Every finding on record at Careline Hmi200 LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed, the agency did not ensure the individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 3: The patient elected hospice services on 04/05/2024 with a terminal illness of unspecified malignant neoplasm of the esophagus. The initial nursing assessment dated 04/05/2024 included documentation that the patient had dysphagia, required precautions to avoid aspiration, and was a high fall risk. The written plan of care dated 04/05/2024 did not reflect patient and family goals and planned interventions associated with the patient’s aspiration and fall risks identified in the comprehensive assessment. Clinical Record 5: The patient elected hospice services on 10/03/2023 with a terminal illness of hypertensive heart and chronic kidney disease with heart failure and unspecified stage 1-4 chronic kidney disease. The initial nursing assessment dated 10/03/2023 included documentation that the patient had abdominal tenderness, abdominal distention, constipation, and was a high fall risk. The written plan of care dated 10/03/2023 did not reflect patient and family goals and planned interventions associated with the patient’s constipation and fall risk identified in the comprehensive assessment. Clinical Record 6: The patient elected hospice services on 06/01/2024 with a terminal illness of unspecified severe protein-calorie malnutrition. The initial nursing assessment dated 06/01/2024 included documentation that the patient had dysphagia, required precautions to avoid aspiration, and would not be started on a bowel protocol due to frequent loose stools. The written plan of care dated 06/01/2024 did not reflect patient and family goals and planned interventions associated with the patient’s aspiration risk and diarrhea identified in the comprehensive assessment. Clinical Record 12: The patient elected hospice services on 01/11/2024 with a terminal illness of Huntington’s disease. The initial nursing assessment dated 01/11/2024 included documentation that the patient had dysphagia leading to recurrent aspiration and a Percutaneous Endoscopic Gastrostomy (PEG) tube in place which was flushed twice a day by the assisted living facility staff. The written plan of care dated 01/11/2024 and updated 07/09/2024 did not reflect patient and family goals and planned interventions associated with the patient’s aspiration risk identified in the comprehensive assessment. Clinical Record 14: The patient elected hospice services on 10/04/2023 with a terminal illness of unspecified Alzheimer’s disease. The initial nursing assessment dated 10/04/2023 included documentation that the patient had a history of seizures, was incontinent of bowel and bladder, and was at a high risk for falls. The written plan of care dated 10/04/203 and updated on 01/01/2024 did not reflect patient and family goals and planned interventions associated with the patient’s fall risk identified in the comprehensive assessment. During joint clinical record reviews and interviews on 08/23/2023, the Administrator, Regional Clinical Director, and Vice President of Hospice confirmed, for the clinical records identified, the individualized plans of care did not reflect patient and family goals, and planned interventions associated with problems, including aspiration and fall risks, diarrhea, and constipation, identified during the initial comprehensive assessment.

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 an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse prepared specific written patient care instructions for the aide to follow. Clinical Record 7: The patient elected the hospice benefit on 02/16/2024 with a terminal illness of secondary malignant neoplasm of the bone. The initial nursing assessment dated 02/16/2024 included documentation that the patient had contractures of the right upper and lower extremities and paralysis of the left upper extremity. The hospice aide care plan dated 02/16/2024 and updated on 02/19/2024 did not alert the aide to the patient’s contractures and paralysis. Clinical Record 10: The patient elected the hospice benefit on 04/18/2024 with a terminal illness of Atherosclerotic heart disease of the native coronary artery with unspecified angina. The initial nursing assessment dated 04/18/2024 included documentation that the patient was at a high fall risk and required two persons to assist with stand-pivot transfers. The plan of care dated 04/18/2024 included orders for two-person assistance with transfers. The hospice aide care plan dated 04/18/2024 included instructions for the aide to place the patient on the bedside commode for showering using one-person assistance. The plan did not alert the aide to the required two persons for stand-pivot transfers. During joint clinical record reviews and interviews on 08/22/2023, the Administrator, Regional Clinical Director, and Vice President of Hospice confirmed that the hospice aide care plans identified did not alert the aide to patient conditions that could affect the safety of the care provided.

It is required that volunteers be used in day-to-day administrative and direct patient care roles. Volunteer services provided to patients/families are in a defined role and supervised by a designated hospice employee. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed with volunteer services provided, the agency did not ensure volunteer services were noted in the plan of care. Clinical Record 6: The patient elected hospice services on 06/01/2024 with a terminal illness of unspecified severe protein-calorie malnutrition. The volunteer care plan dated 06/21/2024 included plans for volunteer services to be provided to the patient once per month for pet therapy companionship. The clinical record contained no evidence that the plan of care that was reviewed and updated no less frequently than every 15 days since 06/01/2024 noted the volunteer services provided. Clinical Record 12: The patient elected hospice services on 01/11/2024 with a terminal illness of Huntington’s disease. The volunteer care plan dated 02/21/2024 included plans for volunteer services to be provided to the patient once per month for pet therapy companionship. The clinical record contained no evidence that the plan of care that was reviewed and updated no less frequently than every 15 days since 01/11/2024 noted the volunteer services provided. Clinical Record 16: The patient elected hospice services on 09/14/2023 with a terminal illness of Hypertensive heart disease with heart failure. The patient revoked the hospice benefit on 06/09/2024 to seek aggressive treatment. The volunteer care plan dated 10/17/2023 included plans for volunteer services to be provided to the patient once a week for companionship and emotional support. The clinical record contained no evidence that the plan of care that was reviewed and updated no less frequently than every 15 days from 09/14/2023 through 06/09/2024 noted the volunteer services provided. During joint clinical record reviews and interviews on 08/23/2024, the Administrator, Regional Clinical Director, and Vice President of Hospice confirmed that the clinical records contained no evidence that the plans of care were updated to include the volunteer services provided.

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 review of clinical record, home visit observation, and interview which revealed that 2 of 4 (50%) applicable records in which a hospice aide was accepted were missing documentation of clear and specific written instruction on the hospice aide assignment, thus leaving the aide to make decisions regarding care to provide, which is outside of the aides' scope of practice. Record #91736 - The aide plan dated 09/08/2021 assigned the aide to provide a bed bath twice a week and partial bad bath as needed. The patient was admitted with a primary diagnosis of prostate cancer and presented with a rapid decline since their benefit election on 09/02/2021. Medications included increasing doses of morphine and increased daily visits from 09/09/2021 through their death on 09/14/2021. No decision maker was identified to determine the type if bath to provide since the patient was not able to make decisions as a result of their decline beginning 09/09/2021. Record #89304: The aide plan reviewed was dated 09/08/2021, with an update on 09/21/2021. The patient was admitted with co-morbidities, that included vascular dementia. During a home visit observation on 10/12/2021, from 1:00pm - 1:30pm with the social worker (Record #46762), the patient presented with garbled and unintelligible words and required direction for all tasks. Duties assigned on the aide plan included providing a complete bed bath if the patient was too drowsy for shower every visit, and a shower every visit. There was no decision maker identified to determine the type bath to provide from 09/08/2021 - 09/21/2021. Interview on 10/13/2021 with the Administrator and Clinical Supervisor stated that they missed those items in record review.

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 review of clinical record, hospice aide job description, observed visit and interview. In 2 of 4 (50%) applicable records in which aide services were accepted, the record did not include documentation of coordination with the registered nurse/case manager when the aide duties were not completed as assigned on the aide plan. The "Hospice Aide Job Description" (revised 2/17/2020) stated in part: "Documents services provided and pertinent findings during each visit. Seeks clarification of duties when indicated." Record #29435 - The aide plan assigned the aide to provide a shampoo every visit. Documentation on the aide visit note dated 09/16/2021 stated "No shampoo" with the reason of "patient preference". During the home visit observation on 10/12/2021 with the aide (Record #96933) the patient presented as agitated, with garbled language, and required redirection for all tasks. There was no evidence that the nurse was notified that the task was not completed as assigned. Record #89304 - The aide plan assigned the aide to provide a shampoo every visit. Documentation on the aide visit notes dated 9/10/2021, 9/17/2021, and 9/24/2021 stated that "No shampoo" with the reason of "patient preference". There was no evidence that the nurse was notified that the task was not completed as assigned. During interview on 10/13/2021 with the administrator and clinical supervisor, they stated the aide likely notified someone but it was not documented.