as all hospice aide visit documentation contained evidence that they completed a bed bath every visit since admission on 4/13/2023.

Based on record reviews and interview, the provider failed to demonstrate a completed discharge summary for 4 out of 20 Sampled Patients (SP). (SP#12, SP#13, SP#14 and SP#15) --- Findings include: Review of the clinical record for SP#12 revealed the patient was admitted to service with an election date of 11/09/2022 and was discharged on 01/15/2023 due to revocation for reason stated as aggressive treatment. Review of the clinical record for SP#13 revealed the patient was admitted to service with an election date of 08/17/2022 and was discharged on 11/10/2022 due to discharge planning for no longer terminally ill. Review of the clinical record for SP#14 revealed the patient was admitted to service with an election date of 05/01/2021 and was discharged on 01/24/2023 due to request to transfer, change in designated hospice. Review of the clinical record for SP#15 revealed the patient was admitted to service with an election date of 10/23/2021 and was discharged on 01/04/2023 due to request to transfer, change in designated hospice. Further review of all the clinical records omitted a summary of the patients stay including treatments, symptoms and pain management; the patients current plan of care; the patients latest physician orders; and any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility. On 02/09/2023 the Director of Nursing was requested to provide the physician discharge order and the discharge summaries for SP#12, SP#13, SP#14 and SP#15. On 02/10/2023 the Director of Nursing only provided the discharge orders for SP#12, SP#13, SP#14 and SP#15 that stated the discharge date and the discharge reason. Interview conducted with the Director of Nursing and the Administrator on 02/10/2023 at 3:15 PM acknowledged findings, failure of the provider to have a complete clinical record with all discharge summaries completed.