Every finding on record at Headwaters Hospice and Palliative Care, LLC

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 the following, intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed, the agency did not ensure the individualized plan of care included interventions to manage pain. Clinical Record 1: The patient elected hospice benefit on 10/28/2023 with a terminal diagnosis of atherosclerotic heart disease of the native coronary artery. The skilled nurse visit dated 11/27/2023 documented the patient reported "pain of 5/10 [0 to 10 scale] over the weekend and was helped with Tylenol and Bio freeze. [The patient] also reported occasional chest pain." The skilled nurse visit dated 12/04/2023 documented "Patient reports pain is a dull ache in the left shoulder." The plan of care dated 10/28/2023 did not include goals or interventions to address the patient's pain. During an interview and joint clinical record review on 12/06/2023, the Director of Clinical Services confirmed goals and interventions related to pain were not added to the patient’s plan of care.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) 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 5 of 9 (56%) clinical records reviewed in which aide services were provided, the agency did not ensure specific written patient care instructions were provided for the hospice aide. Clinical Record 1: The patient elected the hospice benefit on 10/28/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery. On the initial nursing assessment dated 10/28/2023 the nurse documented a wound care order for "barrier cream to a Stage II to entire buttock with every brief change." The aide care plan dated 10/28/2023 assigned the tasks of assisting the patient with a brief change and dressing the patient every visit. The aide care plan did not document that the wound was present or provide instructions for the aide related to care of the wound during brief change and/or dressing the patient. On the skilled nursing visit dated 11/25/2023 the nurse documented a wound order for a skin tear on the left shin covered with a dry bandage. The aide care plan was not updated after this visit to include notification to the aide of the skin tear or instructions on whether to cover the wound dressing during bathing. Clinical Record 2: The patient elected the hospice benefit on 11/20/2023 with a terminal diagnosis of Alzheimer's disease. The initial nursing assessment dated 11/20/2020 included documentation that the patient was "cognitively impaired, maximum assist and confused." The aide care plan dated 11/20/2023 assigned the tasks of shower or bed bath every visit, per patient preference. The aide care plan did not include a specific task for dressing the patient. Clinical Record 3: The patient elected the hospice benefit on 11/16/2023 with a terminal diagnosis of chronic obstructive pulmonary disease. On the initial nursing assessment dated 11/16/2023 the nurse documented the patient was on continuous oxygen at 3 liters per minute and had a Stage II wound on the coccyx. The aide care plan dated 11/16/2023 assigned the aide the tasks of assisting the patient with bathing and dressing every visit. The aide care plan did not provide instructions to the aide on whether the oxygen should be left on or could be removed during bathing and dressing the patient and did not include documentation of the wound and how to care for the wound during bathing and dressing the patient. Clinical Record 8: The patient elected the hospice benefit on 10/16/2023 with a terminal diagnosis of hepatic failure. The nurse documented on the initial nursing assessment dated 10/16/2023 that the patient was on oxygen at 2 liters per minute continuously. The aide care plan dated 10/16/2023 assigned the tasks of assisting the patient with bathing and dressing every visit. The aide care plan did not include specific instructions for the oxygen and did not include whether the oxygen could be removed during the tasks of bathing and dressing. Clinical Record 10: The patient elected the hospice benefit on 11/01/2023 with a terminal diagnosis of protein calorie malnutrition. The nurse documented on the initial nursing assessment dated 11/01/2023 a Stage II wound on "gluteal cleft and coccyx" and a Stage III pressure ulcer to the right heel covered with optifoam. The aide care plan dated 11/01/2023 assigned the tasks of bathing and dressing the patient. The aide care plan did not inform the aide of either wound or provide specific instructions on how to care for the wounds/wound dressings during bathing. During joint clinical record review and interview on 12/05/2023, the Director of Clinical Services confirmed the wounds and oxygen had not been added to the aide care plans.

It is required that each patient’s record includes, physician orders. This standard was not met as evidenced by document review, clinical record review, and interview. In 6 of 12 (50%) clinical records reviewed, the agency did not ensure physician orders contained required elements as specified in agency policy. Agency policy Physician Order, dated 2023, stated in part, all medication orders must include "route, reason..." Clinical Record 5: The physician order dated 09/09/2023 ordered "Ativan 0.5 mg tablet 1-4 tabs 2 hours PRN [as needed]” and “Hyoscyamine 0.125 mg tablet 1 tablet q 4 hours PRN, may increase to 2 if not effective." The medication orders did not include the indication or reason for administration of these as needed medications. Clinical Record 6: The physician order dated 09/27/2023 ordered "Ativan 0.5 mg tablet 1-4 tabs 2 hours PRN” and “Morphine 20 mg/ml. Directions 0.25 ml q [every] 2 hours PRN. May increase in 0.25 ml increments up to 1 ml every 2 hours PRN." The medication orders did not include the indication or reason for administration of these as needed medications. Clinical Record 7: The physician order dated 10/12/2023 ordered "Ativan 0.5 mg tablet 1-4 tabs 2 hours PRN.” The medication order did not include the indication or reason for administration of this as needed medication. Clinical Record 8: The physician order dated 10/16/2023 ordered "Ativan 0.5 mg tablet 1-4 tabs 2 hours PRN,” “Acetaminophen 500 mg capsule. Directions: 1 tab PO [by mouth] scheduled three times daily and 1 tab PO every 8 hours PRN,” and “Atropine 1% solution. Directions: 2 drops under the tongue every 4 hours as needed." The medication orders did not include the indication or reason for administration of these as needed medications. Clinical Record 10: The physician order dated 11/01/2023 ordered "Acetaminophen 500 mg 2 tablets PO 6 hours PRN” and “Wound order Stage III, right heel, 2.5 cm x 2 cm, Optifoam 3 to 4 days and PRN." The orders did not include the indication or reason for administration of the Acetaminophen or a reason for the as needed wound care. Clinical Record 12: The physician order dated 11/24/2023 ordered "Haloperidol 2 mg/ml. Directions: 2 mg q 4 hours PRN." The medication order did not include the indication or reason for administration of this as needed medication. During joint clinical record review and interview, the Director of Clinical Services acknowledged the physician orders did not include PRN reasons for administration and explained the agency had developed a performance improvement project (PIP) related to this issue and charts were still being audited related to the PIP.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF [skilled nursing facility/nursing facility] or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed in which a patient resided in a SNF, the agency did not ensure the plan of care included a delineation of responsibilities between the hospice agency and the facility. Clinical Record 9: The patient elected the hospice benefit on 10/18/2023. The initial nursing assessment dated 10/18/2023 included documentation that the patient resided in a SNF and was being admitted to hospice with a terminal diagnosis of Alzheimer's disease. The hospice plan of care dated 10/18/2023 did not specify which provider was responsible for performing the interventions listed on the plan of care. During joint clinical record review and interview on 12/06/2023, the Director of Clinical Services agreed the patient's plan of care did not include interventions for facility coordination with the SNF. A form titled "integrated plan of care" was produced but had not been added to the clinical record.