Every finding on record at Bristol Hospice-Sacramento, 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 medication review process includes the identification of the following: 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 measures 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, observation, and interview. In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a review of the patient's current medications. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 02/07/2024 with a diagnosis of Alzheimer's disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 11/20/2024, the hospice medication list (printed on 11/19/2024) was compared to the SNF medication profile (printed on 11/20/2024). The hospice medication profile contained the following medications not listed on the SNF medication list: lorazepam 1 mg tablet, give one (1) tablet every 4 hours as needed for anxiety or nausea (ordered 07/08/2024); and Senna 8.6 mg tablet, give one (1) tablet 2 times daily as needed for constipation (ordered 07/11/2024). The SNF medication profile contained the following medication not listed on the hospice medication profile: Docusate 100 mg, give one (1) capsule every 12 hours as needed for constipation (ordered 07/07/2024). Clinical Record 14: The patient elected the hospice benefit on 01/08/2024 for the diagnosis of senile degeneration of the brain. The patient resided in a skilled nursing facility (SNF). A review of the clinical record revealed the hospice medication profile (printed on 11/20/2024) and the SNF medication profile (printed on 11/20/2024). The hospice medication profile contained the following medications not listed on the SNF medication list: guaifenesin 100mg/5ml, give 10 ml every 6 hours as needed for cough; haloperidol 2mg/ml concentrate, give 1 mg every 4 hours as needed for delirium or nausea; lorazepam 1 mg tablet, give one (1) tablet every 4 hours as needed for anxiety or nausea (ordered 06/06/2024); atropine sulfate 1% solution two (2) drops every 4 hours as needed for excessive secretions (ordered on 06/07/2024); and Tylenol 500 mg tablet, give one (1) tablet 3 times daily (ordered 10/28/2024). During an interview and a joint clinical record review on 11/21/2024, the Regional Clinical Director confirmed the differences in the medication profiles between the hospice and SNF lists.

It is required that medical social services are provided by a qualified social worker based on a psychosocial assessment; according to the patient’s and family’s needs and acceptance of these services; per the plan of care; and under the direction of a physician. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed in which social worker services were accepted, the agency did not ensure that medical social worker services were provided per the plan of care. Clinical Record 3: The patient elected hospice care on 02/23/2024. The plan of care (POC) dated 08/21/2024 ordered Social Worker (SW) services one (1) time per month. A clinical record review revealed no documented SW visit for September 2024. There was no documented evidence of refusal of visits by the patient/caregiver or change in the POC visit frequency. Clinical Record 5: The patient elected hospice care on 03/09/2024. The POC dated 03/12/2024 ordered SW services one (1) time per month to "follow up with funeral arrangements and caregiver needs." Social Worker visits were completed on 05/31/2024 and 07/31/2024, which documented "continue to visit one-time monthly." There was no SW visit documented for June 2024. The SW documented a phone call on 08/20/2024, no visit in September 2024, and a phone call on 10/10/2024. There was no documented evidence of refusal of visits by the patient/caregiver or change in the POC visit frequency. Clinical Record 12: The patient elected hospice care on 06/10/2024. The POC dated 06/27/2024 ordered SW services one (1) time per month to "assist with expression of grief and funeral planning." On 08/26/2024, the SW documented a phone call to the patient, "SW received a message for SW support." There was no SW visit documented until 11/06/2024. There was no documented evidence of refusal of visits by the patient/caregiver or change in the POC visit frequency. Clinical Record 15: The patient elected hospice care on 05/27/2022. The POC dated 08/25/2022 ordered to continue with SW services one (1) time per month. There was no SW visit documented in September 2022. The SW visit note dated 10/21/2022 documented, "needs increased caregiving-wants monthly phone check-ins." The POC dated 11/23/2022 ordered to continue SW services one (1) time monthly visits. No visit was documented in November 2022. There was no documented evidence of refusal of visits by the patient/caregiver or change in the POC visit frequency. During an interview and a clinical record review on 11/21/2024, the Regional Clinical Director confirmed the missing visits, stating there "had been issues with this social worker completing her visits and documenting her visits, and she had been on a performance plan."

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the hospice election form for each patient/resident. This standard was not met as evidenced by observation, clinical record review, and interview. In 2 of 2 (100%) home visits observed of patients residing in a skilled nursing facility (SNF), the agency did not ensure the facility received the hospice election form. Home Visit 1/Clinical Record 1: The patient elected the hospice benefit on 02/07/2024 with the diagnosis of Alzheimer's disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 11/20/2024, the patient's hospice binder was reviewed with the RN. The binder did not contain the patient's hospice election form. The RN stated the "patient had moved there 2 months ago, and perhaps the forms had not been placed in her binder." Home Visit 2/Clinical Record 2: The patient elected the hospice benefit on 08/20/2024 with the diagnosis of malignant neoplasm of the colon. The patient resided in a SNF. During the home visit with the Hospice Aide (HHA) [Personnel Record 7] on 11/20/2024, the patient's hospice binder was reviewed. The binder did not contain the hospice election form. During an interview on 11/20/2024, the RN [Personnel Record 4] confirmed the finding, stating they "thought the admission forms meant the admission nurse assessment." The RN stated they had placed the admission nurse assessment in the facility binder "behind the tab where it stated admission paperwork."

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by review of clinical records and interviews. In 1 of 13 (8%) clinical records, there was no documented evidence that the nurse was compliant with the visit frequency as ordered on the plan of care. Record #46889 - The start of the benefit period was 8/30/2021. The patient expired 11/3/2021. The ordered nursing visit frequency during the benefit period was two times a week. The clinical record was missing one documented nursing visit the week of 10/3/21 and missing two documented nursing visits the week of 10/10/21. During interview, the Alternate Administrator stated that she reviewed the clinical record and that nursing visits were scheduled on 10/8/21, 10/11/21 and 10/13/21 and that she could not locate the missing nursing visit documentation. During clinical record review, the Vice President of Quality stated that she could not locate the missing nursing visits or missed visit reports).