Every finding on record at Camellia Hospice of Northeast Alabama, LLC

It is required that the hospice designates a Registered Nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs and ensure the implementation of the interdisciplinary plan of care. 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 continuous assessment and implementation of the patient's plan of care. Clinical Record 8: The patient with an election of hospice benefits dated 12/2/2022 had a primary diagnosis of lung cancer with metastasis and a suprapubic catheter. The plan of care update order dated 2/2/2023 documented, "Hospice nurse to place the suprapubic catheter, 14-18 FR, with 10 CC balloon inflated with 10 CC of sterile water. May irrigate with 60mL. Change suprapubic catheter every month or as needed to maintain comfort." However, the Hospice RN Visits dated 2/10/2023, 2/16/2023, 3/2/2023, 3/9/2023, 3/23/2023, and 3/30/2023 documentation did not include the suprapubic catheter being changed per the plan of care. An interview with the Director of Nursing on 4/6/2023 stated the patient had the catheter for a long time and changed the catheter himself despite no documentation of the patient changing or being capable of changing it himself. The plan of care was updated after a discussion of findings with the Director of Nursing: "Patient with long term suprapubic catheter. Skilled Nurse (SN) may teach/follow up on the return demo of insertion/care of the suprapubic catheter. Patient (Pt.)or SN may change 14-18FR suprapubic catheter with 10 cc balloon. Inflate the balloon with 10 cc sterile water monthly and PRN. Pt or SN may irrigate with 60 cc sterile water for PRN dysfunction. Add catheter buddy code monthly." Clinical Record 13: The patient with an election of hospice benefits dated 10/12/2022 had a primary diagnosis of cerebral palsy and had a PEG tube based on the admission documentation. The admission nursing note dated 10/12/2022 documented the "PEG tube in place from prior hospitalization but is no longer used" and a plan of care problem statement for the "need for skilled teaching related to the care of gastrostomy-hospice and altered." Additionally, there was a medication order dated 2/28/2023 for lorazepam 2mg/mL, 1mL via g-tube every four (4) hours as needed for seizures or agitation; All other medications were written with the oral route of medication administration. The plan of care update order dated 2/3/2023 documented "hospice to provide instructions for performing gastrostomy feedings to include care of equipment and preparation of feedings." There was no assessment, education, or documentation of the PEG tube after admission on 10/13/2022 by the skilled nurse in the visit notes with a frequency of twice weekly (2xW). The following skilled nursing visits notes were reviewed, and the PEG tube was not assessed or addressed: 10/13/2022; 10/20/2022; 10/25/2022; 10/27/2022; 11/1/2022; 11/4/2022; 11/8/2022; 11/10/2022; 11/12/2022; 11/17/2022; 11/21/2022; 11/23/2022; 12/1/2022; 12/5/2022; 12/6/2022; 12/9/2022; 12/14/2022; 12/16/2022; 12/21/2022; 12/23/2022; 12/28/2022; 1/4/2023; 1/10/2023; 1/13/2023; 1/17/2023; 1/18/2023; 1/24/2023; 1/26/2023; 2/1/2023; 2/3/2023; 2/8/2023; 2/10/2023; 2/14/2023; 2/16/2023; 2/22/2023; 2/24/2023; 2/28/2023; 3/8/2023; 3/13/2023; 3/20/2023; 3/22/2023; 3/24/2023; 3/29/2023; 3/31/2023; 4/5/2023. During the joint record review, an interview with the Director of Nursing on 4/6/2023 confirmed that the skilled nurses did not address the PEG tube per the care plan.

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 observation. In 10 of 12 (83%) clinical records reviewed where hospice aide services were accepted, the agency did not include all patient care instructions on the hospice aide care plans. Home Visit 1: During the home visit on 4/4/2023, it was identified that oral care was not on the hospice aide care plan dated 4/3/2023. The patient (RECORD 14), with an election of hospice benefits dated 1/23/2023, received hospice aide services twice weekly (2xweekly). The hospice aide verbally reviewed all the care provided for the patient, and she stated while the patient was in the seated shower, she provided him with the setup of a toothbrush and toothpaste for oral care. She said it was difficult for the patient to sit in the wheelchair and brush his teeth at the sink because the counter was too high. The clinical supervisor witnessed the conversation, and the findings were discussed. The clinical supervisor updated the care plan on 4/4/2023 to include oral care and other specific detailed instructions identified during the home visit. Clinical Record 18: The patient with an election of hospice benefits dated 3/10/2023 received aide services twice weekly. The hospice aide care plan dated 3/14/2023 documented assigned tasks to be completed every visit, including bed bath, skin care lotion, shaving, and dressing. However, it was missing the basic care of oral care. Clinical Record 13: The patient with an election of hospice benefits dated 10/12/2022 received aide services at a skilled nursing facility. The patient had a primary diagnosis of cerebral palsy, a PEG tube, a FOLEY catheter, and a history of seizures. The hospice aide care plan dated 10/12/2022 had assigned tasks to be completed every visit for the FOLEY catheter, which included routine catheter care and emptying the urinary drainage bag. However, the aide care plan was missing the instructions for the PEG tube care and safety precautions for seizure precautions. Clinical Record 3: The patient with an election of hospice benefits dated 12/10/2021 received aide services twice weekly. The hospice aide care plan dated 6/9/2022 documented assigned tasks for Activities of Daily Living (ADL) services to be completed every visit of showering, shampoo, hair care, skin care lotion, and dressing. However, it was missing the basic care of oral care. Clinical Record 6: The patient with an election of hospice benefits dated 11/9/2022 received aide services twice weekly. The hospice aide care plan dated 11/9/2022 documented assigned tasks for ADL services of showering and dressing. However, it was missing the basic care of oral care. Clinical Record 7: The patient with an election of hospice benefits dated 1/9/2023 received aide services twice weekly. The hospice aide care plan dated 1/10/2023 documented assigned tasks for ADL services: showering, hair care, skin care, and dressing. However, it was missing the basic care of oral care. Clinical Record 9: The patient with an election of hospice benefits dated 3/17/2023 received aide services twice weekly. The hospice aide care plan dated 3/22/2023 documented assigned tasks for ADL services: shower bench bath, perineal care, and dressing. However, it was missing the basic care of oral care. Clinical Record 12: The patient with an election of hospice benefits dated 1/30/2023 received aide services thrice weekly (3xW). The hospice aide care plan dated 2/2/2023 documented assigned tasks for ADL services to be completed every visit: stand-by assistance with ambulation, shower bath, hair care, and dressing. However, it was missing the basic care of oral care. Clinical Record 17: The patient with an election of hospice benefits dated 12/5/2022 received aide services thrice weekly (3xW). The hospice aide care plan dated 4/4/2023 documented assigned tasks for ADL services to be completed every visit: transfer client from bed/chair, bed bath, hair care, skin care lotion, perineal care, and dressing. However, it was missing the basic care of oral care. Clinical Record 19: The patient with an election of hospice benefits dated 8/9/2022 received aide services at a skilled nursing facility. The hospice aide care plan dated 3/9/2023 documented assigned tasks for ADL services: bed bath, shampoo, hair care, skin care lotion, perineal care, clean nails, and dressing. However, it was missing the basics care of oral care. An interview on 4/6/2023 with the Director of Nursing and the Administrator confirmed the hospice aide care plans needed to include individualized and accurate instructions for the assigned hospice aide.

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 2 of 19 (11%) clinical records reviewed. the agency did not have physician orders included in the plan of care based on the patient's individualized needs. Clinical Record 9: The patient with an election of hospice benefits dated 3/17/2023 had a primary diagnosis of cerebrovascular disease. Based on the after-hours call log and documentation, the patient had an emergency room visit on 3/25/2023 due to urinary tract infection symptoms. The Hospice RN Start of Care note dated 3/17/2023 documented the presence of a urinary diversion device of a condom catheter and that the "patient has since become incontinent of the bladder, using condom catheter...patient has plenty of condom catheter supplies in the home for now." However, the current plan of care did not include physician orders for condom catheters or interventions of education and assessments. During a joint record review, an interview with the Director of Nursing on 4/6/2023 confirmed a physician order for the condom catheter was missing from the patient's plan of care. Clinical Record 13: The patient with an election of hospice benefits dated 10/12/2022 had a primary diagnosis of cerebral palsy and a PEG tube. The plan of care was missing physician orders for PEG tube maintenance, including water flushes and ostomy skin integrity treatment and assessments. The admission nursing note dated 10/12/2022 documented the "PEG tube in place from prior hospitalization but is no longer used" and a plan of care problem statement for the "need for skilled teaching related to the care of gastrostomy-hospice and altered." Additionally, there was a medication order dated 2/28/2023 for lorazepam 2mg/mL, 1mL via g-tube every four (4) hours as needed for seizures or agitation; All other medications were written with the oral route of medication administration. The plan of care update order dated 2/3/2023 documented "hospice to provide instructions for performing gastrostomy feedings to include care of equipment and preparation of feedings." The plan of care update order dated 2/3/2023 documented "hospice to provide instructions for performing gastrostomy feedings to include care of equipment and preparation of feedings," however, the patient was not receiving tube feedings and was able to swallow and eat meals per the nursing assessments. An interview with the Director of Nursing during the joint record review on 4/6/2023 confirmed the physician orders were missing for the PEG tube care. The care plan problems and interventions were inaccurate since the patient ate by mouth.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 3 of 4 (75%) clinical records reviewed where patients received hospice services at skilled nursing facilities, the agency did not adhere to their policy by not documenting a coordinated plan of care for the hospice and facility. The agency's standard operating procedure number 7.43 was revised on 1/25/2023 and titled Long-term care (LTC) partnership binders, stated in part...Hospice has specific regulations (418.112...) related to providing coordination of care with an LTC facility. The hospice has developed a Long-term Care Partnership Binder to meet the requirement that the local agency assembles. The clinical care coordinator ensures each hospice patient in a long-term care community receives our binder and ensures the appropriate documents are maintained and added as needed while on service with our Hospice agency. The agency form titled Coordinated Plan of Care Hospice/LTC Facility is one of the forms included in the agency's LTC binder process and documents the patient's needs. In addition, it specified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. The form documents the hospice team planned visits and frequencies, the medical supplies, and treatment for incontinence, ostomy, trach, Foley/urinary catheter, and wounds. It also includes the DME provided by the hospice, with dated signatures from both the hospice agency and LTC staff. Clinical Record 19: The patient with an election of hospice benefits dated 8/9/2022 received hospice services at a skilled nursing facility and received daily wound care treatment. There was no evidence that the Coordinated Plan of Care Hospice/LTC Facility form was completed per the agency process, and it was missing from the clinical record. The wound care order was to be performed daily but was not delineated when the hospice skilled nurse or the facility nurse was to complete the wound care. The hospice skilled nursing frequency was twice weekly. The Registered Nurse was interviewed during the home visit (Home Visit 3) on 4/4/2023, and she stated she completed the wound care twice weekly on her visits, and the facility staff knew not to do it on those days. Home Visit 3: During the home visit on 4/4/2023 with the Registered Nurse with a patient (Record 19) that resided at a skilled nursing visit, the long-term care partnership binder (LTC) was provided and reviewed. However, the binder was missing the LTC Coordinated Plan of Care, which identified the care and services needed and specified which provider was responsible for performing the functions agreed upon and included in the care plan. The Clinical Supervisor was present at the home visit and confirmed the LTC Coordinated Plan of Care was missing from the binder. The Registered Nurse and the Clinical Supervisor confirmed the written care plan did not specify when and which provider was responsible for performing the wound care functions that were agreed upon. Clinical Record 5: The patient with an election of hospice benefits dated 2/4/2022 received hospice services at a skilled nursing facility and had a primary diagnosis of respiratory failure. There was no evidence that the Coordinated Plan of Care Hospice/LTC Facility form was completed per the agency process, and it was missing from the clinical record. Clinical Record 13: The patient with an election of hospice benefits dated 10/12/2022 received hospice services at a skilled nursing facility and was receiving daily wound care treatment. There was no evidence that the Coordinated Plan of Care Hospice/LTC Facility form was completed per the agency process and was missing from the clinical record. The physician order dated 1/13/2023 documented the hospice "skilled nurse to perform wound care to coccyx area stage 2 pressure ulcer. Cleanse with wound cleanser apply SSD cream topically to the wound bed. Cover with foam dressing using a clean, aseptic technique—wound care will be performed daily and PRN until healed. SN may educate/teach wound care to the caregiver. Caregiver to provide wound care in the absence of SN. SN to measure wound weekly and pictures PRN." The Director of Nursing confirmed during the joint record review on 4/6/2023 that the Coordinated Plan of Care form was missing.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident the most recent hospice plan of care, hospice election form and any advance directives. Physician certification and recertification of the terminal illness, names and contact information for hospice staff involved in the patient’s care, and instructions on how to access the hospice’s 24-hour on-call system. hospice medication information. and hospice physician and attending physician (if any) orders. This standard was not met as evidenced by document review, interview, and observation. In 1 of 2 (50%) home visits observed where the patients resided in skilled nursing facilities. the agency's facility binder was missing the required documents. The agency's standard operating procedure number 7.43 was revised on 1/25/2023 and titled Long-term care (LTC) partnership binders, stated in part...Hospice has specific regulations (418.112...) related to providing coordination of care with an LTC facility. The hospice has developed a Long-term Care Partnership Binder to meet the requirement that the local agency assembles. The clinical care coordinator ensures each hospice patient in a long-term care community receives our binder and ensures the appropriate documents are maintained and added as needed while on service with our Hospice agency. The binder will include a table of contents and the following (1) agency contact page and LTC Call Us First flyer; (2) under Tab 1: LTC Facility Documentation Audit Tool, LTC Billing Notification, and LTC Coordinated Plan of Care; (3) Tab 2: State-Specific Advanced Directives/OOH/DNR; (4) Tab 3: Hospice Plan of Care; (5) Tab 4: IDG Notes; (6) Tab 5 Hospice Certifications of Terminal Illness (CTI) and Physician Orders: (7) Tab 6: Medication Profile/Review: (8) Tab 7: Election of Hospice Medicare/Medicaid Benefit; (9) Tab 8: Hospice Informed Consent; (10) Tab 9: Medicaid Election Form. Home Visit 3: During the home visit on 4/4/2023 with the registered nurse with a patient (Record 19) that resided at a skilled nursing visit, the long-term care partnership binder (LTC) was provided and reviewed. However, the binder was missing the LTC Coordinated Plan of Care. The current hospice plan of care was missing, but the plan of care for the previous benefit period of 8/9/2022 through 11/6/2022 was present. The IDG meeting dated 8/16/2022 was present, but no recent IDG meetings were found. There were no hospice certifications of terminal illness (CTI) documents. However, the Election of Hospice Medicare form and the signed DNR were present. The Clinical Supervisor was a witness during the home visit and the binder review and confirmed missing items.