Every finding on record at Careline Hmi300 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 3 of 19 (16%) clinical records reviewed, it was revealed that 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 2: The patient, a skilled nursing facility resident, elected hospice services on 01/12/2024 with a terminal diagnosis of Parkinson’s disease without dyskinesia with fluctuations. The initial nursing assessment dated 01/12/2024 included documentation that the patient had dysphagia, required a pureed diet with thickened liquids, had a cough, and was at risk for aspiration. The written plan of care dated 01/12/2024 did not reflect patient and family goals and planned interventions associated with the patient’s dysphagia and aspiration risk identified in the comprehensive assessment. A nursing coordination note dated 01/17/2024 included documentation that the patient had tested positive for COVID-19. The clinical record contained no evidence that the plan of care was updated to reflect patient and family goals, planned interventions, and precautions associated with the patient’s diagnosis of COVID-19. Clinical Record 7: The patient, an assisted living facility resident, elected hospice services on 02/02/2024 with a terminal diagnosis of multiple sclerosis. The initial nursing assessment dated 02/02/2024 included documentation that the patient had a high fall risk. The written plan of care dated 02/02/2024 did not reflect patient and family goals and planned interventions associated with the patient’s fall risk identified in the comprehensive assessment. The nursing assessment dated 07/12/2024 included documentation that the patient had increased dysphagia and coughing with oral intake. The clinical record contained no evidence that the plan of care was updated to reflect patient and family goals, planned interventions, and precautions associated with the patient’s dysphagia and aspiration risk. Clinical Record 11: The patient elected hospice services on 09/06/2024 with a terminal diagnosis of unspecified chronic obstructive pulmonary disease. The initial nursing assessment dated 09/06/2024 included documentation that the patient had a high fall risk. The written plan of care dated 09/6/2024 did not reflect patient and family goals and planned interventions associated with the patient’s fall risk identified in the comprehensive assessment. A nursing coordination note dated 09/22/2024 included documentation that the patient had tested positive for COVID-19. The clinical record contained no evidence that the plan of care was updated to reflect patient and family goals, planned interventions, and precautions associated with the patient’s diagnosis of COVID-19. During joint clinical record reviews and interviews on 09/27/2024, the Administrator, Regional Clinical Director, and Vice President of Hospice confirmed that the plans of care identified did not reflect goals and planned interventions specific to the patients’ assessed problems.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, it was revealed that the agency did not ensure the individualized written plan of care (POC) included measurable outcomes anticipated from implementing and coordinating the POC. Clinical Record 1: The patient, an assisted living facility resident, elected the hospice benefit on 08/23/2024 with a terminal diagnosis of unspecified pulmonary hypertension. The initial nursing assessment dated 08/23/2024 included documentation that the patient had verbally reported pain rated four out of ten and required scheduled hydrocodone 5mg/acetaminophen 325mg three times a day and as needed up to six tablets in a 24-hour day. The plan of care dated 08/23/2024 included the goals, pain would be managed at a level acceptable to the patient and medications would be managed appropriately as evidenced by steady symptom control. The plan did not include the measurability of acceptable pain level, appropriate medication management, and steady symptom control as identified by and specific to the patient and family. Clinical Record 10: The patient elected the hospice benefit on 11/30/2023 with a terminal diagnosis of other cerebrovascular disease. The plan of care dated 07/27/2024 included the goal, that changes in neurological status would be addressed appropriately. The plan did not identify the specific neurological changes possible with the patient’s specific terminal illness and the measurability of appropriate as identified by and specific to the patient and family. Clinical Record 11: The patient elected the hospice benefit on 09/06/2024 with a terminal diagnosis of unspecified chronic obstructive pulmonary disease. The initial nursing assessment dated 09/06/2024 included documentation that the patient had a Pain Assessment in Advanced Dementia (PAINAD) score of six out of ten. The plan of care dated 09/06/2024 included the goal, pain would be managed at a level acceptable to the patient. The plan did not include the measurability of acceptable as identified by and specific to the patient and family. Clinical Record 13: The patient elected the hospice benefit on 03/19/2024 with a terminal diagnosis of other symptoms and signs with cognitive functions following other cerebrovascular disease. The plan of care dated 03/19/2024 included the goal, changes in neurological status would be addressed appropriately. The plan did not identify the specific neurological changes possible with the patient’s specific terminal illness and the measurability of appropriate as identified by and specific to the patient and family. During joint clinical record reviews and interviews on 09/27/2024, the Administrator, Regional Clinical Director, and Vice President of Hospice confirmed the individual written plans of care identified did not include measurable outcomes associated with pain and defined neurological changes as identified by and specific to the patient and family.

It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 18 (22%) clinical records reviewed of patients that received hospice aide services, it was revealed that the agency did not ensure the aide provided services as ordered by the Interdisciplinary Group (IDG) and included in the plan of care. Clinical Record 1: The patient elected the hospice benefit on 08/23/2024 with a terminal diagnosis of unspecified pulmonary hypertension. The plan of care dated 08/23/2024 included a visit frequency order for the hospice aide of two visits per week starting the week of 08/25/2024. A missed hospice aide visit dated 08/29/2024 included documentation that the patient had refused aide services on 08/29/2024. The clinical record contained no evidence that a second aide visit was provided the week of 08/25/2024 and no documentation of why the visit was missed. Clinical Record 4: The patient elected the hospice benefit on 04/29/2024 with a terminal diagnosis of hemiplegia following a cerebral infarction affecting the left dominant side. The physician’s order dated 09/16/2024 included a visit frequency order for the hospice aide of three visits per week starting the week of 09/15/2024. The clinical record contained documented visits on 09/16/2024 and 09/20/2024. The clinical record contained no evidence that a third aide visit was provided the week of 09/16/2024 and no documentation of why the visit was missed. Clinical Record 8: The patient elected the hospice benefit on 12/08/2023 with a terminal diagnosis of Alzheimer’s disease with late onset. The plan of care dated 08/04/2024 included a visit frequency order for the hospice aide of two visits per week. The clinical record contained documented visits on 08/06/2024 and 08/30/2024. The clinical record contained no evidence that a second aide visit was provided the weeks of 08/04/2024 and 08/25/2024 and no documentation of why the visits were missed. Clinical Record 16: The patient elected the hospice benefit on 02/13/2024 with a terminal diagnosis of other cerebrovascular disease. The plan of care dated 04/14/2024 included a visit frequency order for the hospice aide of once per week for eight weeks. The clinical record contained a documented visit on 04/17/2024. The clinical record contained no evidence that the aide provided visits for the weeks 04/21/2024 through 06/02/2024 and no documentation of why the visits were not made. During joint clinical record reviews and interviews on 09/27/2024, the Administrator, Regional Clinical Director, and Vice President of Hospice confirmed the clinical records contained no evidence of aide visits made as ordered during the weeks identified and no documentation of why the visits were missed or not made.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of 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 2 of 4 (50%) clinical records reviewed of patients that received volunteer services, it was revealed that the agency did not ensure volunteer services were noted in the plan of care. Clinical Record 4: The patient, an assisted living facility resident, elected the hospice benefit on 04/29/2024 with a terminal diagnosis of hemiplegia following a cerebral infarction affecting the left non-dominant side. The volunteer care plan dated 05/14/2024 included plans for volunteer services to be provided to the patient once bi-weekly for companionship The plans of care, reviewed and updated every 14 days since volunteer assignment on 05/14/2024, contained no documented evidence of the volunteer services provided. Clinical Record 5: The patient, an assisted living facility resident, elected the hospice benefit on 06/05/2024 with a terminal diagnosis of hypertensive heart and chronic kidney disease (CKD) with heart failure and unspecified stage 1-4 CKD. The volunteer care plan dated 07/29/2024 included plans for volunteer services to be provided to the patient once per week for pet therapy companionship. The plans of care, reviewed and updated no less frequently than every 14 days since volunteer assignment on 07/29/2024, contained no documented evidence of the volunteer services provided. During joint clinical record reviews and interviews on 09/27/2024, the Administrator, Regional Clinical Director, and Vice President of Hospice confirmed the plans of care (POCs) identified did not include documentation of volunteer services provided. The leaders confirmed that an organizational plan of correction has been developed and a process to ensure volunteer services are added to POCs for patient’s currently receiving volunteer services and immediately upon volunteer assignment.

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; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in 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 and interview. In 1 of 6 (17%) clinical records reviewed, the agency did not ensure update of the medication profile and consequently a full medication review for potential interactions. Clinical Record 4: The nursing assessment dated 9/7/23, documented a patient complaint of urinary tract infection (UTI), and urine was concentrated. The physician was notified and Levaquin 250mg po daily started. However, the medication profile was not revised to include Levaquin. No review of the medication was documented. During an interview, the Administrator and Corporate Clinical Supervisor confirmed the finding and stated the visit was made by a new Nurse Practitioner who was still learning.

It is required that each patient’s individualized written plan of care: 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. 1 of 6 (17%) clinical records reviewed, revealed the agency did not ensure the plan of care was updated with all interventions and goals identified in the initial or updated comprehensive assessment. Clinical Record 4: The nursing visit dated 9/7/23, documented the patient felt like she had a urinary tract infection (UTI), and had concentrated urine. The physician was contacted and Levaquin 250mg started. The plan of care was not updated with interventions or goals for urinary tract infections. During an interview, the Administrator and Corporate Supervisor confirmed the finding and stated that interventions and goals for UTI were not added to the plan of care.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by review of clinical record, document review, and interview. In 1 of 5 (20%) records reviewed the hospice failed to document all discipline assessments within 5 calendar days of the hospice benefit election. Agency Policy: 1-014 (annual review 2021) Comprehensive Assessment stated in part, "A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care....The patients psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation.....An assessment of the patients and family/caregivers spiritual orientation, including as appropriate, any involvement in a religious group such as a church or synagogue or support groups....". Record #96101: Review of the record identified the patient elected hospice on 10/28/21. The social worker completed their assessment on 11/2/21 (day 6). Interviewed Clinical Manager: 12/9/2021 stated that the register nurse communicated with the son 10/28/2021, and that the son requested a Tuesday visit (11/02/2021).

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by review of clinical record, document review, and interview. In 2 of 5 (40%) the registered nurse did not provide visits per plan of care ordered frequency and did not coordinate all care including accurate review of plan of care. Record # 53968: Plan of care updated 11/24/2021 documented order for nursing visits 2 x a week. Week starting 11/28/2021 one visited documented, no missed visit documented for second visit or reason for a second visit not delivered, as of review 12/08/2021. Interdisciplinary plans of care 11/09/2021, 11/23/2021, and 12/07/2021 failed to update the identified volunteer problem which was incorrectly entered on the plan of care. The registered nurse failed to coordinate the plan entered incorrectly for 6 weeks to assure accuracy for implementation of care. This error potentially could lead to services being missed and not provided and could impact patient care. Record # 42351: The comprehensive assessment completed 10/29/2021 identified a patient with underlying Dementia and a problem with social relations. The plan of care dated 10/29/2021 documented a problem with a need for volunteer services. No documented evidence of volunteer provided as of review date 12/8/2021. Interview 12/9/2021, with Administrator and Clinical Manager stated that nurse was turned away by facility, no second visit noted , updated 12/9/2021 for why visit was missed. Additionally the Administrator and Clinical Manager during interview 12/09/2021 stated that the volunteer problem was entered incorrectly on the plan of care.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by review of clinical record, document review, and interview that in 1 of 5 (20%) records reviewed identified the plan of care developed was not supported by the comprehensive assessment findings related to volunteer services. Agency Policy 9-017 (revised December 2018) Plan of Care stated that, " The written plan of care will contain, but will not be limited to the following: problems identified in the initial and updated comprehensive assessment." Record # 42351: The comprehensive assessment completed 10/29/2021 identified a patient with underlying Dementia and problem with social relations. The plan of care dated 10/29/2021 documented a problem for need for volunteer services. No documented evidence of volunteer provided as of review date 12/8/2021. Updated plans of care 11/09/2021, 11/23/2021, and 12/07/2021 failed to update the volunteer problem identified. Interview on 12/9/2021 with Administrator and Clinical Manager stated Volunteer service was added incorrectly. Family declined volunteer services. Correction order entered 12/9/2021 by clinical manager.

It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: Measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by review of clinical record, documentation review, and interview that 1 of 5 (20%) records failed to document measurable goals Agency Policy 9-017 (revised December 2018) Plan of Care stated that, " The written plan of care will contain, but will not be limited to the following: statement of treatment goals." Record #53968: Problem of pain identified 10/29/2021 on the plan of care. Goal documented, "patient/caregiver will verbalize/demonstrate understanding of pain management measures." (understanding is not measurable) and "patient/caregiver understands the need to report changes in pain level to hospice staff." (understands is not measurable) Initial assessment 10/29/2021, documented diagnosis not limited to Dementia and senile degeneration of the brain. Interview with Clinical Manager 12/9/2021 stated patient pain is measured with Wong-Baker scale and goal should have included this.

It is required that medical social services are provided: Based on a psychosocial assessment and per the plan of care. The psychosocial assessment addresses: The patient’s and the family’s adjustment to the terminal illness. The social and emotional factors related to the terminal illness. The presence or absence of adequate coping mechanisms. Family dynamics and communication patterns. Financial resources and any constraints. The caregiver’s ability to function effectively. Obstacles and risk factors that may affect compliance with the plan of care. Family support systems to facilitate coping with end-of-life issues. This standard was not met as evidenced by review of clinical record, document review, and interview. In 1 of 5 (20%) records reviewed the hospice failed to document evidence of a psychosocial assessment. Agency Policy 1-019 (annual review, 2021) Psychosocial assessment stated in part, "A thorough psychosocial assessment will be initiated at the time of admission and continued through the course of care. psychosocial assessment will be completed by a qualified hospice social worker. Record # 53968: The plan of care dated 10/29/2021 ordered social work evaluation. Documentation on 11/2/2021 stated facility positive for COVID, social work unable to visit. Quarantine of facility ended 11/14/2021. On review date 12/8/2021, no documented coordination with patient/family/facility or evidence of completed psychosocial assessment had been completed. Interview with Clinical Manager 12/9/2021 stated that coordination with a social worker for visit now scheduled 12/10/2021.