Every finding on record at Caridad Healthcare Inc.

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 record review and document review. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the patient's drug profile included all current prescription and over the counter medications. Agency policy "Medication List and Monitoring" (PC.85), with the revised date of 10/02/2021, stated in part, "The hospice will maintain a current, accurate list of all prescription and over the counter (OTC) medications taken by the patient. The medication will be documented on the medication profile...Changes in the medication regimen will be documented in the medical record either on the medication profile, on a verbal order POC [plan of care] ... The medication profile will be updated as frequently as necessary to reflect changes in the medication regimen, keeping the profile accurate." Clinical Record 1: The patient elected the hospice benefit on 11/5/2021, with a terminal diagnosis of emphysema. The Nurse Practitioner documented on the Face-to-Face visit note dated 8/5/2023, the patient “is suffering from constipation due to chronic opioid use and is on Senna, MiraLAX and will need the occasional enema." In the skilled nurse visit assessment dated 8/2/2023, the Registered Nurse marked in the gastrointestinal section, “Abnormal Stool: Constipation”. The skilled nurse documented that the patient takes fiber daily to prevent constipation, skilled nurse was told that patient had been constipated for about 2-3 days and was already having minimal and not complete bowel movements. Review of the patient’s mediation profile revealed Senna, MiraLAX, and enemas as needed, were not included in the patient's medication list.

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 record review, document review, and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure that the patient's plan of care included updated problems and interventions to address updates to the patient's comprehensive assessments. Agency policy "Review and Revision of Patient Care" (PC.45) with the revised date of 10/1/2021, stated in part, "The hospice will review and revise patient care in accordance with changes in the patient's condition ... specific interventions will accompany each change. All written changes to the Plan of Care (POC) will be incorporated into the patient's medical record." Clinical Record 1: The patient elected the hospice benefit on 11/5/2021, with a terminal diagnosis of emphysema. In the skilled nurse visit note dated 8/2/2023, the Registered Nurse marked in the gastrointestinal section, "Abnormal Stool: Constipation." The skilled nurse documented that the patient takes fiber daily to prevent constipation, skilled nurse was told that patient had been constipated for about 2-3 days and was already having minimal and not complete bowel movements. The Nurse Practitioner documented on the Face-to-Face visit note dated 8/5/2023, the patient “is suffering from constipation due to chronic opioid use and is on Senna, MiraLAX and will need the occasional enema." The patient's plan of care did not include any identified problem, interventions, or goals to address constipation. Clinical Record 4: The patient elected the hospice benefit on 8/16/2022, with a terminal diagnosis of chronic kidney disease. The skilled nurse visit note dated 8/1/2023 included documentation that the patient was agitated, anxious, irritable, and hallucinating. Review of the patient's medication list revealed the physician had prescribed Alprazolam as needed for anxiety (dated 6/16/2023), and Quetiapine for agitation/irritability (dated 5/16/2022). The patient's plan of care dated 7/14/2023 through 9/11/2023 did not include any identified problem, interventions, or goals to address the patient's anxiety and agitation. Clinical Record 10: The patient elected the hospice benefit on 12/9/2022, with a terminal diagnosis of liver cancer. In the initial comprehensive assessment dated 12/9/2022, the Registered Nurse documented the patient was agitated, anxious, and irritable. In the narrative section the nurse documented, "Patient noted restless/agitated at times." The nurse documented on the skilled nurse visit note dated 12/13/2023, the patient was agitated and anxious. The nurse documented in the narrative section, "As per CG [caregiver]/Spouse, patient has been experiencing episodes of confusion and irritability for the past 2-3 days. Daughter/spouse state they are constantly re-orienting patient during his waking hours, provide relaxation massages to calm down his irritability. CG/daughter does not know why this sudden change in the patient's behavior." The patient's medication list included an order dated 12/9/2022 for Alprazolam 0.5mg disintegrating oral tablet every eight hours as needed for anxiety. The patient's plan of care does not include any identified problems, interventions, or goals to address the patient's assessed anxiety and restlessness. During a group discussion on 9/8/2023, the Director of Nursing, the Quality Nurse, and the Alternate Administrator confirmed that the patient's plans of care should have been updated.

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by record review, document review, and interview. In 1 of 11 (9%) clinical records reviewed in which a Licensed Vocational Nurse (LVN) provided care; the agency did not ensure that the Registered Nurse (RN) documented supervision of the LVN every 30-60 days as required by agency policy. Agency policy "Employee Supervision" (HR.60), with the revised date of 10/1/2021, stated in part, "A registered nurse will make an onsite visit...to supervise the LPN/LVN at least every 30-60 days or more frequently as indicated." Clinical Record 13: The patient elected the hospice benefit on 2/4/2023. The LVN documented nursing visits to the patient on 4/3/2023, 4/5/2023, 4/7/2023, 4/10/2023, 4/12/2023, 4/17/2023, 4/19/2023, 4/24/2023, 4/27/2023, 5/1/2023, 5/4/2023, 5/5/2023, 5/15/2023, 5/29/2023, 6/13/2023, and 6/14/2023. Clinical record review revealed no documented evidence that LVN supervisory visits were completed from the start of care on 2/4/2023 to the patient's death on 6/14/2023, which was 131 days without a documented LPN supervisory visit by the RN. During an interview on 9/8/2023, the Director of Nursing stated that there were some staffing changes and was not surprised that some documentation was missing during that time period. During another interview on 9/8/2023, the Alternate Administrator and the Quality Nurse stated there had been some problems within the Electronic Medical Record (EMR) with things being deleted or not generated properly, and they have been in contact with the EMR company regarding this issue.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by record review, document review and interview. In 2 of 9 (22%) clinical records reviewed with hospice aide services, the agency did not ensure Hospice Aides were supervised by a Registered Nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days. Clinical Record 13: The patient elected the hospice benefit on 2/14/2023, with a terminal diagnosis of Parkinson’s disease. The plan of care included an order for Hospice Aide services twice a week beginning 2/7/2023. The clinical record contained documented Hospice Aide supervisory visits dated 3/31/2023, 4/21/2023, and 5/10/2023. The agency did not ensure the RN completed hospice aide supervisory visits every 14 days as required by the standard. Clinical Record 12: The patient elected the hospice benefit on 4/13/2023, with a terminal diagnosis of rheumatic heart disease. The plan of care included an order for Hospice Aide services three times a week beginning 5/10/2023. The patient remained on hospice care with hospice aide services until the patient’s death on 8/4/2023. Clinical record review revealed no documented evidence that Hospice Aide supervisory visits were completed. During an interview on 9/8/2023, the Director of Nursing stated that there were some staffing changes and was not surprised that some documentation was missing during that time period. During another interview on 9/8/2023, the Alternate Administrator and the Quality Nurse stated there had been some problems within the Electronic Medical Record (EMR) with things being deleted or not generated properly, and they have been in contact with the EMR company regarding these issues.