Every finding on record at Country Care Hospice, Inc.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. The 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 document review, clinical record review, and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the medication profile included the patient’s current medications. Agency policy PC.M55 Medication-Profile, required in part, "A patient-specific medication profile is maintained for each patient and reviewed, at a minimum, every fifteen days. When a patient is admitted to hospice, a medication profile is initiated to document all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy." Clinical Record 13: Clinical record review revealed a physician order dated 02/08/2024 for "Oxygen at 2 liters per nasal cannula as needed for dyspnea." The patient’s medication profile dated 02/08/2024 did not include oxygen. Clinical Record 14: Clinical record review revealed a physician order dated 04/28/2024 for "Oxygen at 5 liters per nasal cannula continuously." The patient’s medication profile dated 04/28/2024 did not include oxygen. During an interview on 09/25/2024, the Clinical Director reviewed the records and stated, "Oxygen is not listed on 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 2 of 14 (14%) clinical records reviewed, the agency did not ensure that problems identified in the comprehensive assessment had interventions and goals in the written plan of care. Clinical Record 3: The initial nursing assessment dated 04/23/2024 included the documentation "Patient is diabetic and is receiving insulin." The plan of care dated 04/23/2024 to 07/21/2024 did not include planned interventions and goals related to diabetes. Clinical Record 10: The initial nursing assessment dated 11/21/2023 included the documentation "Patient is diabetic." The plan of care dated 11/21/2023 to 02/19/2024 did not include planned interventions and goals related to diabetes. During an interview on 09/25/2024, the Clinical Director reviewed the records and stated, "There are no interventions or goals regarding diabetes in the plans of care."

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide; ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 6 of 13 (46%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse completed aide supervisory visits no less frequently than every 14 days. Clinical Record 2: Clinical record review revealed a physician order dated 09/01/2024 that ordered "Aide visits 2 times per week starting 09/04/2024." The first aide visit note was dated 09/04/2024 and the first aide supervisory visit was dated 09/19/2024, fifteen days after the first aide visit and one day outstanding. Clinical Record 3: Clinical record review revealed a physician order dated 04/23/2024 that ordered "Aide visits 2 times per week starting 04/26/2024." The first aide visit note was dated 04/26/2024 and the first aide supervisory visit was dated 06/06/2024, 41 days after the first aide visit and 27 days outstanding. Clinical Record 8: Clinical record review revealed a physician order dated 03/11/2024 that ordered "Aide visits 2 times per week starting 03/13/2024." The first aide visit note was dated 03/13/2024 and the first aide supervisory visit was dated 03/19/2024. The next aide supervisory visit was dated 04/29/2024, a total of 41 days after the 03/19/2024 supervisory visit and 27 days outstanding. The next aide supervisory visit was dated 05/15/2024, 16 days after the 04/29/2024 supervisory visit and 2 days outstanding. The next aide supervisory visit was dated 06/07/2024, 23 days after the 05/15/2024 supervisory visit and 9 days outstanding. Clinical Record 10: Clinical record review revealed a physician order dated 11/21/2023 that ordered "Aide visits 2 times per week starting 11/29/2023." The first aide visit note was dated 11/29/2023 and the first aide supervisory visit was dated 01/12/2024, 44 days after the first aide visit and 30 days outstanding. The next aide supervisory visit was dated 01/30/2024, 18 days later and 4 days outstanding. The next aide supervisory visit was dated 02/29/2024, 30 days later and 16 days outstanding. The next aide supervisory visit was dated 03/15/2024, 16 days later and 2 days outstanding. An aide supervisory visit was completed on 04/12/2024 with the next supervisory visit dated 04/29/2024, 17 days later and 2 days outstanding. The next aide supervisory visit was dated 05/15/2024, 16 days later and 2 days outstanding. The next aide supervisory visit was dated 06/06/2024, 22 days later and 8 days outstanding. Clinical Record 12: Clinical record review revealed a physician order dated 06/16/2023 that ordered "Aide visits 2 times per week starting 06/17/2023." An aide supervisory visit was completed on 07/21/2023 and the next aide supervisory visit was dated 09/12/2023, 53 days after the 07/21/2023 supervisory visit and 39 days outstanding. Clinical Record 14: Clinical record review revealed a physician order dated 04/28/2024 that ordered "Aide visits 2 times per week starting 04/28/2024." The first aide visit note was dated 04/29/2024. The clinical record contained no documented evidence that aide supervisory visits were completed. During an interview and review of records on 09/25/2024, the Administrator stated, "There should have been aide supervisory visits every 14 days."

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. This standard was not met as evidenced by record review and interview. The agency failed to provide evidence the drug profile was updated with the comprehensive assessment in 5 of 5 (100%) records reviewed. Record #39764: This patient was admitted to hospice on 8/31/2021. The hospice drug profile revealed Tramadol 50 MG tab, one tab, frequency of PRN/AS NEEDED for pain, start date 8/3/2020. The facility medication record revealed Tramadol 50 MG tab, one tab, frequency of Q6H PRN MODERATE PAIN, start date 4/19/2021. The hospice drug profile was reviewed for 8/31/2021 and there was no evidence the tramadol was correctly updated to the drug profile. The hospice drug profile reviewed through 11/1/2021 revealed all medications with a PRN frequency had PRN/AS NEEDED with no time parameters. Record #29798: This patient was admitted to hospice on 9/13/2021. The hospice drug profile revealed Tramadol 50 MG tab, one tab, frequency of PRN/AS NEEDED for pain, start date 7/30/2021. The facility medication record revealed Tramadol 50 MG tab, two tabs, frequency of FOUR TIMES A DAY AS NEEDED FOR PAIN, start date 7/30/2021. The hospice drug profile was reviewed for 7/30/2021 and there was no evidence the tramadol was correctly updated to the drug profile. The hospice drug profile reviewed through 11/1/2021 revealed all medications with a PRN frequency had PRN/AS NEEDED with no time parameters. Record #33733: This patient was admitted to hospice on 9/16/2021. The hospice drug profile revealed Norco 5-325 MG tab, one tab, frequency of PRN/AS NEEDED for pain, start date 9/16/2021. The facility medication record revealed Norco 5-325 MG tab, one tab, frequency of EVERY 4 HOURS AS NEEDED FOR MODERATE PAIN, dated 9/16/2021. The hospice drug profile was reviewed for 9/16/2021 and there was no evidence the Norco was correctly updated to the drug profile. The hospice drug profile reviewed through 11/1/2021 revealed all medications with a PRN frequency had PRN/AS NEEDED with no time parameters Record #36329: This patient was admitted to hospice on 10/7/2021. The drug profile revealed Diclofenac Sodium 3%, one application, frequency of PRN/AS NEEDED for pain, start date 10/7/2021. The hospice admission orders dated 10/7/2021 revealed Diclofenac Gel 2 grams/2.25 inches, one application, frequency of EVERY 12 HOURS AS NEEDED FOR BUE JOINT PAIN. The drug profile was reviewed for 10/7/2021 and there was no evidence the Diclofenac was correctly updated to the drug profile. The hospice drug profile reviewed through 11/1/2021 revealed all medications with a PRN frequency had PRN/AS NEEDED with no time parameters. Record #72707: This patient admitted to hospice on 10/8/2021. The comprehensive assessment dated 10/13/2021 stated “Tramadol TID at 6am, 12 noon, 6pm and prn every 6 hours. Prior to this change, Tramadol and Tylenol were prn" The hospice drug profile was reviewed for 10/13/2021 and there was no evidence the Tramadol was correctly updated to the drug profile. The drug profile reviewed through 11/1/2021 revealed all medications with a PRN frequency had PRN/AS NEEDED with no time parameters. The Clinical Director and Alternate Clinical Director were interviewed on 11/2/2021 and stated the drug profile would only allow “PRN/AS NEEDED” to be added to the drug profile for any PRN medications and would not allow frequency parameters, such as every 6 hours to be entered. The Alternate Clinical Director and Clinical Director confirmed this finding.

It is required that each patient’s individualized written plan of care: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by record review and interview. The agency failed to provide evidence the patient’s written plan of care was individualized with measurable outcomes in 5 of 5 (100%) records reviewed. Record #39764: The plan of care identified “pain” as a problem on 8/31/2021 with a goal “patient/caregiver will verbalize pain relief measures including pharmacologic and non-pharmacologic measures.”. The nursing assessment on 8/31/2021 stated, “moderate osteoarthritis pain to hips and possible lower back. Noted facial grimacing and rubbed left hip and lower back upon standing. Increases with movement and is relieved by rest. PAINAD 4.”. Record #29798: The plan of care identified “pain” as a problem on 9/13/2021 with a goal “patient/caregiver will verbalize pain relief measures including pharmacologic and non-pharmacologic measures.”. The nursing assessment on 9/13/2021 stated, “primary pain site: shoulders, hips, knees, lower back. Facial grimacing, frequent, constant, worsened by a change in position and movement, relieved by medication and repositioning, breakthrough pain daily Current pain management and effectiveness: Tylenol, Morphine, Meloxicam, Prednisone, Salonpas gel-staff state patient eats better with this pain regimen. PAINAD 5.”. Record #33733: The plan of care identified “pain” as a problem on 9/16/2021 with a goal “patient/caregiver will verbalize pain relief measures including pharmacologic and non-pharmacologic measures.”. The nursing assessment on 9/16/2021 stated, “7/18/21 patient had a fall that resulted in a left hip fracture. Patient has mild intermittent discomfort with weight bearing. Today I transferred patient from wheelchair to bed and patient limped and stated ‘oh’ and then smiled at me. No facial grimacing through transfer or after sitting on side of bed. PAINAD 2.”. Record #36329: The plan of care identified “pain” as a problem on 10/7/2021 with a goal “will work with patient and staff on non-pharmacologic pain relief measures and a patient/caregiver will verbalize pain relief measures including pharmacologic and non-pharmacologic measures.”. The nursing assessment on 10/7/2021 stated, “Pain location in lower back. At rest patient rated pain at a 4 and at worst rated pain at 8. Describe pain as a shooting pain with ambulation and repositioning and lessens with rest. Pain occurs daily and does not affect activities or sleeping.”. Record #72707: The plan of care identified “pain” as a problem on 10/8/2021 with a goal “caregiver will verbalize pain relief measures including pharmacologic and non-pharmacologic measures.”. The nursing assessment on 10/8/2021 stated, “Pain severity: severe. Pain is located in left hip with noted pain increase anxiety with ADLs, and facial grimacing and pushing away with transfers. Facial grimacing and pushing away stops when patient is resting either in chair or laying in bed. When laying or resting can identify pain by increase restlessness and increase mumbling. Pain is relieved by medication and rest and worsens with movement and weight bearing. Pain affects appetite and sleeping.”. The Alternate Clinical Director was interviewed on 11/2/2021 and stated “we agree they are not individualized and measurable.”. The Clinical Director confirmed this finding on 11/3/2021.