Every finding on record at Emerald Wings Hospice 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, 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 and interview. In 1 of 7 (14%) clinical records reviewed, the agency did not ensure development of a drug profile that contained the patient’s current prescription and over the counter drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. Clinical Record 4: The patient elected the hospice benefit on 07/19/2024 with a terminal diagnosis of malignant neoplasm of overlapping sites of the bladder. The initial nursing assessment dated 07/19/2024 included documentation that the patient had reported pain with a verbal score of ten out of ten and required pain medication every two hours while awake. The Medical Director’s plan of care review dated 07/25/2024 included documentation that the patient’s scheduled Oxycontin and Fentanyl patch were increased during hospice care. The clinical record contained no documented evidence that a drug profile was developed for the patient. During joint clinical record reviews and interviews on 10/10/2024, the Administrator, Director of Nursing, and Chief People Officer confirmed the clinical record contained no evidence of a developed drug profile.

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 5 of 7 (71%) clinical records reviewed, the agency did not ensure the individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 07/23/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The Medical Social Worker (MSW) visit dated 07/25/2024 identified the problem of altered psychosocial issues evidenced by stress and primary caregiver needs. The written plan of care reviewed, revised, and updated on 07/25/2024 did not reflect patient and family goals and planned interventions associated with the altered psychosocial issues identified by the MSW. Clinical Record 3: The patient elected the hospice benefit on 08/03/2024 with a terminal diagnosis of malignant neoplasm of bilateral ovaries. The nursing assessment and physician’s order dated 08/13/2024 included documentation that the patient had an indwelling urinary catheter placed and would be changed each month. The clinical record contained no evidence that the plan of care was updated to reflect patient/family goals and planned interventions associated with the indwelling urinary catheter. Clinical Record 4: The patient elected the hospice benefit on 07/19/2024 with a terminal diagnosis of malignant neoplasm of overlapping sites of the bladder. The initial nursing assessment dated 07/19/2024 included documentation that the patient had limited mobility, lived a chairbound existence, and had a sacral wound requiring the use of a Mepilex border dressing. The written plan of care dated 07/19/2024 did not reflect patient/family goals and planned interventions associated with the patient’s skin integrity risk and sacral wound identified in the comprehensive assessment. Clinical Record 6: The patient elected the hospice benefit on 07/22/2024 with a terminal diagnosis of unspecified malignant neoplasm of the bladder. The initial nursing assessment dated 07/22/2024 included documentation that the patient had dyspnea at rest, required continuous oxygen, continued to smoke, and had periods of anxiety and agitation. The written plan of care dated 07/22/2024 did not reflect patient/family goals and planned interventions associated with the patient’s dyspnea, oxygen safety, anxiety, and agitation identified in the comprehensive assessment. The initial spiritual assessment dated 07/24/2024 included documentation that the patient had family stress/conflict, emotional pain, grief, regret, and unresolved issues. The clinical record contained no documented evidence that the plan of care was updated to reflect patient/family goals and planned interventions associated with the patient’s family stress/conflict, emotional pain, grief, regret, and unresolved issues. Clinical Record 7: The patient elected the hospice benefit on 06/30/2024 with a terminal diagnosis of moderate protein-calorie malnutrition. The initial nursing assessment dated 06/30/2024 included documentation that the patient had difficulty swallowing. The written plan of care dated 06/30/2024 did not reflect patient/family goals and planned interventions associated with the patient’s difficulty swallowing and aspiration risk identified in the comprehensive assessment. During joint clinical record reviews and interviews on 10/10/2024, the Administrator, Director of Nursing, and Chief People Officer confirmed that the plans of care identified did not include issues identified during the patients’ initial and comprehensive assessments.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed, the agency did not ensure the individualized written plan of care included the drugs and treatments needed in the palliation and management of the patient’s terminal illness. Clinical Record 4: The patient elected the hospice benefit on 07/19/2024 with a terminal diagnosis of malignant neoplasm of overlapping sites of the bladder. The initial nursing assessment dated 07/19/2024 included documentation that the patient had a pain score of ten out of ten and required opioid pain medication every two hours. The patient was placed on a bowel regimen due to the use of opioids and had a sacral wound with a Mepilex border dressing in place for treatment. The written plan of care dated 07/19/2024 did not include the drugs and treatments used to meet the patient’s pain, bowel, and wound care needs. During joint clinical record review and interview on 10/10/2024, the Administrator, Director of Nursing, and Chief People Officer confirmed the plan of care did not include medications and treatment orders for wound care.

It is required that hospice aides be assigned to a specific patient by the Registered Nurse (RN), who is a member of the Interdisciplinary Group (IDG). Written patient care instructions for the hospice aide are prepared by the RN responsible for supervising the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse prepared specific written patient care instructions for the aide. Clinical Record 1: The patient elected the hospice benefit on 07/23/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. The initial nursing assessment dated 07/23/2024 included documentation that the patient had dysphagia (difficulty swallowing) secondary to previous throat cancer and included an intervention to avoid hard, dry, and large pieces of food. The hospice aide care plan dated 07/23/2024 and updated on 08/20/2024 instructed the aide to encourage fluids during each visit. The aide care plan did not alert the aide to the patient’s dysphagia, including the risks associated with the patient’s dysphagia and precautions to be taken. Clinical Record 7: The patient elected the hospice benefit on 06/30/2024 with a terminal diagnosis of moderate protein-calorie malnutrition. The initial nursing assessment dated 06/30/2024 included documentation that the patient had difficulty swallowing. The hospice aide care plan dated 06/30/2024 included instructions for the aide to assist the patient with feeding if the visit was made at mealtime and encourage fluids at each visit. The aide care plan did not alert the aide to the patient’s difficulty swallowing, including the risks associated and precautions to take. The hospice aide care plan dated 06/30/2024 included instructions for the aide to perform two bath types, a shower and a bed bath. Further instructions included that the bed bath was to be performed only if the patient refused a shower; however, the plan did not identify if the patient was cognitively able to make personal care decisions, forcing the aide to make decisions outside the aide’s scope of practice. During joint clinical record reviews and interviews on 10/10/2024, the Administrator, Director of Nursing, and Chief People Officer confirmed that the Registered Nurse, for the clinical records identified, did not prepare specific written patient care instructions for the hospice aide including alerts related to the patient’s difficulties with swallowing, dietary restrictions, and cognitive ability to make care decisions.

It is required that the hospice aide provides services that are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 5 (20%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services as ordered by the Interdisciplinary Group (IDG) and included in the plan of care. Clinical Record 5: The patient elected the hospice benefit on 08/12/2024 with a terminal diagnosis of unspecified Alzheimer’s disease. The hospice aide care plan dated 08/12/2024 included instructions for the aide to inspect the patient’s mouth and call the nurse if problems, inspect the skin and check for pressure areas, provide perineal care, shampoo hair, shave, and shower during each visit. The aide visit dated 09/24/2024 contained no evidence that the aide performed the assigned tasks and no documentation of why the tasks were not completed. During joint clinical record review and interview on 10/10/2024, the Administrator, Director of Nursing, and Chief People Officer confirmed the hospice aide visit identified contained no evidence that assigned tasks were performed and no documentation of why the tasks were not completed.

It is required that hospice aides are supervised by a Registered Nurse (RN) 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 and 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 document review, clinical record review, and interview. In 3 of 5 (60%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse completed supervisory visits to assess the quality of care and services provided by the aide, no less frequently than every 14 days. Agency policy PC.H40 Hospice Aide Supervision, no date, required in part, “The supervising RN (Registered Nurse) assesses an aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but are not limited to: a. following the patient’s plan of care for completion of assigned tasks; b. creating successful interpersonal relationships with the patient and family: c. demonstrating competency with assigned tasks; d. assessing the quality of care and services provided; e. whether the ordered services meet the patient’s needs; f. complying with infection control practices; and g. reporting changes in the patient’s condition. The supervisory visits are documented in the patient’s clinical record every two weeks and include notations regarding the aide’s competency, whether the aide is following the patient’s plan of care and is satisfactory to the patient/family.” Clinical Record 1: The patient elected the hospice benefit on 07/23/2024 with a terminal diagnosis of Alzheimer’s disease with early onset. A nursing visit dated 09/17/2024 included documentation that the RN performed a supervisory visit to assess the aide’s care and services provided. The next aide supervisory visit was dated 10/03/2024, 16 days after the last supervisory visit and two days outstanding. Clinical Record 2: The patient elected the hospice benefit on 07/01/2024 with a terminal diagnosis of unspecified Alzheimer’s disease. Hospice aide services began on 07/27/2024. The RN supervisory visits dated 08/03/2024 and 08/22/2024 documented, “continue existing plan of care” and “the existing plan of care was developed in conjunction with and approved by the patient and family.” The visits contained no evidence that the quality of care and services provided by the hospice aide were assessed. Clinical Record 6: The patient elected the hospice benefit on 07/22/2024 with a terminal diagnosis of unspecified malignant neoplasm of the bladder. Hospice aide services began on 07/24/2024. The RN supervisory visit dated 08/03/2024 documented, “continue existing plan of care” and information about hospice services, comfort medications, how to request pain medication, when to call after hours, and oxygen use. The visit contained no evidence that the quality of care and services provided by the hospice aide were assessed. During joint clinical record review and interview on 10/10/2024, the Administrator, Director of Nursing (DON), and Chief People Officer confirmed that the clinical records identified contained no evidence that the supervision visit included an assessment of the hospice aide’s quality of care and services completed by the RN were completed every 14 days. The DON reported self-discovery of the deficiency and stated education was provided to the RN on supervisory visit documentation requirements.