Every finding on record at Comforting Hands Hospice of Grove LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals, 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 14 (21%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient's date of election was 04/18/2024. The primary hospice diagnosis was chronic kidney disease, unspecified, with comorbidities including diabetes mellitus type 2. The initial nursing assessment on 04/18/2024 documented that the patient had shortness of breath upon exertion, used a CPAP/BiPAP, used insulin, used a blood glucose monitor, had a pain rating of 6/10 to the lower back, and had a fall risk of 9 on the MAHC-10 with a score of 4 or more was considered at risk for falling. The recertification assessment on 07/09/2024 documented that the patient had shortness of breath upon exertion, used a CPAP/BiPAP, used insulin, and used a blood glucose monitor. The plan of care dated 04/18/2024-07/16/2024 and 07/17/2024-10/14/2024 lacked problems, interventions, and goals for altered respiratory status, insulin dependence, glucometer management, potential fall risk, and pain management. Clinical Record 2: The patient's date of election was 07/01/2023. The primary hospice diagnosis was heart failure, unspecified. The initial nursing assessment on 07/01/2023 documented that the patient had a right lower leg skin tear, bowel and bladder incontinence, and shortness of breath upon exertion. The recertification assessment on 08/25/2023 documented that the patient had bowel and bladder incontinence. The plan of care dated 07/01/2023-08/29/2023 and 08/30/2023-10/28/2023 lacked problems, interventions, and goals for altered respiratory status, wound, and risk for skin breakdown. Clinical Record 3: The patient's date of election was 06/27/2024. The primary hospice diagnosis was chronic obstructive pulmonary disease with acute exacerbation with comorbidities of diabetes mellitus type 2. The initial nursing assessment on 06/27/2024 documented that the patient had skin tears to the lower left leg, lower right leg, and the left arm/wrist, bladder incontinence, diabetes mellitus type 2 managed by blood glucose monitoring, a recent history of falls, a MAHC-10 score of 8, and the presence of a cardioverter-defibrillator. The medication record reviewed on 09/06/2024 revealed the patient was taking glimepiride, Jardiance, and metformin, which were added on 06/27/2024. The plan of care dated 06/27/2024-09/24/2024 lacked problems, interventions, and goals for hyperglycemia, hypoglycemia, falls, cardioverter-defibrillator, wounds, and risk for skin breakdown. During a joint clinical record review and interview on 09/05/2024, the Administrator/Registered Nurse confirmed there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the assessments.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed revealed the agency did not ensure that counseling services, including spiritual counseling, were provided based on an assessment of the patient’s and family’s spiritual needs. Clinical Record 5: The patient’s date of election was 03/11/2024. The initial plan of care dated 03/11/2024-06/08/2024 ordered the chaplain to assess and evaluate 03/11/2024-03/15/2024. The record lacked evidence the chaplain made a visit from 03/11/2024 through 03/15/2024. The record lacked evidence that the order was discontinued. Clinical Record 7: The patient’s date of election was 04/18/2024. The initial plan of care dated 04/18/2024-07/17/2024 ordered the chaplain to assess and evaluate 04/18/2024-04/22/2024. A missed visit dated 04/19/2024 documented, "Unable to contact patient for initial assessment. Will try again later." The records lacked any further contact with the patient or caregiver. The record lacked evidence that the order was discontinued. During a joint clinical record review and an interview on 09/06/2024, the Director of Nursing confirmed that there was no documented evidence that spiritual counseling services were provided during the times identified.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure that the hospice aide care plan provided specific instructions to the aide. Clinical Record 1: The patient’s date of election was 04/18/2024. The primary hospice diagnosis was chronic kidney disease, unspecified. The hospice aide care plan dated 04/18/2024, reviewed on 09/05/2024, assigned the hospice aide the tasks, "Hygiene: Bath: Tub; Hygiene: Bath: Partial; Hygiene: Bath: Shower; Hygiene: Bath: Bed; Hygiene: Bath: Shower Chair; Hygiene: Bath: Complete; Hygiene: Bath." The care plan did not provide clear instructions to the hospice aide regarding the type of bath. Clinical Record 2: The patient’s date of election was 07/01/2023. The primary hospice diagnosis was heart failure, unspecified. The hospice aide care plan dated 07/01/2023, reviewed on 09/05/2024, assigned the hospice aide the tasks "Hygiene: Bath: Shower Chair; Hygiene: Bath: Complete; and Hygiene: Bath: Shower." The care plan did not provide clear instructions to the hospice aide regarding the type of bath. During a joint review of the record and an interview on 09/05/2024, the Administrator/Registered Nurse agreed the instructions on the hospice aide care plan were not specific.

It is required that a hospice aide provide services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records with hospice aide services reviewed revealed the agency did not ensure that a hospice aide provide services included in the plan of care. Clinical Record 3: The patient's date of election was 06/27/2024. The date of the aide plan of care was 06/27/2024 included to document bowel movements, report to RN if no BM in 3 days, give SSE as directed by RN; give SSE as directed by RN; bed bath; complete bath; shower; pt to be non-weight bearing; bath; partial bath; do patient laundry; dinner; clean living area of the patient; blood pressure; report patient pain to nurse; assist with positioning, repositioning, alignment; change adult diapers; water temperature check; snack; oral care; foot care; ambulate only with assistance; transfer belt; assist with meal preparation; shave: safety razor; may trim or file any long or uneven finger nails; standard precautions; ROM exercises; pulse; assist patient to open medication container; document bowel movements; assess pain; independent ambulation; denture care; shampoo; clean up kitchen after meal preparation; emergency call system; assist with meal preparation, set-up, feeding; report to RN if no BM; weight; assist with meal planning; assist to commode; bath: shower chair; remind patient to take medications; change patient linen; temperature; lunch; breakfast; incontinent care; fall precautions; assist with transfers, ambulation, exercise program; respirations; clean bathroom after patient care; nail care; universal precautions; assist with transfers; recognize and report any changes in the patient's skin condition; record intake and output; meal planning/preparation; shopping/errands; shave; fluid intake; skin care; assist patient with dressing; assist to BSC/toilet; shave electric; assist with medication administration; up in chair/wheelchair; report abnormal vital signs to nurse; perineal care; encourage to wear glasses/hearing aids; transfer to bed/chair with assistance; encourage patient to wear dentures; oxygen precautions; teach/reinforce home safety interventions (lighted stairs, clear walkways, no throw rugs, personal alert system, etc.); and patient to dangle. The aide follow up visit note dated 07/03/2024 documented, "Applied cream to legs, applied Nystatin cream on feet and wound care was provided to shin wounds and big toe and applied compression sock on patient." The aide's plan of care did not include interventions to apply Nystatin cream on the feet and to complete wound care to shin wounds and the big toe. During a joint review of the record and an interview on 09/06/2024, the Administrator/Registered Nurse confirmed that the hospice aide provided services not included in the plan of care.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1, and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Upon reviewing the volunteer program, the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from January 2024 to March 2024. The documentation lacked evidence of the amount that, at a minimum, equals five percent (5%) of the total patient care hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions During a joint review of the volunteer program records and interview on 09/06/2024, the Administrator/Registered Nurse confirmed that the agency did not document the direct care staff hours, the volunteer percentage, and the cost savings from January 2024 through March 2024, and the average percentage for April 2024 through August 2024 did not equal five percent (5%). Upon reviewing the volunteer program, the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from January 2024 to March 2024. The documentation lacked evidence of the amount that, at a minimum, equals five percent (5%) of the total patient care hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. In 3 of 13 (23%) personnel records reviewed revealed that the agency did not ensure employees were assessed for skills and competencies. Personnel Record 2: The Patient Care Coordinator's date of hire was 08/25/2022. The record lacked evidence of skills and competency. Personnel Record 9: The Registered Nurse's date of hire was 11/13/2023. The record lacked skills and competency. Personnel Record 13: The Licensed Practical Nurse's date of hire was 07/12/2023. The record lacked evidence of skills and competency. During a joint record review and interview on 09/06/2024, the Administrator/Registered Nurse confirmed that the records did not include evidence that the employees were assessed for skills and competencies. The Administrator/Registered Nurse stated that nursing staff have an initial competency complete before seeing patients on their own.

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 clinical record review and interview. In 2 of 2 (100%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 11: The revocation date was 10/05/2023. The discharge summary electronically signed on 10/09/2023 lacked documentation that the discharge summary was forwarded to the patient's attending physician. Clinical Record 12: The revocation date was 07/11/2024. The discharge summary electronically signed on 07/12/2024 lacked documentation that the discharge summary was forwarded to the patient's attending physician. During a joint record review and interview on 09/06/2024, the Administrator/Registered Nurse confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records for discharged patients reviewed revealed that the agency did not ensure that the discharge summary included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Clinical Record 11: The date of the revocation was 10/05/2023. The Discharge Summary lacked a summary that included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Clinical Record 12: The date of the revocation was 07/11/2024. The Discharge Summary lacked a summary that included at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. During a joint record review and interview on 09/06/2024, the Administrator/Registered Nurse confirmed that the record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician.

It is required that the written Patient Bill of Rights includes the right to choose his or her attending physician. This standard was not met as evidenced by a review of patient admission documents, clinical records, and interview with the Administrator. 2 of 10 (20%) records reviewed revealed the election of hospice statements designated an attending physician who was not the hospice medical director to oversee their care Record #35793: The patient admission documents, includes a signed election of hospice benefit on the date of admission, 10/1/2021. The Patient documented the choice of Attending Physician on the election statement, who is not the hospice medical director. The hospice medical director has been fulfilling the role of attending physician since admission. There were no orders that transferred care from the Attending Physician to the Hospice Medical Director. There were no communication notes related to an Attending Physician refusing to oversee care. Record #11145: The patient admission documents, includes a signed election of hospice benefit on the date of admission, 9/16/2021. The Patient documented the choice of Attending Physician on the election statement, who is not the hospice medical director. The hospice medical director has been fulfilling the role of attending physician. There were no orders that transferred care from the Attending to the Hospice Medical Director. There were no communication notes related to an attending refusing to provide care. This was confirmed during an interview with the Administrator.

It is required that the drug profile is updated at the time of each comprehensive assessment and/or when a new medication is added, or changes are made to existing medication. This standard was not met as evidenced by observation during the home visit, clinical records, and interview with the Administrator. 1 of 2 (50%) observations and interviews during home visits with skilled nursing, and review of plans of care and drug profiles revealed drug profiles are not updated during comprehensive assessments, when medication is added, or when changes are made to existing medications. Record #70701: During a home visit on 10/26/2021 with the RN and LVN, Tylenol 325mg was present with current medications administered to the patient. When the site visitor asked if the medications present include all currently administered medications, the RN and LVN stated “yes.” Tylenol was not present on review of the drug profile in the Plan of Care dated 10/15/2021. Skilled Nurse (SN) visit completed on 9/21/2021 includes documentation of “patient receiving 2 Tylenol.” On an SN visit of 10/14/2021, the SN documented receipt of a verbal order for “Magnesium 2 tablets at HS for constipation” The Hospice Medical Director signed this order on 10/15/2021. Magnesium was not present on the review of the drug profile as of 10/26/2021. An interview with the Administrator confirmed magnesium was not present on the drug profile. An interview with the Administrator confirmed magnesium and Tylenol were not present on the drug profile.

It is required that each patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records, policy, and interview. 1 of 10 (10%) records reviewed revealed the plan of care, and the drug profile did not include the route of drug administration as per agency policy. Record #35793: The patient was admitted on 10/1/2021 with medication orders from the Hospice Medical Director. The Plan of Care and drug profile did not list the route of administration for the following medications, Melatonin 10mg 1x/day, Trazadone 50mg 1x/day, atorvastatin 20mg 1x/day, ASA 81mg 1x/day, multivitamin 1x/day, Fiber powder ¼ tsp 1x/day, Zinc 50mg 1x/day, super B, Omega 3500mg 1x/day, Protonix 20mg 1x/day, Hydrocodone 7.5/25mg q4h prn moderate pain, Tamsulosin 4mg 1x/day, Mag oxide 400 mg 1x/day, and Calcitriol 50mg 1x/day. On 10/16/2021, the RN received an order for oxygen 2-5L PRN SOB. The order was documented on the POC and drug profile without a documented route of oxygen. Hospice Policy “Medication Orders” states in part, “all medication orders must contain medication name, dosage, route, and frequency.” An interview with the Administrator confirmed the routes were not present on the plan of care or drug profile.

It is required that the Interdisciplinary Group (IDG), in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient's updated comprehensive assessment and record of the patient's progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by a review of IDG meeting documentation, clinical records, and interview with the Administrator. 1 of 3 (33%) applicable records for patients receiving services for greater than 15 days revealed the IDG does not document revised individualized care plans as frequently as the patient's condition requires, nor less frequently than every 15 calendar days. Record #70701: Review of IDG meeting documentation from IDG meetings occurring from the date of admission on 8/25/2021 and scheduled IDG meetings occurring on 8/25/2021, 9/3/2021, 9/17/2021, 10/1/2021, and 10/15/2021 does not document an IDG revised the Plan of Care (POC). On 9/29/2021, Skilled Nurse comprehensive assessment states, "Pedialyte is being provided as an intervention for nutritional deficiency. The POC was not updated to include Pedialyte as an intervention, nor was Pedialyte ordered by the attending physician. A 10/21/2021 Skilled Nurse comprehensive assessment states a heating pad is used, as an intervention, to relieve abdominal pain. The POC was not updated to include a heating pad as an intervention, nor was it ordered by the attending physician. The review of the patient record does not include updated POCs following updated comprehensive assessments. An interview with the Administrator confirmed IDG does not document revised individualized care plans.