Every finding on record at Halcyon Home LLC

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 19 (5%) clinical records reviewed, revealed the agency did not ensure there was an update to the comprehensive assessment when there was a change in the patient's status. Agency Policy PE.5, "Patient Assessments", last reviewed 10/1/21, stated in relevant parts, “Updates to the comprehensive assessment will be accomplished by the IDG/IDT (in collaboration with the patient’s Attending Physician, (if any) to include but not be limited to: Reassessing a patient’s needs when there is a significant health status change in the patient’s condition, additional information, as necessary, to be used in planning care to meet the patient and/or family needs, and the need for the Hospice to refer the patient or the patient family member to non-agency, appropriate health professionals for further evaluation.” Agency Policy PE.35, "Patient Revocation", last reviewed 10/1/21, stated in relevant parts, “When a patient or authorized representative is considering revoking his or her election of hospice care, the Hospice will counsel the patient or authorized representative in any advantages or disadvantages of the patient’s decision and choice." Clinical Record 15: Patient with election of hospice benefit on 2/16/23 and subsequent live discharge on 2/28/23. The clinical record contained a signed statement of revocation effective 2/28/23 which stated, “The reason for revocation is to seek aggressive treatment." There was no documented evidence in the clinical record that the comprehensive assessment was updated by a member of the hospice interdisciplinary group to include a reassessment of the patient’s condition, as it related to the changes in condition resulting in the patient/family choice to seek aggressive treatment. There was no documentation that the hospice had attempted to counsel the patient or authorized representative on the advantages or disadvantages of their decision and choice. In an interview on 5/18/23, the Clinical Manager confirmed the findings and agreed there was not an update to the comprehensive assessment when the patient's status changed.

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 and includes all services necessary for the palliation and management of the terminal illness, including the following: interventions to manage pain and symptoms, a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 6 of 19 (32%) clinical records reviewed, revealed the agency did not ensure the plan of care (POC) included patient and family goals with measurable outcomes and specific planned interventions, based on the needs identified by the registered nurse in the initial and updated comprehensive assessments. Clinical Record 1: Patient with election of hospice benefit on 4/24/23. The nursing initial assessment dated 4/24/23 included documentation of the presence of a wound on the patient’s left foot and stated “Treatment: Cleanse wound with NS, pat dry, apply hydrogel to wound bed and cover with bordered foam dressing” and “SN to perform wound care 3x/week during scheduled visits.” Wound care was provided on this visit and on subsequent skilled nursing visits on 5/1/23, 5/5/23 and 5/12/23. The plan of care (POC) did not include orders for the wound care and dressing changes that were provided by the skilled nurse. Clinical Record 2: Patient with election of hospice benefit on 4/19/23. A review of the medication profile identified an entry for “Acetaminophen oral capsule 500mg, two capsules three times a day. Indication: pain. Start date 4/11/23.” The skilled nursing assessments on 4/20/23 and 4/21/23 both stated that pain was an active problem for the patient and documented “What makes pain worse: lesions/movement” and “Comments: pt denies pain and objectively appears comfortable on the routine Tylenol 1 gm TID dosing schedule.” The POC did not include documentation of individualized patient/family goals or measurable outcomes related to pain. In addition, a nursing visit on 4/24/23 included documentation of the presence of 3 wounds to the left foot, right heel and right foot with wound care as follows "Using aseptic technique, cleanse with normal saline or wound spray, apply betadine to the open and closed blisters, cover with Mepilex dressing daily." Wound care was provided on this visit and on subsequent skilled nursing visits on 4/21/23, 4/24/23 and 4/27/23. The POC did not include orders for the wound care and dressing changes that were provided by the skilled nurse. Clinical Record 3: Patient with election of hospice benefit on 4/25/23. A review of the medication profile identified an entry for “MiraLAX oral packet 17gm Q HS on M-W-F. Indication: constipation. Start date 4/25/23.” The RN initial assessment dated 4/25/23 documented “Constipation, occasional” and “lax/enema use: MiraLAX M-W-F." A skilled nursing visit note dated 5/2/23 stated “The patient was experiencing mild constipation yesterday and was given MiraLAX 17gm PO last evening which was effective, and the patient had a moderate sized bowel movement." The plan of care POC did not include any individualized patient/family goals or measurable outcomes related to constipation. Clinical Record 9: Patient with election of hospice benefit on 3/30/23. A review of the medication profile identified an entry for “Lorazepam oral tablet 1mg, take 1 tab every night for anxiety, start 4/14/23.” A skilled nursing visit note on 4/14/23 stated, “Spoke with daughter who would like to start patient on a nightly dose of Ativan to assist with anxiety at night. Patient states her brain doesn’t shut off at night.” The POC did not include any individualized patient/family goals or measurable outcomes related to anxiety. Clinical Record 15: Patient with election of hospice benefit on 2/16/23. A review of the medication profile identified an entry for “Norco oral tablet 10-325 mg, 1 tab PO TID, indication: pain, start date 2/19/23” A skilled nursing visit note on 2/19/23 stated, “Patient reports poor control of pain w/current scheduled Norco dose as well as interrupted sleep pattern re: pain. New order for Norco 10/325mg PO TID per (Name), NP.” The POC did not contain any individualized patient/family goals or measurable outcomes related to pain. Clinical Record 19: Patient with election of hospice benefit on 11/4/22. The nursing initial assessment dated 11/4/22 included documentation of the presence of a urinary Foley catheter “last changed 11/1/22, 16 F, 10cc." The POC included an order for “Foley catheter PRN urinary retention” and “change urinary drainage device (e.g., foley, suprapubic catheters, urostomy) as ordered” but did not include specific orders related to the size and maintenance of the Foley catheter. In an interview and review of the findings on 5/18/23, the Clinical Manager agreed that the written plans of care for the identified patients did not include the required elements.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease. This standard was not met as evidenced by interview and observation. During the office tour on 5/18/2023, the contents of the refrigerator, with the stored Tubersol solution, were observed. The refrigerator contained an unopened vial of Tubersol and an opened vial of Tubersol. The vial that had been opened was not dated with the date the Tubersol was opened to ensure the opened vial was used within the manufacturer's guidance on the timeframe for use of the Tubersol after the vial is opened. The manufacturer instructions of the Tubersol, Sanofi Pasteur storage instructions reads in part, "A vial of TUBERSOL which has been entered and in use for 30 days should be discarded." The supervising nurse who was present during the tour stated the vial should have been dated with the date the vial was open. During the office tour on 5/18/2023, the contents of the refrigerator, with the stored Tubersol, were observed. The refrigerator contained an unopened vial of Tubersol and an opened vial of Tubersol. The vial that had been opened was not dated with the date the Tubersol was opened to ensure the opened vial was used within the manufacturer's guidance on the timeframe for use of the Tubersol after the vial is opened. The manufacturer instructions of the Tubersol, Sanofi Pasteur storage instructions reads in part, "A vial of TUBERSOL which has been entered and in use for 30 days should be discarded."

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. 1 of 19 (5%) clinical records reviewed of patients receiving aide services revealed the agency did not ensure the aide care plan contained written instructions prepared by an RN that were pertinent to the care of the patient. Clinical Record 11: Patient with election of hospice benefit on 3/2/23 resided in an assisted living facility. A skilled nursing visit note on 3/22/23 documented “LVN/ADON asked that HHA cover dressing to left heel to keep dry during shower, notified team.” The aide care plan dated 3/2/23 with an aide visit frequency of three times per week effective until 5/30/23 did not alert the aide to the presence of a wound or include written instructions by the RN to cover the wound dressing to the left heel. In an interview on 5/17/22, the hospice clinical manager confirmed the finding that the aide plan of care did not include written instructions for the aide to cover the wound dressing when showering.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 4 of 19 (21%) clinical records reviewed in which hospice aide services were provided to the patient, revealed the agency did not ensure there was documentation of aide services being provided as ordered in the plan of care. Clinical Record 5: Patient with election of hospice benefit on 5/11/22. The aide care plan dated 3/9/23 through 5/5/23 included documentation of an aide visit frequency order for three times per week. During the week of 4/16/23, there was documented evidence that only one visit was provided. The hospice aide documentation included a missed visit note on Monday 4/17/23, that stated, “I called the patient’s wife and she said that for this week she would want visits on Tuesday/Friday this week.” There is another aide missed visit note on Wednesday 4/19/23, a Wednesday, that stated “Patient’s wife only wanted visits on Tuesday/Friday this week.” There was a completed aide visit note for a visit made by the aide on Friday 4/21/23. There was no evidence of a visit on Tuesday of that week per the spouse’s request. In an interview on 5/18/23, the Alternate Administrator stated she had spoken with her staff and confirmed a visit was made on Tuesday 4/18/23, however there was no documentation of the visit in the clinical record. Clinical Record 11: Patient with election of hospice benefit on 3/2/23. The hospice aide care plan dated 3/2/23 effective until 5/30/23 included documentation of an aide visit frequency order for three times per week. During the week of 3/12/23, there is documented evidence that only two visits were completed on 3/13/23 and 3/15/23. The clinical record included documentation of a missed visit note dated 3/17/23 which stated, “Comments: out sick” and “Supervisor notified: Yes, by fax.” There was no documented evidence of communication with the patient/family regarding the missed visit and no evidence that the visit was reassigned to a different clinician. In an interview on 5/17/23, the Clinical Manager confirmed the findings and stated, "we usually have someone else do the visit when this happens, I'm not sure what happened with this one." Clinical Record 7: Patient with election of the hospice benefit on 12/30/21. The hospice aide care plan dated 2/23/23 effective until 4/21/23 indicated the aide frequency was ordered for five times per week and included an intervention for “complete shower every visit.” The aide visit notes on 2/28/23, 3/1/23, 3/3/23, 4/14/23, 4/18/23 documented the shower task as declined. The record did not include documentation that the hospice aide notified a registered nurse that services were not provided as ordered in the plan of care. Clinical Record 13: Patient with election of hospice benefit on 3/23/22. The aide care plan dated 3/18/23 effective until 5/16/23 with aide frequency ordered for three times per week included an intervention “complete shower every visit.” On 4/4/23 the aide visit note indicated a “bed bath” was given instead of a complete shower but did not indicate why and did not document communication with the hospice registered nurse regarding the reason the bath was not provided as ordered. In an interview on 5/17/23, the Clinical Manager confirmed the findings and stated they had recently been providing education to their hospice aides on documentation requirements.

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. This standard was not met as evidenced by clinical record review and interview. 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure the hospice aide reported changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes related to the plan of care. Clinical Record 2: Patient with election of hospice benefit on 4/19/23. The hospice aide care plan dated 4/19/23 with aide frequency of three times per week included interventions for “shampoo hair every visit” and “complete shower every visit.” The aide visit note documentation on 4/21/23 documented those two tasks as declined and “CNA suggested a sponge [bath since] patient was in pain." The clinical record did not include documented evidence that a hospice registered nurse was notified of the patient’s pain or the change to the services provided. In an interview on 5/17/23, the Clinical Manager confirmed the findings and stated they had recently been providing education to their hospice aides on documentation requirements.

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, document review and interview. 1 of 2 (50%) clinical records reviewed of patient with a live discharge from hospice, revealed the agency did not ensure a discharge summary was completed. Agency Revocation Policy stated in relevant parts, “When a patient or authorized representative is considering revoking his or her election of hospice care, the Hospice will counsel the patient or authorized representative in any advantages or disadvantages of the patient’s decision and choice” and “The hospice will forward copies of the following information to the patient’s attending physician: A. The hospice discharge summary.” Clinical Record 15: Patient with election of hospice benefit on 2/16/23. The clinical record contained a signed statement of revocation dated 2/28/23 and the patient was discharged from hospice. The clinical record did not include documented evidence of a discharge summary that included all required elements. In an interview on 5/18/23, the Clinical Manager confirmed the absence of a discharge summary in the patient's clinical record.