Every finding on record at Community Hospices of America, LLC

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; [and] 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 clinical record review, document review, and interview. Agency policy #15C, "Medication Reconciliation," dated 01/30/2019, read in part, "Regardless of setting, it is the responsibility of the registered nurse performing the admission visit to complete a comprehensive medication review and reconciliation. Document a complete medication inventory, noting prescriptions, over-the-counter medications, and herbal preparations the patient is currently taking or has on hand." In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current medications. Clinical Record 5: The patient elected the hospice benefit on 10/09/2024. The Registered Nurse (RN) initial assessment dated 10/09/2024 documented, "Patient is on intermittent oxygen." The drug profile dated 10/09/2024 did not document oxygen. Clinical Record 17: The patient elected the hospice benefit on 11/11/2023. The RN initial assessment dated 11/11/2023 documented, "Patient is on oxygen at 2 liters." The drug profile dated 11/11/2023 did not document oxygen. In an interview and a joint record review on 11/06/2024, the Director of Clinical Services stated, "There is no oxygen listed in these medication profiles."

It is required that each patient’s individualized written plan of care reflects patient and family goals; and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that all problems identified in the initial and updated comprehensive assessments had planned interventions in the patient's individualized written plan of care. Clinical Record 3: The patient elected the hospice benefit on 05/07/2024. On 05/07/2024, the physicians ordered: "Eliquis (anticoagulant) 2.5 mg tablet by mouth twice a day." The plan of care dated 05/07/2024 through 08/04/2024 did not include an intervention related to the patient being at risk for bleeding. Clinical Record 8: The patient elected the hospice benefit on 01/11/2024. On 04/10/2024, the physician ordered: "Eliquis 2.5 mg tablet by mouth twice a day." The plan of care dated 04/10/2024 through 07/08/2024 did not include an intervention related to the patient being at risk for bleeding. Clinical Record 14: The patient elected the hospice benefit on 09/04/2024. On 09/04/2024, the physician ordered: "Clopidogrel (antiplatelet) 75 mg tablet by mouth once a day." The plan of care dated 09/04/2024 through 11/02/2024 did not include an intervention related to the patient being at risk for bleeding. In an interview and a joint record review on 11/06/2024, the Director of Clinical Services stated, "These patients do not have interventions for being a bleeding risk."

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 1 of 14 (7%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that all written patient care instructions were included in the aide care plan. Clinical Record 9: The patient elected the hospice benefit on 07/24/2024. On 07/24/2024, the physician ordered "Aide services 2 times per week." The HA care plan dated 07/24/2024 assigned the HA the relevant task of "Bed bath at every visit." On 09/05/2024, the physician ordered wound care with a wound dressing to a wound on the patient's right buttock. The HA care plan was not updated to provide the HA with instructions addressing the right buttock wound dressing should it become wet or dislodged during the bed bath until an updated care plan dated 10/30/2024. On 11/05/2024, the Director of Clinical Services reviewed the record and confirmed that the HA care plan was not updated with wound dressing instructions until 10/30/2024.

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 clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that the patient's clinical record contained physician's orders for the care and services provided. Clinical Record 5: The patient elected the hospice benefit on 10/09/2024. The initial RN assessment dated 10/09/2024 documented, "Patient is on intermittent oxygen." A review of the clinical record revealed no physician's order documenting the flow rate, route, and frequency of oxygen administration. Clinical Record 7: The patient elected the hospice benefit on 09/12/2024. The initial RN assessment dated 09/12/2024 documented, "Patient has a Foley catheter." A review of the clinical record revealed no physician's order documenting the size or the care and maintenance of the Foley catheter. Clinical Record 17: The patient elected the hospice benefit on 11/11/2023. The initial RN assessment dated 11/11/2023 documented, "Patient is on oxygen at 2 liters." A review of the clinical record revealed no physician's order documenting the flow rate, route, and frequency of oxygen administration. Clinical Record 19: The patient elected the hospice benefit on 08/15/2024. The initial RN assessment dated 08/15/2024 documented, "Patient has a 16Fr foley catheter in place that was inserted at the hospital on 08/08/2024." A review of the clinical record revealed no physician's order documenting the size or the care and maintenance of the Foley catheter. In an interview on 11/06/2024, the Director of Clinical Services reviewed the records and stated, "There is not a physician's order for oxygen or Foley catheter in these charts."

It is required that hospice aides must report changes in the patient's medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient's needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy "Hospice Aide: Routine Visit' revised 04/2009 stated, in part, "If other care is required, or plan of care needs to be updated, the Hospice aide must call the RN or the Director of Clinical Service. 1 of 2 (50%) applicable records of patients receiving hospice aide services revealed no documented evidence that the hospice aide reported changes to the RN that might impact the plan of care. Record #80480: This patient was admitted on 08/11/2021. Hospice aide notes dated 08/13/2021 and 08/17/2021 documented that all care was provided but the record included documentation on two consecutive days that the patient refused shampoo, toileting, hair care, transferring from bed to chair and linen change. There was no documentation that the hospice aide had reported changes to the RN. Interview with the Area Executive of Clinical Operations on 12/21/2021 revealed that the hospice aide notifies the RN or the DCS of interventions not performed. These findings were confirmed with the Area Executive of Clinical Operations on 12/21/2021.