Every finding on record at Cypress Hospice

It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 19 (5%) clinical records reviewed, it was revealed that the hospice agency did not ensure the comprehensive assessment identified the physical needs related to the patient's terminal illness. Agency policy 9.7.1, Initial Assessment/Comprehensive Assessment (revised 4/10/18), stated in part, "Each patient will receive an initial and comprehensive assessment. The comprehensive assessment will identify the patient's need for hospice care and identify the patient's need for physical care." Clinical Record 1: A patient who resided in a skilled nursing facility (SNF) with a hospice benefit election date of 10/2/23, had a wound care order dated 10/10/23 that stated, "Perform wound care dressing coccyx cleanse the open area with normal saline. Pat dry. Apply Medihoney and calcium alginate to the wound bed and cover with foam dressing daily and PRN if loose or soiled." However, the initial nursing assessment completed on 10/2/23 did not identify a wound. The comprehensive assessment completed on 10/9/23, stated in part, "Skin was pallor, warm, dry, and loose and lacked tone." The assessment did not identify a wound. The comprehensive assessment dated 10/17/23, stated in part, "Wound care dressing coccyx cleanse the open area with normal saline. Pat dry. Apply Medihoney and calcium alginate to the wound bed and cover with foam dressing. Completed." During a joint record review and interview on 10/30/23, the Administrator confirmed the finding and stated the assessments did not document a wound.

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 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, observation, document review, and interview. In 3 of 4 (75%) observed home visits, it was revealed that the hospice agency did not update the medication profile. Agency policy 8.20.1, Medication Reconciliation, stated in part, "Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication." Home Visit 2 / Clinical Record 3: A home visit was conducted on 10/31/23 at an assisted living facility (ALF), for a patient with a hospice benefit election date of 8/11/23. A medication reconciliation was performed, comparing the hospice agency's medication profile to the patient's medication regimen. The hospice agency's medication profile dated 10/30/23, stated in part, "Dicyclomine ten (10) milligrams (mg). Take two (2) caps orally four (4) times daily as needed (PRN) for IBS." The ALF medication profile dated 10/31/23, stated in part, "Dicyclomine ten (10) milligrams (mg). Take one (1) cap by mouth every six (6) hours as needed (PRN) for IBS." During a joint home visit and interview on 10/31/23, the Administrator confirmed the finding and stated, the hospice agency medication profile did not match the patient's current medication regimen. Home Visit 3 / Clinical Record 4: A home visit was conducted on 10/31/23 at an ALF, for a patient with a hospice benefit election date of 8/11/23. A medication reconciliation was performed, comparing the hospice agency's medication profile to the patient's medication regimen. The hospice agency medication profile dated 10/30/23, stated in part, "Gabapentin three-hundred (300) milligrams (mg). Take one (1) cap three (3) times a day for neuropathic pain." The ALF medication profile dated 10/31/23, stated in part, "Gabapentin three-hundred (300) milligrams (mg). Take one (1) cap one (1) time a day for pain." The hospice agency medication profile stated in part, "Vitamin D3 twenty-five (25) micrograms (mcg). Take three (3) caps one (1) time a day." The medication administration record and medication profile provided by the ALF stated in part, "Vitamin D3 twenty-five (25) micrograms (mcg). Take one (1) tablet by mouth in the morning. The ALF medication profile, stated in part, "Combivent Aerosol eighteen (18)-one hundred three (103) micrograms (mcg) per ACT. Take two (2) inhalations orally as needed (PRN) three (3) times a day for shortness of breath; Artificial Tears Ophthalmic solution. Instill one (1) drop in both eyes every twelve (12) hours as needed (PRN) for dry eyes." However, the hospice agency medication profile did not include Combivent or Artificial Tears Ophthalmic solution. The hospice agency medication profile stated in part, "Vitamin C one thousand (1000) milligrams (mg). Take one-half (1/2) tab orally one (1) time a day." The ALF medication profile did not include Vitamin C. During a joint home visit and interview on 10/31/23, the Administrator confirmed the hospice agency medication profile did not match the patient's current medication regimen. Home Visit 4 / Clinical Record 2: A home visit was conducted on 10/31/23 at a private residence, for a patient with a hospice benefit election date of 5/31/23. A medication reconciliation was performed by comparing the hospice agency medication profile dated 10/30/23, to the patient's current medication regimen. The hospice registered nurse (RN) filled a weekly medication planner by following a medication list dated 6/1/23. The RN added the following medication: Lipitor ten (10) milligrams (mg), one (1) tablet every day. However the hospice agency medication profile dated 10/30/23, did not include Lipitor. The RN confirmed that the patient was taking Lipitor. The RN accessed the electronic medical record (EMR) and reported that Lipitor was discontinued on 9/30/23. The RN stated, "No, she should be taking Lipitor." The RN confirmed the physician would be contacted for clarification. During a joint home visit and interview on 10/31/23, the Administrator confirmed the hospice agency medication profile did not include Lipitor and did not match the patient's current medication regimen.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 19 (16%) clinical records reviewed, it was revealed that the hospice agency did not ensure that the comprehensive assessment included an initial bereavement assessment. Agency policy 9.7.1, Initial Assessment/Comprehensive Assessment (revised 4/10/18), stated in part, "The hospice RN must complete the initial assessment within 48 hours after the election of Hospice care and continued follow up on the initial assessment not to exceed 5 days. The initial assessment includes the patient's immediate physical, psychosocial, emotional, and spiritual status related to the terminal illness." Agency policy 4.27.1, Bereavement Services (revised 2/17/14), stated in part, " An initial bereavement risk assessment will be performed as a part of the comprehensive assessment. Depending on the initial assessment, a plan of care will be developed to include specific counseling to patient and family members." Clinical Record 2: A patient with a hospice benefit election date of 5/31/23, had an initial social work (SW) assessment dated 6/1/23. The Chaplain visit was dated 6/1/23. However, there was no evidence that an initial bereavement assessment was completed. The Registered Nurse (RN) completed the initial comprehensive assessment on 5/31/23, which stated in part, "Bereavement risk assessment completed. No." During a joint record review and interview on 10/30/23, the Administrator confirmed the finding and stated, the record did not contain any evidence of a bereavement risk assessment since admission. Clinical Record 4: A patient with a hospice benefit election date of 8/11/23, had an initial SW assessment dated 8/15/23. The Chaplain visit was dated 8/11/23. However, there was no evidence that an initial bereavement assessment was completed. The RN completed the initial comprehensive assessment on 8/11/23, which stated in part, "Bereavement risk assessment completed. No." During a joint record review and interview on 10/30/23, the Administrator confirmed the finding and stated, the record did not contain any evidence of a bereavement risk assessment since admission. Clinical Record 9: A patient with a hospice benefit election date of 4/6/22, had an initial SW assessment dated 4/8/23. The Chaplain visit was dated 4/8/23. However, there was no evidence that an initial bereavement assessment was completed. The skilled nurse visit dated 4/6/23, stated in part, "Bereavement risk assessment completed. No." The initial bereavement risk assessment was completed on 7/1/23 by the social worker. During a joint record review and interview on 11/1/23, the Administrator confirmed the finding and stated, the initial bereavement assessment was not completed within five (5) days, as required.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review, interview and observation. In 1 of 4 (25%) observed home visits, it was revealed that the hospice agency did not follow standard precautions for hand hygiene. Agency policy 5.4.1, OSHA Control Plan, revised 2/17/24), stated in part, "Upon entering the home, place the bag on a clean surface. Paper towels or plastic bags may be used to create a clean area. Wash hands thoroughly. Remove all items that will be needed for the visit. Place the items on one of the paper towels. If additional items are needed after care has started, wash hands before re-entering the bag, Close the bag, and give patient care. Clean any visibly soiled items, which will be returned to the bag. Wash hands and return equipment to the bag. Close the bag ... Thermometers will be wiped with an alcohol pad after each use. Allow to air dry." Agency policy 5.7.1, Hand Hygiene, revised 2/17/14, stated in part, "Indications for hand hygiene are: before and after each procedure when hands are soiled, and after any contact with contaminated materials." Home Visit 4 / Clinical Record 2 / Staff 3: On 10/31/23, the Registered Nurse (RN) was observed for a patient with a hospice benefit election date of 5/31/23. Upon entrance to the private residence, the RN performed hand hygiene and placed the medical supply bag on the couch with a barrier. The RN removed the blood pressure cuff, pulse oximeter, and thermometer from the bag and placed the equipment on the patient's over-the-bed table. However, the over-the-bed table was not cleaned, and a barrier was not used. The RN performed the assessment of vital signs, without any gloves. Following the completion of the assessment of vital signs, hand hygiene was not performed. The RN removed sanitizing wipes from the package and cleaned the equipment with her soiled, bare hands. The equipment was not allowed to dry for three (3) minutes per the manufacturer's instructions. The wet equipment was placed directly back into the supply bag. The RN donned gloves, and removed a soiled brief. After the brief was removed, the RN did not change gloves. The RN proceeded to remove a soiled dressing. The RN did not change gloves, and hand hygiene was not performed. The RN then placed a clean dressing on the patient, while wearing the dirty gloves that were used to remove the soiled dressing and soiled brief. During a joint observation and interview on 10/31/23, the Administrator confirmed the findings.

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. In 2 of 19 (11%) clinical records reviewed, it was revealed that the agency did not ensure that hospice aides reported changes in the patient's needs. Agency policy 9.12.0, Coordination of Patient care, revised 2/17/14, stated in part, "The hospice has developed and maintains a system of communication and integration to ensure that the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided ... Staff will share relevant information to facilitate appropriate continuity and care coordination." Clinical Record 6: The clinical record review revealed a hospice benefit election date of 5/19/23. The care plan dated 5/19/23 - 8/16/23, included hospice aide interventions that stated in part, "Hygiene nail care: clean nails every visit." The hospice aide documented the following on 7/5/23: "Hygiene nail care: clean nails every visit.: Unable to document: not applicable this visit." There was no evidence the RN was notified of the change in the patient's needs. Clinical Record 12: The clinical record review revealed a hospice benefit election date of 1/6/23. The care plan dated 4/6/23 - 7/4/23, included hospice aide interventions that stated in part, " Elimination: Assist to bedside commode/toilet each visit." The hospice aide documented the following on 6/14/23: "Unable to document: Not applicable this visit." There was no evidence the RN was notified of the change in the patient's needs. During a joint record review and interview on 11/1/23, the Administrator confirmed the findings.

It is required that a patient's clinical record contains correct clinical information that is available to the patient's attending physician and hospice staff. Each patient's record must include the initial and updated plans of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 19 (5%) clinical records reviewed, it was revealed that the hospice agency did not ensure the clinical record contained correct clinical information. Agency policy 9.13.1, IDG Care Planning Process, stated in part, " The plan of care specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment ... An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments." Clinical Record 1: A patient with a hospice benefit election date of 10/2/23, had a plan of care (POC) dated 10/2/23 -12/30/23, that stated in part, "Cleanse open area to coccyx with normal saline, pat dry, apply Medi-honey and calcium alginate to wound bed and cover with foam dressing. Change daily and as needed (PRN) if loose or soiled." The physician order stated, "Cleanse open area to coccyx with normal saline, pat dry, apply Medi-honey and calcium alginate to wound bed and cover with foam dressing. Change daily and as needed (PRN) if loose or soiled." An Interdisciplinary Group (IDG) Comprehensive Conference Care Plan dated 10/18/23, stated in part, "Coccyx: Dakins 0.25% strengths, calcium alginate for dressing." The nurse visit notes dated 10/17/23 and 10/19/23, documented the following intervention: "Cleanse open area to coccyx with normal saline and pat dry; apply Medi-honey and calcium alginate to wound bed, and cover with foam dressing. Change daily and as needed (PRN) if loose or soiled." During a joint record review and interview on 10/30/23, the Administrator confirmed that the POC and physician order did not match the IDG Care plan dated 10/18/23. The Administrator reported that the agency manually typed the IDG care plans, and believed the Dakins solution was entered in error. The Administrator contacted the RN (registered nurse) Case Manager and confirmed the wound care order as, "Cleanse open area to coccyx with normal saline, pat dry, apply Medi-honey and calcium alginate to wound bed and cover with foam dressing. Change daily and as needed (PRN) if loose or soiled." The RN Case Manager confirmed the Dakins solution was entered in error.