Every finding on record at Capital Hospice & Palliative Care 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, observation, document review and interview. In 4 of 4 (100%) home visits conducted where medication reconciliations were completed it was revealed that the agency medication profiles were not updated accurately compared to the patient's current regimen. Document 11: Policy# 2-004, titled Medication Profile (revised November 2020) sub-section one (1), stated in part, "Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current regimen. "Sub-section two (2) stated in part, "A drug regimen review will be performed at the time of the initial and comprehensive assessment when updates to the comprehensive assessments are performed and with the addition of a new medication." Home Visit 1: A home visit was conducted on 8/22/2023 for a patient with a hospice benefit election date of 11/4/2021 (record 1). A medication reconciliation was performed, comparing the hospice agency medication profile to the medication profile in the Skilled Nursing Facility (SNF). The hospice agency mediation profile dated 8/22/2023 stated in part, "Acetaminophen 325 mg tablet. Take one (1) tablet twice daily, as needed (PRN) for pain." The SNF medication profile stated in part, "Acetaminophen 325 mg tablet. Take two (2) tablets twice daily, as needed (PRN) for pain. The hospice medication profile stated in part, "Simvastatin 10 mg. take one (1) tablet at bedtime." The SNF medication profile did not contain the medication Simvastatin. The Clinical Director confirmed that the hospice agency medication profile did not match the medication profile at the Skilled Nursing Facility. Home Visit 2: A home visit was conducted on 8/22/2023 for a patient with a hospice benefit election date of 8/23/2021 at a Skilled Nursing Facility (SNF). A medication reconciliation was performed comparing the hospice agency medication profile to the Skilled Nursing Facility (SNF) profile. The hospice agency medication profile dated 8/22/2023 stated in part, "Oxybutin Chloride ER 10 mg. take one (1) tablet daily." The SNF medication profile stated in part, "Oxybutin Chloride ER 10 mg. take two (2) tablets daily. The hospice agency medication profile stated in part, "Scopolamine 2.5 mg patch. Apply one (1) patch every six (6) hours as needed (PRN) for nausea." The SNF medication profile did not contain the medication Scopolamine. The hospice agency medication profile stated in part, "Acetaminophen 650 mg rectal suppository. Insert one (1) suppository every six (6) hours as needed (PRN) for pain/fever. The SNF medication profile stated in part, Acetaminophen 650 mg rectal suppository. Insert one (1) suppository every four (4) hours as needed (PRN) for pain/fever. The Clinical Director confirmed that the hospice agency medication profile did not match the medication profile at the Skilled Nursing Facility. Home Visit 3: A home visit was conducted on 8/22/2023 for a patient with a hospice benefit election date of 2/1/2023 at a Skilled Nursing Facility (SNF). The hospice medication profile dated 8/22/2023 stated in part, "Prochlorperazine 10 mg. take one (1) tablet every four (4) hours as needed (PRN) for nausea. The SNF medication profile stated in part, "Prochlorperazine 10 mg. take one (1) tablet every six (6) hours as needed (PRN) for nausea. The hospice agency medication profile stated in part, "Coumadin 2.5 mg. take one (1) tablet daily. The SNF medication profile stated in part Coumadin 2 mg. take one (1) tablet daily. The Clinical Director confirmed that the hospice agency medication profile did not match the medication profile at the Skilled Nursing Facility. Home Visit 4: A home visit was conducted on 8/22/2023 for a patient with a hospice benefit election date of 3/6/2021 at a private residence. The hospice agency medication profile stated in part, "Senna 8.6 mg. Take two (2) tablets every night at bedtime. The medication bottle provided by the hospice pharmacy stated, "Senna 8.6 mg. Take one (1) tablet every night at bedtime. The patient confirmed they take Senna 8.6 mg one (1) tablet every night at bedtime. The hospice agency medication profile stated in part, "Potassium Chloride 20 mEq. Take one (1) tablet daily. The patient was taking Potassium OTC 99 mg. take one (1) tablet daily. The patient confirmed taking the medication Certrizine10 mg. one (1) tablet daily. The hospice agency medication profile did not contain the drug Certrizine. The Clinical Director confirmed that the hospice agency medication profile did not match the patient's medication regimen.

It is required that each patient’s individualized written plan of care include 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. In 1 of 19 (5%) records reviewed it was revealed that the agency did not ensure all treatments necessary to meet the patient's needs were included in the plan of care. Document 4: Policy# 9-017, titled The Plan of Care (revised November 2020) sub-section for (4) stated in part, "The plan of care will identify the patient's needs and services to meet those needs". Subsection twelve (12) stated in part, "The written plan of care will contain, but will not be limited to the following (R) pain and symptom management, and (S) Drugs and treatments." Clinical Record 8: A home hospice patient with a hospice benefit election date of 6/15/2023 had an RN assessment on 6/29/2023, 7/3/2023, 7/6/2023, 7/10/2023, 7/13/2023, and 8/3/2023 that identified a wound. The narrative statement on each visit stated in part, "Laceration to right leg cleaned and redressed." The plan of care dated 6/15/2023-9/12/2023 did not contain any wound care identification, or instructions for care and treatment. The SN visit note skin section had available documentation areas labeled for wound #1 and wound #2 to document location, length, width, diameter, and wound bed description. All skin section documentation sections were blank for all the RN visit notes dated 6/29/2023, 7/3/2023, 7/6/2023, 7/10/2023, 7/13/2023, and 8/3/2023. A joint record review and interview with the Director of Nursing on 8/23/2023 confirmed the plan of care did not contain any reference to the wound. The Director of Clinical Services called the patient's assigned hospice aide on 8/23/2023 in the presence of the surveyor and asked the hospice aide if the patient had a wound to the right leg. The hospice aide confirmed the patient did have an active wound to the right leg.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 13 (31%) records reviewed where hospice aide services were provided, it was revealed that the agency did not ensure that the hospice aide reported all changes in patient needs as related to the plan of care, to a Registered Nurse (RN). Document 4: Policy# 9-017, titled The Plan of Care (revised November 2020) policy sub-section, stated in part, "The care provided to the patient must be in accordance with the plan of care," Sub-section ten (10) stated in part," Any changes in the patient's condition must result in a change to the plan of care prior to implementation." Clinical Record 1: A patient with a hospice benefit election date of 11/4/2021 who accepted hospice aide services had a care plan dated 7/12/2023-7/25/2023. The following interventions were ordered every visit, "ambulation with a walker, mouth care, and shave." The hospice aide visit completed on 7/17/2023 documented that "mouth care was refused, and shave was not performed because caregiver completed prior to visit." The hospice aide note documented that it was not completed. The record did not contain any evidence that the hospice aide updated the RN of the tasks that were not completed. Clinical Record 8: A patient with a hospice benefit election date of 6/15/2023 who accepted hospice aide services had an aide care plan dated 6/15/2023-9/12/2023. Every visit, the following interventions were ordered: "mouth care, nail care, make the bed, and change linens." The hospice aid visit completed 7/31/2023 documented that "mouth care, nail care, make the bed, and change linens" was not performed. The record did not contain evidence that the hospice aide updated the RN about the tasks that were not performed. Clinical Record 9: A patient with a hospice benefit election date of 5/16/2022 who accepted hospice aide services had a care plan dated 6/5/2023-8/3/2023 in which the following hospice aide tasks were ordered every visit, " mouth care, meal setup, change bed linens, and make the bed." The hospice aide documented on the visits dated 6/12/2023 and 6/17/2023 that "mouth care, meal setup, change bed linens, and make the bed as needed (PRN) were not completed because the patient refused. The record did not contain any documentation that the hospice aide reported the tasks not completed to the RN. Clinical Record 13: A patient with a hospice benefit election date of 3/30/2023 had a hospice aide care plan dated 6/28/2023-8/26/2023 ordering two (2) types of bath that stated, "shower every visit and complete bed bath every visit." The hospice aide completed a visit on 6/30/2023 in which the aide charted shower not completed. The record did not contain any evidence the RN was notified of the bed bath not being completed. A joint record review and interview with the Clinical Director on 8/23/2023 confirmed the hospice aide did not notify the RN of interventions that were not completed.

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: Physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) records reviewed it was revealed that the agency did not ensure the clinical record contained physician orders for all treatments and services provided. Document 4: Policy# 9-017, titled The Plan of Care (revised November 2020) sub-section for (4) stated in part, "The plan of care will identify the patient's needs and services to meet those needs". Subsection twelve (12) stated in part, "The written plan of care will contain, but will not be limited to the following (R) pain and symptom management, and (S) Drugs and treatments." Clinical Record 8: A home hospice patient with a hospice benefit election date of 6/15/2023 had an RN assessment on 6/29/2023, 7/3/2023, 7/6/2023, 7/10/2023, 7/13/2023, and 8/3/2023 that identified a wound. The narrative statement on each visit stated in part, "Laceration to right leg cleaned and redressed." The plan of care dated 6/15/2023-9/12/2023 did not contain any wound care identification, instructions, or orders for care and assessment frequency. A joint record review and interview with the Director of Nursing on 8/23/2023 confirmed the plan of care did not contain any reference to the wound and did not have any physician's orders for the cleansing or dressing the wound.

It is required that the Interdisciplinary Group determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. The plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) records reviewed it was revealed that the hospice agency did not determine if the patient and/or family could safely administer medications. Document 4: Policy# 9-017, titled The Plan of Care (revised November 2020) sub-section twelve (12), stated in part, " The written plan of care will contain, but will not be limited to the following" (Patient and family/caregiver educational needs and assessment of their ability to learn and understand teaching and their ability to safely self-administer drugs and biologics." Clinical Record 12: A patient with a hospice benefit election date of 4//21/2023 had an initial RN assessment completed on 4/21/2023 that listed a history of opiate overdose as a past medical diagnosis. The plan of care dated 4/21/2023-7/19/2023 did not identify if the patient was able to administer medications safely. The Interdisciplinary Team (IDT) updated the plan of care dated 4/26/2023 and 5/10/2023 and did not identify if the patient could safely administer medications. The IDT updated the Plan of Care on 5/24/2023 identified patient/caregiver could safely administer drugs and biologicals. A joint record review and interview with the Director of Clinical Services confirmed that the hospice agency did not identify if a patient could safely administer medication for over one month. The Director of Clinical Services also confirmed the Medical Director and agency were aware of the patient history of opiate overdose, and this was referenced in the Certification of Terminal Illness (CTI).

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 and interview. In 1 of 8 (12%) records reviewed where hospice care was provided in a facility, it was revealed that the agency did not ensure the written plan of care specified the services provided by the hospice and services to be provided by the facility. Document 12: Policy #1-006, titled Care/Service Coordination (revised 2020) sub-section policy, stated in part, "It will be the responsibility of the Case Manager to facilitate communication about changes in the patient status among assigned personnel. Sub-section four (4) stated in part, "Care coordination will include, but not be limited to, (A) Clearly outlining each clinician's responsibilities to avoid duplication of services, (F) Appropriate involvement of the patient and caregivers, (I) Integration of services, whether services are provided directly or under arrangement, (J) Coordination of care delivery to meet the patient's needs and involve the patient representative, as appropriate in the coordination of care activities. Clinical Record 12: A patient with a hospice benefit election date of 4/21/2023 who resided in a Skilled Nursing Facility (SNF). had a Certification of Terminal Illness (CT)I signed and dated 4/22/2023 that stated in part, "Sactral Pressure wound." The initial RN assessment was completed on 4/21/2023 sub-section integumentary stated in part, "Stage two (2) wound to sacrum. Cleansed with NSS and covered with foam dressing." The Plan of Care did not identify who would be managing the wound, the SNF or the hospice agency. The updated Interdisciplinary Team (IDT) plans of care on 4/26/2023 and 5/10/2023 did not record any coordination of wound management. The integumentary system sub-sections for IDT care plans dated 4/26/2023 and 5/10/2023 were blank. A joint interview and record review with the Director of Clinical Services confirmed the hospice agency did not coordinate care with the Skilled Nursing Facility (SNF) concerning managing the sacral pressure wound. The Clinical Director reported the standard workflow for the hospice agency would be to have the SNF manage the pressure wound on a daily and as-needed basis.