Every finding on record at Catholic Hospice, Inc.

It is required that the documented comprehensive assessment includes 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 35 (3%) clinical records reviewed revealed that the agency did not ensure that the medication profile was updated to include indication for as needed medications. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/21/2024 with malignant neoplasm of cervix. The Plan of Care for the certification period of 11/21/2024 to 02/18/2024 included the following medications: Ondansetron 4mg PO every six hours as needed, Acetaminophen 325mg PO every six hours PRN, Oxygen 2 LPM PRN, Oxycodone 10 mg PO every four hours, and Loperamide 2 mg PO every four hours as needed. There was no documented evidence that the plan of care included a description of the patient’s medical signs and symptom for the as-needed medication. In an interview with the clinical director, it was agreed that the medication profile was incomplete.

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, intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. In 6 of 27 (22%) clinical records reviewed of patient receiving services in private residence or skilled nursing facilities revealed that the agency did not ensure there were documented interventions to manage pain and systems on the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 12/29/2021. The certification period 10/14/2024-12/12/2024 was reviewed. In the comprehensive assessment dated 10/14/2024 the RN documented "patient's restlessness continues mainly in the afternoon, oxygen 3L via nasal cannula for anxiety/agitation, with more frequently using Haldol, Quetiapine ordered, lorazepam, and pain medication as needed." In the RN note of the IDT meeting dated 10/23/2024 the RN documented, "increased anxiety/agitation, using medication to control, using Haldol, Lorazepam, increased dysphagia resulting in recent weight loss." On the most recent plan of care dated 10/23/2024 there was no documented evidence of planned interventions based on problems identified in the IDT meeting dated 10/23/2024. CLINICAL RECORD 5: The patient elected the hospice benefit on 02/21/2024. In an RN IDT note dated 12/11/2024 the RN documented that the patient had dysphagia and high aspiration risk. A problem of anorexia and dysphagia was identified on the plan of care dated 10/18/2024-12/16/2024. There were no planned interventions documented for these problems identified. CLINICAL RECORD 8: The patient elected the hospice benefit on 10/08/2024, The Plan of Care (POC) for the certification period 10/08/2024 to 01/05/2025 included Levetiracetam 250mg by mouth twice daily (anticonvulsant). The POC did not include seizure precautions or any planned interventions to manage possible seizures. CLINICAL RECORD 12: The patient elected the hospice benefit on 05/24/2023 with cerebral atherosclerosis. The Plan of Care (POC) for the certification period of 09/15/2024 to 11/13/2024 included Eliquis (anticoagulant) 5 mg twice daily. The plan of care did not include bleeding precautions or any planned interventions to prevent or treat any bleeding issues. CLINICAL RECORD 22: The patient elected the hospice benefit on 03/25/2023. The plan of care dated 11/27/2024 in certification period 11/20/2024 -01/18/2025 identified problems of pain and shortness of breath at times. There was no documented evidence of planned interventions based on problems identified. CLINICAL RECORD 28: The patient elected the hospice benefit on 12/10/2024. On an RN assessment dated 12/11/2024 the RN documented "PO meds given; patient swallowed with great difficulty". The RN assessment dated 12/13/2024 also specified that patient suffered from dysphasia. On the plan of care update on 12/12/2024 there was no documented evidence of planned interventions based on problems identified in the updated assessments. In the RN assessment dated 12/11/2024 the RN documented "Multiple bruises, scratches, and scabs noted all around the patient's body". On the plan of care dated 12/12/2024 there was no documented evidence of planned interventions based on the dysphasia and the skin integrity problem identified. In an interview and joint review of the clinical records with the clinical director she agreed that the plans of care did not include interventions based on problems identified in the comprehensive assessments.

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 a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 35 (11%) clinical records reviewed revealed that the agency did not ensure that the plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/11/2024. The clinical record for the certification period dated 07/11/2024 - 10/08/2024 included volunteer notes on 10/03/204 and 10/08/2024. There was no documented evidence on the plan of care of a detailed statement of volunteer services needed to meet patient and family needs. CLINICAL RECORD 11: The patient elected the hospice benefit on 12/29/2021. The clinical record for the certification period of 08/11/2024 to 11/08/2024 included volunteer visit notes for 08/13, 08/14, 08/15, 9/18 (two notes for this date), 09/19 (four notes for this date), 09/20 (four notes for this date), and 09/23/2024 (four notes for this date). There was no documented evidence on the plan of care dated 08/11/2024 of a detailed statement of volunteer services needed to meet patient and family needs. CLINICAL RECORD 17: The patient elected the hospice benefit on 08/13/2023. On the initial RN assessment, it was documented that the patient was to receive physical therapy. Visits were made by physical therapy on 08/19/2024 for evaluation and again on 08/27/2024 and 08/29/2024. There was no documented evidence of a detailed statement of the service necessary to meet patient needs, or scope and frequency of the service on the plans of care dated 08/15/2024, 08/22/2024, and 09/05/2024. CLINICAL RECORD 21: The patient elected the hospice benefit on 07/27/2023. The plan of care dated 07/27/2023 ordered "Nursing/APRN/HLPN: (PRN) 25 visits starting 09/19/2023 (week 11) Reason for PRN: follow up." In an interview with the clinical director, she stated "this is a generic reason they put for as needed visits, so it covers everything." In an interview on 12/20/2024 with the clinical director she agreed that the needed services to meet patient and family needs were missing from the plan of care.

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 clinical record review and interview. In 4 of 35 (11%) clinical records reviewed revealed that the agency did not ensure that the plan of care included measurable outcomes anticipated from implementing the plan of care. CLINICAL RECORD 2: The patient elected the hospice benefit on 05/23/2023. Certification period 11/13/2024-01/11/2025 was reviewed. On the plan of care dated 11/13/2024 the RN identified a problem of "RN noted a deep tissue injury in the right hip." During joint review and interview with the Director of clinical care there was no documented evidence found on the plan of care of measurable outcomes anticipated form implementing and coordinating the plan of care for integumentary. CLINICAL RECORD 22: The plan of care dated 11/27/2024 in certification period 11/20/2024 -01/18/2025 identified problems of pain and shortness of breath at times. There was no documented evidence of measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 28: The patient elected the hospice benefit and admitted as GIP on 12/10/2024. On the plan of care dated 12/10/2024 problems of agitation and safety were documented, however there was no documented evidence of any measurable outcomes anticipated from implementing the plan of care related to these problems. CLINICAL RECORD 30: The patient elected the hospice benefit on and admitted GIP on 12/11/2024. A care plan created on 12/16/2024 identified pain management, the RN documented "patient c/o pain 7/10 in abdomen and chest, grimacing, and is restlessness." There is no documented evidence of measurable outcomes anticipated from implementing interventions on the plan of care. The goal created stated "patient's pain will be controlled within limits of disease."

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed that were on the bereavement program revealed that the agency did not ensure that a bereavement plan of care was developed by the qualified professional responsible for the bereavement program. CLINICAL RECORD 26: The patient elected the hospice benefit on 05/28/2024 and expired on 07/04/2024. There was no documented evidence of a bereavement plan of care or post-death bereavement risk assessment. There was a phone call made to bereaved on 07/05/2024 and 07/24/2024 with no answer and message left. There was a card sent on 07/05/2024. There was no documented evidence of any other follow up made. CLINICAL RECORD 27: The patient elected the hospice benefit on 05/06/2024 and expired on 07/18/2024. There was one call documented on 07/18/2024 that was made to the bereaved and a card sent. There was no documented evidence of a bereavement plan of care or any other follow up made to the bereaved. CLINICAL RECORD 25: The patient elected the hospice benefit on 04/09/2024 and expired on 08/14/2024. There was no documented evidence of a bereavement plan of care, or any contact made with the bereaved until 08/14/2024, 4 months after the patient expired. A call was made on 08/14/2024 with no answer, and 08/29/2024 with no answer and a message left. No other contact was found. CLINICAL RECORD 24: The patient elected the hospice benefit on 07/30/2024 and expired on 08/16/2024. THer was no documented evidence of a bereavement plan of care, or any contact made with the bereaved until 12/18/2024, 5 months after the patient expired. There was one documented phone call made on 12/18/20204 with no answer and message left. In an interview on 12/20/2024 with the clinical directors and the bereavement coordinator they all agreed that the bereavement plan of care should be included in the patient record.

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 clinical record review and interview. In 3 of 28 (11%) clinical records reviewed did not ensure that there were written patient care instructions for the hospice aide. CLINICAL RECORD 2: The hospice patient elected the hospice benefit on 05/23/2024. The plan of care dated 11/13/2024-01/11/2024 included an order aide visit for 7 times a week for 9 weeks (7xwx9). The patient had an unstageable deep tissue wound documented on her sacrum. On the aide plan of care dated 11/15/2024 a shower and shampoo hair were ordered with no notification of wound on sacrum or instructions for soiled or dislodged dressing. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/21/2024. The plan of care dated 11/21/2024 to 02/18/2025 included aide services with bed baths. The patient was on oxygen 2LPM as needed and had nephrostomy tubes that required dressings and draining. The aide care plan dated 11/25/2024 did not include oxygen precautions or notification of the nephrostomy tubes. There were no documented instructions for aide in a situation that the dressings for tubes or tubes themselves needed attention. The Plan of Care dated 11/21/2024 to 02/18/2025 included Eliquis (anticoagulant) 5 mg twice daily. There were no specific instructions or precautions on the aide plan of care for bleeding precautions. CLINICAL RECORD 16: The patient elected the hospice benefit on 11/12/2024. The Plan of Care for the certification period 10/06/2024 to 12/04/2024 included Levetiracetam (anticonvulsant) 1000mg twice daily. The aide care plan dated 11/13/2024 did not include seizure precautions or instructions on when to notify the RN in the situation of patient having a seizure. In an interview and joint review of the clinical record on 12/20/2024 with the Director of Clinical she agreed that the aide plan of care should include written instructions for the aide to follow when the patient has special needs.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed for patients that received physical therapy services revealed the agency did not ensure that the patient's record included physician's order for physical therapy services. CLINICAL RECORD 17: The patient elected the hospice benefit on 08/13/2024 with a diagnosis of heart disease. A review of the clinical record included documentation for visits made by the physical therapist on the dates of 08/19/2024, 08/27/2024 and 08/2029. There was no documented evidence of a physician's order for physical therapy. In an interview and joint review of clinical record with director of clinical (Personnel Record 11), she was unable to locate a physician's order for physical therapy in the clinical record.

Based on record review and interview, the provider failed to demonstrate it has investigated all alleged violations involving anyone furnishing services on behalf of the hospice and conducted in accordance with established procedures for 1 out of 7 Sampled Patients (SP). (SP#3) --- Findings include: Review of the providers policy titled ";Customer Comment Form" and ";Complaint Resolution" reads ";Each complaint will be documented, researched, and resolved in a timely manner to the best of our ability". The procedure states ";A documented investigation is conducted by appropriate personnel of all written or verbal complaints received by the hospice". Review of the complaint logged for SP#3 dated 03/23/23 revealed under ";Immediate Action Taken", documentation reads ";An email was sent to [name of agency] so they can follow up with night nurse [name] to address the complaint." An interview was conducted with the Manager, Continuous Care and Pool Department on 06/15/23 at 10:37 AM. As per Manager, the staffing company did the follow up to the complaint logged for SP#3. The Manager stated that the staffing company instructed and re-educated the staff regarding respecting the family wishes. The Manager states that the staff in question was asked to provide a written statement, and she did. Then as per Manager, she spoke with their Regional Director, and in this case specific, determined that the education provided was enough and the nurse could continue providing care to their patient. The Manager stated that the staff was noted to be in compliance as per her completing the in-service provided by the staffing company and the staff voicing to the staffing company that she understood. The Manager acknowledged that the resolution was omitted as part of the documentation requirement for the complaint.

Based on review of the Hospice's Policy, record review and interview, the Hospice failed to update their patient's assessment for changes in condition for 1 of 3 sampled patients (Patient #1). The findings include: --- Review of the Hospices Administrative Policy titled, "Level of Care General Inpatient Care, Policy# 5.16," last review date August 2021, documents under Procedure, ";Short-term inpatient hospice care is provided when the patients condition or disease progression must be closely monitored in order to manage pain and/or related symptoms that cannot safely be managed in the patients own home" and ";The RN (Registered Nurse) Care Manager gives the attending physician or designee a report of the patients medical status and obtains an order for the change in level of care and inpatient admission" and ";When the patient returns to routine home care, his or her comprehensive assessment and plan of care are updated to reflect current status, needs, interventions and goals." Patient #1's "Face Sheet" documents the patient started hospice care on 02/10/22 with an admitting diagnosis requiring hospice care. Review of the record reveals Patient #1's last 2 RN visits before a transfer to the Inpatient Unit on 08/04/22 were conducted on 07/18/22 and 07/25/22. There was no evidence of a further documented RN assessment to give the physician an accurate report of the patients medical status before the decision to send the patient to the Hospice Inpatient Unit on 08/04/22 for IV (Intravenous) antibiotics to treat a .. (type of) infection that had been identified on a laboratory report, dated 07/23/22. Patient #1's "Continuous Care Assessment Note," dated 08/23/22 documented the patient had blue discoloration of the fingertips, toes and ears and that Oxygen was placed at 2L (2 liters) by nasal cannula. The physician saw Patient #1 on 08/24/22 and documented blisters on the toes and heels, for which cream was recommended and the caregiver was advised to keep the sheets off the patient's skin. Patient #1s status was changed to "Routine Home Care" on 08/25/22 without further evidence of documentation of a nursing assessment of the patient's needs to maintain the patient at this lower level of care and further review reveals that the patient's family took Patient #1 to the hospital for worsening skin changes on 08/26/22. During an interview on 11/15/22 at 11:07 AM, Patient #1's Registered Nurse/Case Manager, Staff A stated she visited Patient #1 on 08/26/22, that the family had called 911 before she arrived, and while she was at the home the ambulance arrived to take the patient to the hospital, so she did not document that as a "Nurse Visit."

Based on review of the Hospice's Policies, record review and interview, the Hospice failed to update their Plan of Care, including collaboration with the attending physician, with changes in patient condition for 1 of 3 sampled patients (Patient #1). The findings include: --- Review of the Hospices Policy titled, "Level of Care General Inpatient Care, Policy #5.16," last review date August 2021, documents under Procedure, ";Short-term inpatient hospice care is provided when the patients condition or disease progression must be closely monitored in order to manage pain and/or related symptoms that cannot safely be managed in the patients own home" and ";The RN (Registered Nurse) Care Manager gives the attending physician or designee a report of the patients medical status and obtains an order for the change in level of care and inpatient admission" and ";When the patient returns to routine home care, his or her comprehensive assessment and plan of care are updated to reflect current status, needs, interventions and goals." Review of the Hospices Policy titled, "Level of Care Continuous Care, Policy #5.17," last review date August 2021, documents under Policy, ";Continuous Care is provided to hospice patients during periods of medical crisis" and under Procedure, ";The RN Care Manager or designee assesses the patient to determine whether he/she requires a level of care change. Obtain orders from the hospice physician for a change in level of care. Revise the plan of care to reflect the symptoms to be managed." Review of Patient #1's record reveals Patient #1 was admitted to the hospice on 02/10/22 with a primary diagnosis requiring hospice care. Review of Patient #1's "Nursing Visit Note," dated 7/18/22 documents the patient's urine had sediments and a slight odor, and the nurse encouraged fluid intake and will continue to monitor. There was no evidence of documentation on this "Nurse Visit Note" of communication with the physician or nurse practitioner or an order for urine testing. Review of Patient #1's laboratory report for urinalysis and culture and sensitivity documents the sample was received on 07/21/22, report date of 7/23/22, and print date of 7/28/22; positive leukocytes, bacteria, protein, and white blood cells in the urine; and the bacteria cultured from the sample, Pseudomonas Aeruginosa was resistant to 8 of 12 antibiotics tested but susceptible to Zosyn, Amikacin, Gentamycin, and Meropenem. During an interview, on 11/15/22 at 11:53 AM, an inquiry was made to the Nurse Educator of a physician's order for the urine test that was collected on 07/21/22. During a further interview on 11/15/22 at 11:53 AM, after time to review Patient #1's record, the Nurse Educator denied evidence of an order for urine testing and confirmed there should have been an order. During an interview on 11/15/22 at 11:58 AM with the Clinical Care Manager of the Pink Team, Manager C explained the process is for the nurse to get an order for laboratory testing from the physician, then enter the order in the electronic record and e-mail a notice to the secretary who contacts the laboratory company to pick up the sample. Review of Patient #1's next "Nursing Visit Note," dated for 07/25/22, lacks evidence of documentation of urine testing or follow-up for urine test results. Review of Patient #1's IDG (Interdisciplinary Group) Meeting Notes dated 07/27/22 document the patient had a urinary catheter with no signs or symptoms of infection and contains no evidence of documentation of urine testing. Documentation of the Nurse Practitioner's "face-to-face" visit for recertification on 08/02/22 reveals no evidence of documentation of awareness of urine testing or the results reported on 07/23/22 and printed 07/28/22, and no order for antibiotics or decision whether to treat for the positive results. Review of Patient #1's record revealed no evidence of communication of the laboratory results reported 07/23/22 among staff or with the patient and their representative/family, or of the decision to send Patient #1 to the Inpatient Unit until physician's orders on a ";Admission and New Prescription Order Form," dated 08/04/22 (not timed) for admission to the Inpatient Unit (known as General Inpatient Care) that included an order for Zosyn (an antibiotic) 2.25 gm (grams) IV (intravenously) Q6 hrs. (every 6 hours) x7 days (for 7 days) for UTI (Urinary Tract Infection), as well as orders for diet, other medications, and urinary catheter maintenance. During interview on 11/15/22 at 2:40 PM, Manager C reported their office received the urine test results on 07/23/22 and they were e-mailed to the nurse and physician that same day. Upon request for evidence of this communication, on 11/15/22 at 2:42 PM Manager C provided a print-out of an e-mail sent 07/28/22 at 10:36 AM to the physician and nurse (Staff C) with the laboratory result attachment of the report with result date 07/23/22 and print date of 07/28/22. During telephonic interview on 11/15/22 at 3:05 PM with the Director of Clinical Care to a representative of the laboratory that completed Patient #1's urine testing result on 07/23/22, that laboratorys representative confirmed the results of the urinalysis, culture and sensitivity were completed in their entirety and faxed to .. (a telephone number with another county's area code) on 7/23/22. During interview on 11/15/22 at 3:20 PM, the Regional Director of Nursing and Hospice Operations called staff in the Hospice's other County's office and confirmed the telephone number provided by the laboratory as that to which Patient #1's results were faxed goes to but was unable to verify receipt or learn whether that laboratory result had been forwarded to the Hospice's office location, that provided services to Patient #1. During interview on 11/15/22 at 3:19 PM, upon inquiry to the further delay in response to Patient #1's laboratory result from the Hospice's office receipt of the result on 07/28/22 until the antibiotic was started on 08/05/22, Manager C reported they discussed the case with Manager B at the inpatient unit who stated that the medication, Zosyn, was not available and there was no point in transferring Patient #1 before the medication was available; upon further questioning, Manager C admitted she was not part of that conversation but reported Staff A had relayed this information to her "a few days before" Patient #1 went to the inpatient unit. An interview was conducted on 11/15/22 at 3:22 PM with the Regional Director of Nursing and Hospice Operations and, by telephone, the Manager of the Hospice Inpatient Unit, Manager B; during this interview, Manager B reported she remembered Patient #1 had a "complicated UTI" and came to the Inpatient Unit with orders for Zosyn but denied there was any delay in that admission to get the medication and Manager B reported that Patient #1 arrived at the Inpatient unit on 08/04/22 at 3:59 PM. During a telephone interview on 11/15/22 at 3:42 PM, the Pharmacist from the Hospice-contracted pharmacy reported they first received the order for Zosyn on 08/04/22 at 5:11 PM but the medication was not in stock, so it was delivered to the inpatient unit on 08/05/22 at 6:49 PM. Review of Patient #1's record reveals no evidence of further revision to the patient's Plan of Care, other than documented, such as changes to frequencies of visits by involved disciplines, for the ";General Inpatient" stay that began on 08/04/22. Review of Patient #1's "verbal (physician's) order, dated 08/04/22 at 4:54 PM, transcribed by Staff A documents new frequencies of visits for the Hospice Aide and Nurse effective 08/09/22, and SNV (Skilled Nurse Visit) for ";RHC" (Routine Home Care), although Patient #1 was prescribed a 7-day course of IV antibiotics while on the Inpatient unit, and therefore was not expected to return home by the effective date. Further review of the record reveals no revision to these frequencies to reflect that the patient remained in the Inpatient Unit and did not go home until 08/12/22. Review of the "On-Call record" reveals documentation that on 08/20/22, Patient #1's private caregiver called and reported the patient was wheezing and short of breath, and Patient #1's record documents the patient was started on "Continuous Care" that day. However, there was no evidence of a physician's order for Continuous Care, of how many hours a day Continuous Care would be necessary, or how many of these hours needed to be provided by a Nurse rather than unskilled staff. Further review of Patient #1's record reveal no new orders and no change to the Care Plan to address management of the uncontrolled symptoms for which Continuous Care was started. Review of the "Continuous Care Note" entries for 08/21/22 at 11:00 AM and 11:20 AM document Ibuprofen (Non Steroidal Anti-Inflammatory) cream was applied to Patient #1's buttock, right thigh, feet, and ankles for comfort. Review of Patient #1's Medication Profile revealed no evidence that the patient was prescribed Ibuprofen cream. A CC (Continuous Care) Assessment Note for 08/22/22 documents Patient #1 was starting to develop fluid filled blisters on multiple body parts, the physician was notified and planned to visit Patient #1 the following day. Patient #1's "CC Assessment Note," for 08/23/22 documents the patent had blue discoloration to their fingertips, toes and ears and Oxygen was placed at 2 liters per minute by nasal cannula; had fluid-filled blisters to multiple areas of their body; the doctor was notified and would follow up. A Provider (Physician's) Note for a visit on 08/24/22 at 1:30 PM documents Patient #1 has been developing blisters on .. lower extremities and continues to complain of increased pain. Exam (Examination) findings on this Provider's Note included, ";vesicular/bullous lesion an (sic) .. LE (toes and heels)", and acute symptoms ";blisters on LE (lower extremities)." This Provider's Note documents the blisters were possibly secondary to contact with sheets, to avoid direct contact, to use Bacitracin (a type of antibiotic) cream, that there were no signs of infection, and the patient was appropriate for Routine Home Care. Review of Patient #1's Physician Orders and Medication Profile printed 11/14/22 revealed no evidence of an order for Bacitracin cream. Review of Patient #1's record reveals no evidence of revision to the Plan of Care to reflect the change to Routine Home Care on 08/25/22 or RN visit to reassess the patient after 08/23/22. A "Hospice Discharge Summary," by Staff A dated 8/26/22 documents, ";pt (patient) development (sic) fluid-filled blisters on .. BLE that eventually began to enlarge in size and spread to .. hands and face. Due to unknown cause patients family decided to call 911. Pt had abnormal laboratory results that lead to familys decision to have the patient treated" and ";Patient is being "d/cd" (discharged) for treatment for a diagnosis that is unrelated to terminal Hospice diagnosis," and the Discharge Reason as ";Hospice - beneficiary moves out of service area." During interview on 11/15/22 at 10:33 AM, Manager C stated Patient #1's family wanted the patient to have Dialysis for acute kidney injury and after she discussed this with the previously employed Clinical Director, that Clinical Director told her to discharge the patient since they want to pursue aggressive treatment and did not say to contact the family for a revocation; Manager C stated she spoke with Staff A, told her the Clinical Director said to discharge Patient #1, and told her to talk to Patient #1's representative to explain Patient #1 would have to "come off" Hospice to pursue aggressive treatment; Manager C stated Staff A called her back that she had spoken to the representative and was going to complete the discharge documentation; Manager C stated they did not need a physician's order to complete the discharge because the Clinical Director made the decision and that is how they do it here and confirmed there was no revocation, and this was a Hospice-initiated discharge; Manager C stated the nurse, Staff A let the physician know of the discharge. Further into the conversation, on 11/15/22 at 10:33 AM, Manager C stated this should have been a Hospice revocation completed with the representative. During telephonic interview on 11/15/22 at 11:07 AM, Staff C reported she made a visit to Patient #1's home on 08/26/22 but the family had already called emergency services and the ambulance arrived while she was there, that she followed the patient to the hospital and spoke with the ER (Emergency Room) physician who said it was going to be up to the family whether to pursue aggressive treatment with steroids and address the patient's dehydration and an abnormal potassium level, or have the patient return home with Hospice; Staff C stated the patients representative wanted to keep Patient #1 at the hospital and was aware once the patient completed treatment, the patient could always come back on Hospice, so she called Manager C with an update, told her she was going to discharge Patient #1 and documented the discharge; Staff C said she believed the representative understood Patient #1 had been discharged because they texted the next day to notify her the hospital was discharging Patient #1 back home with Hospice and she was trying to coordinate that; Staff C denied getting a physician's order to discharge Patient #1 but said she made the decision, notified Manager C she would discharge the patient, and Manager C was "ok" with that.

Based on review of the Hospice's Policies, record review and interview, the Hospice failed to coordinate care among disciplines, with laboratory services, and with the patient and/or patient's representative for changes in the patient condition and/or levels of care for 1 of 3 sampled patients (Patient #1). The findings include: --- Review of the Hospices Policy titled, "Level of Care General Inpatient Care, Policy #5.16," last review date August 2021, documents under Procedure, ";The RN (Registered Nurse) Care Manager gives the attending physician or designee a report of the patients medical status and obtains an order for the change in level of care and inpatient admission." Review of the Hospices Policy titled ,Level of Care Continuous Care, Policy #5.17," last review date August 2021, documents under Policy, ";Continuous Care is provided to hospice patients during periods of medical crisis" and under Procedure, ";The RN Care Manager or designee assesses the patient to determine whether he/she requires a level of care change. Obtain orders from the hospice physician for a change in level of care. Revise the plan of care to reflect the symptoms to be managed." Review of the Hospices Policy titled, "Discharge from Hospice Care, Policy #5.41," last review date February 2022, documents under Policy, ";Catholic Hospice provides a consistent plan for discontinuance of services and supports the patient/caregiver with referrals and planning for continued care as appropriate" and under Procedure, ";Hospice services may be discontinued: if the patient moves outside the geographical area serviced by the hospice or transfers to another hospice... if the patient desires curative care or aggressive treatment that is inconsistent with the hospice philosophy and/or the patients plan of care; if the patient chooses to receive treatment from an inpatient facility with which Catholic Hospice does not have and/or can not obtain a written agreement..." and ";Before the patient can be discharged for cause, the hospice advises the patient that a discharge for cause is being considered; makes a serious effort to resolve the problem(s) caused by the patients behavior or the situation; ensured that the decision to discharge the patient is not related to the patients use of necessary hospice services; and documents in the patients clinical record the problem(s) and efforts made to resolve the situation..." and ";Prior to discharge, the hospice obtains a written physicians discharge order from the hospice Medical Director and consults with the patients attending physician (if there is one), documenting his or her review of the discharge decision in the discharge note." Review of Patient #1's record reveals Patient #1 was admitted to the hospice's services on 02/10/22 a the primary diagnosis requiring Hospice care. Review of the "Nursing Visit Note ,"dated 7/18/22 documents the patient's urine had sediments and a slight odor, the nurse encouraged fluid intake and will continue to monitor. There was no evidence of documentation on the "Nurse Visit Note" of communication with the physician or nurse practitioner or an order for urine testing. Review of Patient #1's laboratory report for urinalysis and culture and sensitivity documents the sample was received on 07/21/22, report date of 7/23/22, and print date of 7/28/22; positive leukocytes, bacteria, protein, and white blood cells in the urine; and the bacteria cultured from the sample, Pseudomonas Aeruginosa was resistant to 8 of 12 antibiotics tested but susceptible to Zosyn, Amikacin, Gentamycin, and Meropenem. During an interview, on 11/15/22 at 11:53 AM, an inquiry was made to the Nurse Educator for a physician's order for the urine test that was collected on 07/21/22. During a further interview on 11/15/22 at 11:53 AM, after time to review Patient #1's record, the Nurse Educator denied evidence of an order for urine testing and confirmed there should have been an order. During interview on 11/15/22 at 11:58 AM with the Clinical Care Manager, Manager C explained the process is for the nurse to first get an order for laboratory testing from the physician, then enter the order in the electronic record and e-mail notice to the secretary who contacts the laboratory company to pick up the sample. Review of Patient #1's next "Nursing Visit Note," dated for 07/25/22, lacks evidence of documentation of urine testing or follow-up for the urine test results. Patient #1's ";IDG (Interdisciplinary Group) Meeting Notes," dated 07/27/22 document the patient had a urinary catheter with no signs or symptoms of infection lacked any documentation of the urine laboratory testing or of any urinary complaints. The ";IDG Meeting Notes" for 07/27/22 also documented Patient #1s urinary catheter was changed on 07/22/22, although there was no evidence of documentation Patient #1 had a nurse or clinician visit on 07/22/22. Documentation of the Nurse Practitioner's "face-to-face" visit for recertification on 08/02/22 reveals no evidence of documentation of awareness of urine testing or the results reported on 07/23/22 and printed 07/28/22, and no order for antibiotics or decision whether to treat for the positive results. Review of Patient #1's record reveals no evidence of communication of the laboratory results reported 07/23/22 among staff or with the patient and their representative/family, or of the decision to send Patient #1 to the Inpatient Unit until physician's orders on a ";Admission and New Prescription Order Form," dated 08/04/22 (not timed) for admission to the Inpatient Unit (known as General Inpatient Care) that included an order for Zosyn (an antibiotic) 2.25 gm (grams) IV (intravenously) Q6 hrs. (every 6 hours) x7 days (for 7 days) for UTI (Urinary Tract Infection), as well as orders for diet, other medications, and urinary catheter maintenance. During interview on 11/15/22 at 2:40 PM, Manager C reported their office received the urine test results on 07/23/22 and they were e-mailed to the nurse and physician that same day. Upon request for evidence of this communication, on 11/15/22 at 2:42 PM, Manager C provided a print-out of an e-mail sent 07/28/22 at 10:36 AM (5 days later) to the physician and nurse (Staff C) with the laboratory result attachment with result date 07/23/22 and print date of 07/28/22. During telephonic interview on 11/15/22 at 3:05 PM with the Director of Clinical Care to a representative of the laboratory that completed Patient #1's urine testing resulted on 07/23/22, that laboratorys representative confirmed the results of the urinalysis, culture and sensitivity were completed in their entirety and faxed to .. (a telephone number with another county's area code) on 7/23/22. Immediately after concluding this call, the Director of Clinical Care denied awareness that their patients laboratory results were going to another office, but this will be corrected. During interview on 11/15/22 at 3:20 PM, the Regional Director of Nursing and Hospice Operations called staff in the hospice's other County's office and confirmed the telephone number provided by the laboratory, and to which Patient #1's results were faxed, goes to the other County's office but was unable to verify receipt or learn whether that laboratory result had been forwarded to this Hospice's office that provided services to Patient #1. During an interview on 11/15/22 at 3:19 PM, upon inquiry to the further delay in response to Patient #1's laboratory result from this Hospice's office receipt of the result on 07/28/22 until the antibiotic was started on 08/05/22, Manager C reported they discussed the case with Manager B at the Inpatient Unit who stated that the medication, Zosyn, was not available and there was no point in transferring Patient #1 before the medication was available; Upon further questioning, Manager C admitted she was not part of that conversation but reported Staff A had relayed this information to Manager C "a few days before" Patient #1 went to the Inpatient Unit. An interview was conducted on 11/15/22 at 3:22 PM with the Regional Director of Nursing and Hospice Operations and, by telephone, the Manager of the Hospice Inpatient Unit, Manager B; during this interview, Manager B reported she remembered Patient #1 had a "complicated UTI" and came to the Inpatient Unit with orders for Zosyn but denied there was any delay in that admission to get the medication and Manager B reported Patient #1 arrived at the Inpatient Unit on 08/04/22 at 3:59 PM. During a telephone interview on 11/15/22 at 3:42 PM, the Pharmacist from the Hospice-contracted pharmacy reported they first received the order for Zosyn on 08/04/22 at 5:11 PM but the medication was not in stock, and it was delivered to the inpatient Unit on 08/05/22 at 6:49 PM. Review of Patient #1's record reveals no evidence of further revision and coordination of the Plan of Care, other than documented, such as changes to frequencies of visits by involved disciplines, for the ";General Inpatient" stay that began on 08/04/22. Review of Patient #1's (Physician's) verbal order, dated 08/04/22 at 4:54 PM, transcribed by Staff A documents new frequencies of visits for the Hospice Aide and Nurse effective 08/09/22, and SNV (Skilled Nurse Visit) for ";RHC" (Routine Home Care), although Patient #1 was prescribed a 7-day course of IV antibiotics while on the Inpatient Unit, and therefore was not expected to return home by the effective date. Further review of the record reveals no revision to these frequencies to reflect that the patient remained in the Inpatient Unit and did not go home until 08/12/22, and no revision/coordination of the Plan of Care with the home care team for Patient #1s return home on 08/12/22. Review of the "On-Call Record reveals on 08/20/22 Patient #1's private caregiver called and reported the patient was wheezing and short of breath, and Patient #1's record documents the patient was started on "Continuous Care" that day. However, there was no evidence of a physician's order for Continuous Care, of how many hours a day Continuous Care would be necessary, or how many of these hours needed to be provided by a nurse rather than unskilled staff. Further review of Patient #1's record reveals no new orders and no change to the Care Plan to address management of the uncontrolled symptoms for which continuous care was started on 08/20/22. "CC (Continuous Care) Assessment Note" entries for 08/21/22 at 11:00 AM and 11:20 AM document Ibuprofen (Non Steroidal Anti-Inflammatory) cream was applied to Patient #1's buttock, right thigh, feet, and ankles for comfort. Review of Patient #1's Medication Profile reveals no evidence that the patient was prescribed Ibuprofen cream. A "CC Assessment Note," for 08/22/22 documents Patient #1 was starting to develop fluid filled blisters on multiple body parts, and the physician was notified and planned to visit Patient #1 the following day. Patient #1's "CC Assessment Note," for 08/23/22 documents the patient had blue discoloration to their fingertips, toes and ears and Oxygen was placed at 2 liters per minute by nasal cannula; had fluid-filled blisters to multiple areas of the body; the doctor was notified and would follow up. A "Provider (Physician's) Note," for a visit on 08/24/22 at 1:30 PM documents Patient #1 has been developing blisters on their lower extremities and continues to complain of increased pain. Exam (Examination) findings on this "Provider's Note" included ";vesicular/bullous lesion an (sic) .. LE (Lower Extremity) toes and heels," and acute symptoms ";blisters on LE." This "Provider's Note" documents the blisters were possibly secondary to contact with sheets, to avoid direct contact, to use Bacitracin (a type of antibiotic) cream, that there were no signs of infection, and the patient was appropriate for Routine Home Care. Review of Patient #1's "Physician Orders and Medication Profile," printed 11/14/22 reveals no evidence of an order for Bacitracin cream. Review of Patient #1's record reveals no evidence of revision and coordination of the Plan of Care to reflect the change to Routine Home Care on 08/25/22 or RN visit to reassess the patient after 08/23/22. A "Hospice Discharge Summary "by Staff A dated 8/26/22 documents, ";pt (patient) development (sic) fluid-filled blisters on .. BLE that eventually began to enlarge in size and spread to .. hands and face. Due to unknown cause patients family decided to call 911. Pt had abnormal laboratory results that lead to familys decision to have the patient treated" and ";Patient is being d/cd (discharged) for treatment for a diagnosis that is unrelated to terminal hospice diagnosis," and the Discharge Reason as ";hospice - beneficiary moves out of service area." During an interview on 11/15/22 at 10:33 AM, Manager C stated Patient #1's family wanted the patient to have Dialysis for acute kidney injury and after she discussed this with the previously employed Clinical Director, that Clinical Director told her to discharge the patient since they want to pursue aggressive treatment and did not say to contact the family for a revocation; Manager C stated she spoke with Staff A, told her the Clinical Director said to discharge Patient #1, and told her to talk to Patient #1's representative to explain Patient #1 would have to come "off Hospice" to pursue aggressive treatment; Manager C stated Staff A called her back that she had spoken to the representative and was going to complete the discharge documentation. Manager C stated they did not need a physician's order to complete the discharge because the Clinical Director made the decision and that is how they do it here; Manager C confirmed there was no revocation, and this was a hospice-initiated discharge; Manager C stated the nurse, Staff A let the physician know of the discharge; further into the conversation, Manager C reported this should have been a hospice revocation completed with the representative. During telephonic interview on 11/15/22 at 11:07 AM, Staff A reported she made a visit to Patient #1's home on 08/26/22 but the family had already called emergency services and the ambulance arrived while she was there, that Staff A followed the patient to the hospital and spoke with the ER (Emergency Room) physician who said it was going to be up to the family whether to pursue aggressive treatment with steroids and address the patient's dehydration and abnormal potassium level, versus having the patient return home with hospice; Staff C stated the patients representative wanted to keep Patient #1 at the hospital and was aware once the patient completed treatment ,the patient could always come back on hospice; Staff C stated she called Manager C with an update, told her she was going to discharge Patient #1, and she documented the discharge; Staff C said she believed the representative understood Patient #1 had been discharged because the representative texted her the next day to notify her the hospital was discharging Patient #1 back home with hospice and she was trying to coordinate that; Staff C denied getting a physician's order to discharge Patient #1 but said she made the decision, notified Manager C she would discharge her, and Manager C was "ok" with that.

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 the hospice populations are anticipated, and, as appropriate, preventive measurements 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 review of records and interview. 5 of 20 (45%) records reviewed revealed medication profiles did not include a listing of all medications in use by patients and were not included in the full review of the patients' medication regimen. Record #57357 was reviewed and revealed the RN assessment dated 12/23/2021 documented the patient received oxygen PRN. The drug profile did not include oxygen. Record #36769 was reviewed and revealed the RN comprehensive assessment dated 1/3/2022 documented the patient received oxygen PRN and an oxygen concentrator was ordered. The drug profile did not include oxygen. Record #69349 was reviewed and revealed the RN documented in the assessment dated 2/22/2022 that oxygen was initiated PRN. The drug profile did not include oxygen. Record #96519 was reviewed and revealed the RN assessment documented on 1/31/2022 the patient was on oxygen 4 LPM via nasal cannula continuous. The drug profile did not include oxygen. Record #14983 was reviewed and revealed the RN assessment dated 2/11/2022 documented the patient declined oxygen. On the RN assessment dated 2/14/2022 the RN documented that oxygen was initiated at 2 LPM PRN. The oxygen was not listed on the medications profile. The Nurse Educator was interviewed on 3/4/2022 and confirmed there was no documentation of oxygen as a medication on the drug profiles, and there was no additional information provided.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by review of records and interview. In 4 of 20 (20%) records reviewed, the hospice failed to provide documentation that the POC addressed the needs identified in assessment. Record #24667 was reviewed and revealed the MSW assessment dated 9/6/2021 documented the patient experienced pain in the wrist from a recent fracture. The POC did not specify interventions related to the patient's complaint of wrist pain. Record #39009 was reviewed and revealed the recertification assessment dated 1/5/2022 documented the patient, "has become very anxious and apprehensive... increasingly confused and agitated". The POC did not specify interventions to address the patient's anxiety and apprehensive. Record #17637 was reviewed and revealed the patient was diagnosed 2/9/2022 with an urinary tract infection and an order was received for Macrodantin, 100 mg, 1 tab 2 times a day. There was no evidence that interventions to address care related to the infection was not added to the POC. Record #14983 was reviewed and revealed the RN assessment dated 2/11/2022 documented that the patient was receiving oxygen at 3LPM continuous and oxygen precautions were initiated. There was no evidence of an order for oxygen on the POC. The Nurse Educator and Regional Director of Nursing were interviewed on 3/4/2022 and confirmed there was no additional documentation in the the POCs that included care for all of the patients' needs which were identified in the assessments. No further evidence or information was provided.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice IDG in collaboration with the attending physician (if any); The patient or patient representative; The primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by record review and interview. 4 of 20 (20%) records reviewed revealed that nursing visits were not completed as ordered in the plan of care. Record #36769 was reviewed and identified on 1/10/2022 an order was written for SN visits to be provided as "7XW". Nursing visit notes were reviewed for the period of 1/10/2022 to 1/18/2022, and there was no documented evidence of a nursing visit completed on 1/16/2022. Record #13894 was reviewed and identified on 2/2/2022 an order was written for SN visits to be provided as "1XW". No documentation was found for a nursing visit completed during the week of 2/20/2022-2/26/2022. Record #22126 was reviewed and identified on 1/20/2022 an order was written for SN visits to be provided as "1XW". No documentation was found for a nursing visit completed during the the week of 1/23/2022-1/29/2022. Record #51428 was reviewed and identified on 12/14/2021 an order was written for SN visits to be provided as "1XW". No documentation was found for nursing visits completed during the weeks of 12/19/2021-12/25/2021, 12/26/2021-1/1/2022, and 1/2/2022-1/8/2022. The Nurse Educator was interviewed on 3/3/2022 and confirmed there was no documentation that described the missing nursing visits and no additional information to provide.

It is required that counseling services are available to the patient and family to assist in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process. This standard was not met as evidenced by review of records and interview. 1 of 3 (33%) records reviewed in which bereavement services were requested revealed that counseling services were not provided for a patient's family as requested. Record #39009 was reviewed and revealed that on 10/13/2021 the MSW documented: "When offered emotional bereavement counseling help, PCG mentioned that it will be very helpful." The MSW made 2 referrals to the Bereavement Department, one on 10/13/2021 and one on 11/8/2021. There was no documented evidence that counseling services were provided. An interview was conducted on 3/4/2022 with the Bereavement Coordinator who confirmed there was no documentation that bereavement counseling was provided.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; and, Consistent with the hospice aide training. This standard was not met as evidenced by review of records and interview. 5 of 15 (33%) clinical records reviewed in which hospice aide services were provided revealed the hospice did not provide hospice aide visits as ordered. Record #36769 was reviewed and identified orders were written on 1/3/2022 for hospice aide visits "2XW". There was no documentation of hospice aide visits provided from 1/3/2022 until the patient's death on 1/18/2022. Record #13894 was reviewed and identified orders were written on 2/3/2022 for hospice aide visits "5XW". There was no documentation found for hospice aide visits completed during the weeks of 2/6/2022-2/12/2022, 2/13/2022-2/19/2022, and 2/20/2022-2/26/2022. Record #13894 was reviewed and identified orders were written on 2/3/2022 for hospice aide visits "5XW". No documentation was found for hospice aide visits completed during the week of 2/6/2022-2/12/2022. The RN documented on 2/3/2022: "coordinate with team secretary for HA services. Will follow up." On 2/11/2022, the SN documented: "HA Services were declined." The Nurse Educator was interviewed on 3/4/2022 and confirmed there was no documentation of the missing hospice aide visits and there was no further information to provide.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: The primary terminal condition; Related diagnosis(es), if any; Current subjective and objective medical findings; Current medication and treatment orders; Information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by review of records and interview. 3 of 20 (15%) records reviewed revealed the certificate of terminal illness was missing documentation of a narrative of the clinical information that was used to support the patients' life expectancy of 6 months or less. Record #57357 was reviewed and identified the patient was admitted on 12/23/2021. There was no documentation of a written certification narrative. Record #13394 was reviewed and identified the patient was admitted on 2/22/2022. There was no documentation of a written certification narrative. Record #98767 was reviewed and identified the patient was admitted on 2/22/2022. There was no documentation of a written certification narrative. The Nurse Educator and the Regional Director of Nursing were interviewed on 3/3/2022 and agreed that the narrative was missing from the CTI. There was no additional information provided.

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 review of records and interview. 1 of 20 (05%) records reviewed was missing documentation of a physician order. Record #36769 was reviewed and revealed there was a change in level of care from routine care to continuous care initiated on 2/10/2022. There was no documentation of a physician order for the change in level of care. The Nurse Educator and Regional Director were interviewed on 3/3/2022 and agreed the physician order was missing No further evidence was provided.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary; and the patient's record, if requested. This standard was not met as evidenced by review of records and interview. 1 of 2 (50%) records reviewed in which patients were discharged revealed that the discharge summary was not sent to the physician when the revocation and discharge occurred. Record 18257 was reviewed and identified that the patient revoked hospice services on 12/24/2021 to seek aggressive treatment. There was no evidence that a discharge summary was sent to the attending physician. The Nurse Educator was interviewed on 3/2/2022 and agreed that the discharge summary was not sent to the attending physician and there was no additional information to provide.