Every finding on record at Care Initiatives

Based on clinical record review, hospice policy review, patient/family interivew and staff interview, the hospice failed to ensure the completion of a drug regimen review which included all the required components with the comprehensive assessment within the first 5 days after election of the hospice benefit and at least every 15 days with the update to the comprehensive assessment for 6 of 17 sampled patients (Patients #5, #8, #11, #12, #13 and #16). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs completed all components of the drug regimen review (DRR) with each update to the comprehensive assessment increased the risk of unidentified side effects and actual interactions of medications. --- Review of the hospice policy, titled Drug Regimen Review (DRR), Initial and Ongoing, last revised 2/1/23, revealed upon admission a nurse documents all medications in the patient's Electronic Health Record (EHR) medication profile. Within 5 days, the Registered Nurse (RN) Case Manager consults the pharmacist to review the medication profile. The pharmacist documents the consult. Or within 5 days, the RN Case Manager will review the medication profile. The review of the patient's current medications includes: therapeutic effectiveness, therapeutic duplication, appropriate dose, frequency and route of administration, adherence to drug regimen, potential drug/food/diagnostic test interactions/disease limits, lab or clinical monitoring methods to detect drug effectiveness, side effects, toxicity or adverse effects, storage specifics/availability/tracking issues, quality versus cost effectiveness and appropriate alternatives. The comprehensive assessment findings which included the consult/review findings are presented to create the individualized care plan during the first comprehensive care interdisciplinary group meeting (IDG). The RN is responsible to review the patient medications with medication changes, changes in patient condition, or at a minimum of every 14 days. On 9/14/23 at 9:40 AM, during an interview, the Interim Administrator/Clinical Manager reported a contracted pharmacist completed a DRR on new admissions. The RN Case Manager reviews the pharmacist's recommendations with the IDG and completes ongoing DRRs with every visit and with the team at the IDG meetings. 1.Patient #5 had a hospice admission date of 8/10/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 8/10/23 to 10/8/23, included IDG orders for skilled nursing services and physician orders for medications. The POC included the following orders for medications with duplicate therapeutic properties: Zyprexa and Seroquel (both antipsychotic medications and used to treat agitation/aggressive behavior); Tramadol and Acetaminophen (both used to treat pain); and, Norvasc and Hydrochlorothiazide (both used to treat high blood pressure). The POC also included a physician order for Levothyroxine (medication associated with laboratory testing related to thyroid functioning levels), Hydrochlorothiazide (medication associated with serum electrolyte levels) and Plavix (medication associated with blood cell counts). The POC included a physician order for complete blood count and comprehensive metabolic panel every 6 months for medication management. b. The comprehensive assessment completed at the start of care by the RN, dated 8/10/23, included documentation the RN completed a DRR. The nurse documented that she did not identify any concerns. The DRR failed to include documentation the RN identified the patient took medications with duplicative therapeutic properties and failed to identify the patient took any medications associated with laboratory monitoring. c. The IDG meeting, dated 8/16/23, included documentation of a DRR completed by the nurse on 8/11/23 which identified no new meds, interactions, symptoms, or labs to monitor. A DRR completed by the RN and Medical Director during the IDG meeting identified they would continue to monitor for drug side effects, labs and interactions. The DRR failed to identify any medications specifically associated with laboratory testing and failed to identify any duplicative medication therapies. On 9/20/23 at 2:26 PM, during an interview, the Quality Assurance Performance Improvement (QAPI) Coordinator agreed hospice IDG members failed to identify duplicate drug therapies taken by the patient and any medication associated with laboratory monitoring. The QAPI Coordinator confirmed this true for the rest of patients with identified DRR concerns. 2. Patient #8 had a hospice admission date of 12/5/22 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 12/5/23 to 3/4/23, included IDG orders for skilled nursing services and physician orders for medications. The POC included the following orders for medications with duplicate therapeutic properties: Milk of Magnesia, Polyethylene Glycol, Bisacodyl and Senna (used to treat/prevent constipation). The POC also included a physician order for Synthroid, a medication associated with laboratory testing related to thyroid functioning levels and Depakote (an anti-seizure and mood altering medication) associated with laboratory monitoring of blood serum levels of Depakote to determine therapeutic effectiveness. b. The comprehensive assessment completed at the start of care by the RN, dated 12/5/22, included documentation the RN completed a DRR. The nurse documented that she did not identify any concerns. The DRR failed to include documentation the RN identified the patient took medications with duplicative therapeutic properties and failed to identify the patient took any medications associated with laboratory monitoring. c. The IDG meeting, dated 12/7/23, included the following documentation: initial drug regimen reviewed with pharmacist. Regimen currently effective. Will monitor for ASE (adverse side effects), labs, and interactions. The DRR failed to identify any medications specifically associated with laboratory testing and failed to identify any duplicative medication therapies. 3. Patient #11 had a hospice admission date of 9/4/23, received routine home care hospice services while residing in a nursing home and died on 9/10/23. Review of the clinical record revealed the following: a. The POC, dated 9/4/23 to 12/2/23, included IDG orders for skilled nursing services and physician orders for medications. The POC included the following orders for medications with duplicate therapeutic properties and associated with laboratory monitoring: Tresiba and Glipizide (medications used to treat high blood sugar levels and associated with lab testing for blood sugar levels). The patient also had a physician order for Depakote. The POC included physician orders for blood sugar level testing twice per day and as needed. b. The comprehensive assessment completed at the start of care by the RN, dated 9/4/23, included documentation the RN completed a DRR. The nurse documented that she did not identify any concerns. The DRR failed to include documentation the RN identified the patient took medications with duplicative therapeutic properties and failed to identify the patient took any medications associated with laboratory monitoring. c. The IDG meeting, dated 9/13/23 (completed after the death of the patient), included documentation of a DRR completed by the pharmacist on 9/7/23, which identified potential drug interactions between Ritonavir and Tamsulosin and Ritonavir and Seroquel. The DRR failed to identify any medications specifically associated with laboratory testing and failed to identify any duplicative medication therapies. 4. Patient #12 had a hospice admission date of 9/5/23, received routine home care hospice services while residing in a private residence and died on 9/12/23. Review of the clinical record revealed the following: a. The POC, dated 9/5/23 to 12/3/23, included IDG orders for skilled nursing services and physician orders for medications. The POC included the following orders for medications with duplicate therapeutic properties: Hydrocodone-Acetaminophen, MS Contin and Tramadol (medications used to treat pain). The POC included a physician order for Lorazepam (a medication used to treat anxiety/restlessness). b. The comprehensive assessment completed at the start of care by the RN, dated 9/5/23, included documentation the RN completed a DRR. The nurse documented that she did not identify any concerns. The DRR failed to include documentation the RN identified the patient took medications with duplicative therapeutic properties and failed to identify the potential for major drug interactions between Lorazepam and MS Contin (Morphine), Lorazepam and Tramadol and Lorazepam and Hydrocodone-Acetaminophen which can increase the risk of sedation and the suppression of respirations. c. The IDG meeting, dated 9/13/23 (completed after the death of the patient), included documentation of a DRR completed by the pharmacist on 9/7/23, which failed to identify the patient took any medications with duplicative therapies or had the potential for interactions between any of the medications. 5. Patient #13 had a hospice admission date of 8/29/23, received routine home care hospice services while residing in a nursing home and died on 9/14/23. Review of the clinical record revealed the following: a. The POC, dated 8/29/23 to 11/26/23, included IDG orders for skilled nursing services and physician orders for medications. The POC included the following orders for medications: Lorazepam oral concentrate, orders for 3 different doses (0.25 milliliters (ml), 0.5 ml and 1 ml) all directed to be given every 2 hours as needed for restlessness, anxiety, nausea; and, Morphine Sulfate concentrate, orders for 2 different doses (0.25 ml and 0.5 ml) by mouth every hour as needed for pain. b. The comprehensive assessment completed at the start of care by the RN, dated 8/29/23, included documentation the RN completed a DRR. The nurse documented that she did not identify any concerns. The DRR failed to include documentation the RN identified the patient took medications with the potential for major drug interaction between Lorazepam and Morphine. c. The IDG meeting, dated 9/6/23, included documentation of a DRR completed by the RN on 9/5/23, the pharmacist on 9/3/23 and the IDG members on 9/6/23. The DRRs failed to identify the potential for drug interaction between Lorazepam and Morphine. 6. Patient #16 had a hospice admission date of 4/20/23, received routine home care hospice services while residing in a nursing home and transferred services to another hospice on 5/15/23. Review of the clinical record revealed the following: a. The POC, dated 2/7/23 to 5/7/23 (patient transferred to the hospice from another hospice on 4/20/23 during this certification period), included IDG orders for skilled nursing services and physician orders for medications. The POC included the following orders for medications with duplicate therapeutic properties: Albuterol Sulfate inhaler, Ipratropium-Albuterol Inhalation solution and Symbicort inhaler (to treat difficulty breathing); Trazadone, Sertraline and Duloxetine (anti-depressant medications); Bisacodyl and Milk of Magnesia (to treat constipation); Ativan and Hydroxyzine (to treat anxiety); and, Amlodipine Besylate and Prazosin (to treat high blood pressure). The POC also included a physician order for Tradjenta, a medication used to treat high blood sugar levels and associated with laboratory monitoring of blood sugar levels. b. The comprehensive assessment completed at the start of care by the RN, dated 4/20/23, included documentation the RN completed a DRR. The nurse documented that she did not identify any concerns. The DRR failed to include documentation the RN identified the patient took medications with duplicative therapeutic properties and failed to identify the patient took any medications associated with laboratory monitoring. c. The IDG meeting, dated 4/26/23, included documentation of a DRR which identified the patient took duplicate therapies to treat breathing difficulties, but failed to identify the patient took any medications associated with laboratory monitoring. The Interim Administrator/Clinical Manager and QAPI Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, home visit observation, hospice policy review, patient, family and hospice staff interview, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or a complete order for all medications and treatments to meet the needs of the patient for 5 of 19 sampled patients (Patients #1, #2, #15, #16 and #19). Failure to ensure the plan of care included complete and accurate physician orders for all necessary medications and treatments placed patients at risk to receive inappropriate treatment of symptoms. --- Review of the hospice's policy, titled Plan of Care (POC), dated 2/1/23, identified the Interdisciplinary Group (IDG) gathers the information from the initial and comprehensive assessment to develop the POC. Review of the hospice's policy, titled Interdisciplinary Team Meetings, dated 7/28/21, identified the IDG reviews and updates each patient's Plan of Care (POC) at least every 15 days, or more frequently, if needed. 1. Patient #1 had a hospice admission date of 11/23/22 and received routine home care hospice services while residing in a private home. Review of the clinical record revealed the following: The POC, dated 7/21/23 to 9/18/23, included IDG orders for skilled nursing services and physician orders for medications. On 9/11/23 at 12:55 PM, during a home visit observation, Staff C, Registered Nurse (RN), completed an assessment of the patient. The surveyor observed an open bottle of Visine eye drops on a shelf behind the patient's chair. In an interview, during the same home visit observation, the patients caregiver/spouse and patient reported the patient had been using Visine Original, 1 drop each eye as needed for several years for eye irritation/redness. The POC, dated 7/21/23 to 9/18/23, failed to include an order for Visine eye drops. On 9/20/23 at 2:26 PM, during an interview, the Quality Assurance Performance Improvement (QAPI) Coordinator confirmed the patient did not have an order for Visine on the POC. 1. Patient #2 had a hospice admission date of 2/22/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POCs, dated 2/22/23 to 5/22/23, 5/23/23 to 8/20/23 and 8/21/23 to 10/19/23, including the following physician order for oxygen: "PRN (as needed) Oxygen if O2 (blood oxygen) saturation drop(s) below 90%." The order failed to specify a liter per minute amount and a route for the delivery of use (such as a mask or nasal cannula). b. The IDG meetings notes, dated 7/26/23 and 8/9/23, identified the patient used oxygen continuously at 2 liters per minute via nasal cannula. The IDG meeting, dated 8/9/23, included an intervention for the hospice aide to encourage the patient to leave the oxygen cannula on. c. The POC, dated 8/21/23 to 10/19/23, included IDG direction to the hospice aide to encourage the patient to leave the oxygen cannula on. On 9/13/23 at 1:35 PM, during a home visit observation, Staff D, RN, completed an assessment of the patient. The patient was reclining in the lift chair in the patients room with oxygen on at 2 liters per minute via nasal cannula. During the home visit, Staff D, RN, discussed with the patient that the patient had been using oxygen during the night and as needed during the day until a month ago, and since then has used oxygen continuously. On 9/20/23 at 2:26 PM, during an interview, the QAPI Coordinator confirmed the patient's oxygen order was incomplete and did not match the patients use of oxygen. The POC orders failed to accurately reflect the patient's use of oxygen and failed to include a complete order for the use of oxygen. 2. Patient #15 had a hospice admission date of 8/9/23, received routine home care hospice services while residing in a private home and revoked the hospice benefit on 8/17/23. Review of the clinical record revealed the following: a. The POC, dated 8/9/23 to 11/6/23, identified the patient used an oxygen concentrator. The POC, lacked a physician order for the use of oxygen. b. The skilled nursing visit, dated 8/10/23, included documentation the patient used oxygen at a rate of 2 liters per minute via nasal cannula intermittently. On 9/20/23 at 2:26 PM, during an interview, the QAPI Coordinator confirmed the patient's POC lacked a physician order for the use of oxygen. 3. Patient #16 had a hospice admission date of 4/20/23, received routine home care hospice services while residing in a nursing home and transferred services to another hospice on 5/15/23. Review of the clinical record revealed the following: a. The POC, dated 2/7/23 to 5/7/23 (patient transferred to the hospice from another hospice on 4/20/23 during this certification period), identified the patient used an oxygen concentrator. The POC, lacked a physician order for the use of oxygen. The POC identified the patient used a urinary catheter and included a physician order to change the catheter every 30 days. The POC failed to specify the size of the catheter and the bulb (balloon-like device inserted into the bladder and filled with fluid to hold the catheter in place) inflation amount. b. The comprehensive assessment completed at the start of care by the RN, dated 4/20/23, identified the patient was using oxygen at a rate of 2 liters per minute via nasal cannula and identified the patient had a size 20 French Foley urinary catheter with a 10 cubic centimeter balloon. c. The skilled nursing visits, dated 4/21, 5/1 and 5/4/23, included documentation that the patient was using 3 liters of oxygen per minute continuously via nasal cannula. On 9/20/23 at 2:26 PM, during an interview, the QAPI Coordinator confirmed the patient's POC lacked a physician order that reflected the oxygen flow rate and route used by the patient. 4. Patient #19 had a hospice admission date of 5/5/23, received hospice services while residing in a private residence and died on 5/14/23. Review of the clinical record revealed the following: a. The POC, dated 5/5/23 to 8/2/23, identified the patient used an oxygen concentrator. The POC, lacked a physician order for the use of oxygen. b. The comprehensive assessment completed at the start of care by the RN, dated 5/5/23, identified the patient was using oxygen at a rate of 2 liters per minute via nasal cannula continuously. c. The skilled nursing visits, dated 5/7/23, 5/8/23, 5/12/23, 5/13/23 and 5/14/23, included documentation the patient used oxygen at a rate of 5 liters per minute via nasal cannula continuously. On 9/20/23 at 2:26 PM, during an interview, the QAPI Coordinator confirmed the patient's POC lacked a physician order for the use of oxygen. 5. Patient #1 had a hospice admission date of 11/23/22 and received routine home care hospice services while residing in a private home. Review of the clinical record revealed the following: The POC, dated 7/21/23 to 9/18/23, included IDG orders for skilled nursing services and physician orders for medications. On 9/11/23 at 12:55 PM, during a home visit observation, Staff C, Registered Nurse (RN), completed an assessment of the patient. The surveyor observed an open bottle of Visine eye drops on a shelf behind the patient's chair. In an interview, during the same home visit observation, the patients caregiver/spouse and patient reported the patient had been using Visine Original, 1 drop each eye as needed for several years for eye irritation/redness. The POC, dated 7/21/23 to 9/18/23, failed to include an order for Visine eye drops. On 9/20/23 at 2:26 PM, during an interview, the Quality Assurance Performance Improvement (QAPI) Coordinator confirmed the patient did not have an order for Visine on the POC. The Interim Administrator/Clinical Manager and QAPI Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey.