Every finding on record at Coastal Hospice Care

Upon patient record review, 2 of 14 (Patients #1, 2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: During the home visit, the patient medical record stated she was taking Lyrica 50mg twice daily. She was not taking Lyrica. Patient had gabapentin that she was taking instead as she stated Lyrica gave her serious side effects. The medical record did not reflect the Claritin 10mg that patient stated she took daily for allergies. Patient #2: During home visit, it was noted patient was taking Tylenol and Ibuprofen regularly for pain management. Neither of these medications were on the medication list.

Upon patient record review, 4 of 14 (Patient #5, 6,7,8) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #5: Patient was admitted on 9/18/24 with no evidence of any subsequent RN visits for continuous assessment. Patient #6: Patient last visit from an RN was 09/18/24, equal to 28 days between RN visits. Patient #7: Patient last visit from an RN was 09/25/24, equal to 21 days between RN visits. Patient #8: Patient last visit from an RN was 09/26/24, equal to 20 days between RN visits.

Upon patient record review, 1 of 14 (Patients #3) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #3: On 06/14/24, a communication note from the RN states patient complaining of overactive bladder. No visit made, medication Mybetriq started by physician order. A visit was not made by nurse until 06/18/24. The Mybetriq was not mentioned in any future nursing visits in regards to effectiveness or side effects.

Upon patient record review, 3 of 14 (Patients #1,6,7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The patient has an oxygen concentrator. There are no problems, goals, or interventions for oxygen on the POC. Patient #6: The patient has Glucerna listed under supplies. There are no problems, goals, or interventions for Glucerna on the POC. Patient #7: The patient has Ensure listed under supplies. There are no problems, goals, or interventions for Ensure on the POC.

Upon patient record review, 3 of 14 (Patients #6, 7, 8) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #6, 7, 8: The orders for nursing visits stated RN q 14 days and prn. There was no evidence of a defined frequency for the RN.

Upon patient record review, 2 of 14 (Patients #1, 4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: The patient has an oxygen concentrator. The oxygen concentrator is not listed on the plan of care. Patient #4: The patient had documented in the medical record they had cane, gloves, personal care supplies but not listed on the plan of care.

Upon patient record review, 5 of 14 (Patients #5, 6, 7, 8, 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: The orders for nursing visits stated RN q14 days and prn. The SN orders stated once weekly and 3 prn. Only one visit was made on 9/18/24. Patient #6: The orders for nursing visits stated RN q 14 days and prn. The SN orders stated once weekly and 3 prn. The last visit from an RN was made on 09/18/24 and one visit made by LVN on 09/27/24. Patient #7: The orders for nursing visits stated RN q 14 days and prn. The SN orders stated once weekly and 3 prn. The last visit from the RN and LVN was 09/25/24. Patient #8: The orders for nursing visits stated RN q 14 days and prn. The SN orders stated once weekly and 3 prn. The last visit from an RN was 09/26/24 and LVN was 09/25/24. Patient #12: This patient was a full code. At the time of death, the LVN was in the home and did not initiate CPR based on patients full code status in the plan of care.

Upon patient record review, 14 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patients #1-14: On the election of benefit, the patient/caregiver requested a Hospice Election Statement Addendum. There was no proof in the electronic or paper chart of this addendum being created and provided to the patient/caregiver. Per CMS regulation 418.24(c), the hospice election statement addendum, titled "Patient notification of Hospice Non-Covered Items, Services and Drugs" must be provided to the patient within the first 5 days of admission when requested.

Upon patient record review, 2 of 14 (Patient #11,12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11: The discharge summary does not include the patient's code status, the current plan of care, including current medications and allergies. There is no evidence that the discharge summary was forwarded to the receiving organization and physician. Patient #12: The discharge summary does not include the patient's code status, the current plan of care, including current medications and allergies. There is no evidence that the discharge summary was forwarded to the receiving organization and physician.

Upon patient record review, 2 of 14 (Patients #11, 12) did not have evidence that the discharge summary includes all required information. Patient #11: The discharge summary does not include the patient's code status, the current plan of care, including current medications and allergies. Patient #12: The discharge summary does not include the patient's code status, the current plan of care, including current medications and allergies.

Observed in Patient Home. While reviewing the patient's home folder during HV#3 the surveyor observed that there was an emergency plan for this patient on one side of a piece of paper and a CHHA supervisory visit note for a patient from another hospice on the other side. It was later learned that the CHHA worked for both organizations, and, that the patient being visited did not have home health aide services ordered. This was reviewed with the Administrator/Director of Patient Care Services.

Observed in Record Review. Interdisciplinary group meeting notes did not document decline, and revisions to plans of care and goals. For example, an RN wrote in the record of RR#2 that a patient had developed edema in both lower legs. There was no evidence that this was discussed during the meeting. This was reviewed with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 7 of 7 patient records reviewed, it was noted that every interdisciplinary group narrative by each discipline did not change from meeting to meeting. The review of the past two weeks was the same and did not address new patient needs or decline. And the plans for the following two weeks were ambiguous. This was reviewed with the Administrator/Director of Patient Care Services.

Observed in Record Review. An RN documented on an aide plan of care in the record of RR#2 that oxygen could be removed for care. This was contrary to the physician’s order which specified continuous use of the oxygen. This was reviewed with the Administrator/Director of Patient Care Services.

Observed in Patient Home. During HV#1 the surveyor observed that the patient refused a shower which was ordered in the aide plan of care. The CHHA contacted an RN Case Manager for directions. The surveyor did not hear what the aide was instructed to do but observed him clean and pack up his equipment to leave. When asked who he had spoken with the CHHA provided the name of an RN who did not work for this hospice. Thus, the instructions provided to him were invalid. This was reviewed with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 7 of 7 patient records reviewed, the Physician Orders for Life Sustaining Treatment document was incomplete. The section where advanced directives are addressed was blank. This was reviewed with the Administrator/Director of Patient Care Services.