Every finding on record at Healing Care Hospice Inc

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, interview and observation. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that the plan of care (POC) included patient goals and interventions related to problems identified in the comprehensive assessment. Clinical Record 2/ Home Visit 1: The patient elected hospice care on 9/11/23. The initial comprehensive assessment completed on 9/11/23 documented the patient was a full code and did not wish to be hospitalized for heart disease. The assessment further documented that a pacemaker was inserted on 1/1/2019 and that "patient reports that she has felt the pacemaker fire twice in the last month." During the home visit on 10/11/23, the patient stated they have had several cardiac episodes, but they have gotten better since having the ICD (implantable cardioverter defibrillator) placed. The plan of care, effective from 9/11/23 to current, did not include goals, problems, or interventions related to the ICD/pacemaker and did not include the patient wishes regarding having the ICD deactivated at any point during the dying process. During an interview and a joint record review on 10/12/23, the Alternate Administrator and the Director of Nursing confirmed that it did not address the patient's ICD.

It is required that the hospice registered nurse completes an initial assessment within 48 hours of the patient’s election of hospice care, in accordance with CMS §418.24 (the elements of the hospice care election statement). THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review and interview which revealed issues with the patients' rights related to the election of the specific hospice as follows: Failure to ensure the patients elected the identified hospice on the election statements (80%) [HCPC.8.I/418.54(a)/L522]; Failure to ensure the consents and election statements were properly dated and authenticated (100%) [HSIM.4.I/418.104(b)/L679]. The cumulative effect of this deficiency could negatively impact the patient's ability to receive hospice benefits and palliation and management of the terminal illness and related conditions.

It is required that the hospice registered nurse completes an initial assessment within 48 hours of the patient’s election of hospice care, in accordance with CMS §418.24 (the elements of the hospice care election statement). 418.24(b)(1) Content of election statement. The election statement must include the following: Identification of the particular hospice and of the attending physician that will provide care to the individual. The individual or representative must acknowledge that the identified attending physician was his or her choice, and the signature of the individual or representative. This standard was not met as evidenced by clinical records review and interview. 4 of 5 (80%) of clinical records reviewed revealed that the agency did not ensure the patients elected the identified hospice on the election statements and admission forms. Record 1: The consent forms, including the election of hospice benefits (EOB) agency form signed by the patient's POA dated 6/5/2023, were reviewed on the agency's ShareFile storage and file sharing system that the agency provided access. The section of the EOB form where the agency's name was inserted had the agency's name typed over correction fluid, obliterating the original entry. Additionally, the signature section of the EOB form had the signature dates handwritten over whiteout. There was no documented evidence that the patient elected the current hospice agency. Record 3: The consent forms, including the election of hospice benefits (EOB) agency form signed by the patient dated 6/4/2023, were reviewed on the agency's ShareFile storage and file sharing system that the agency provided access. The section of the EOB form where the agency's name was inserted had the agency's name typed over correction fluid like white out), obliterating the original entry. Additionally, the signature section of the EOB form had the signature dates typed in a large and bolded highlighted font. There was no documented evidence that the patient elected the current hospice agency. Record 4: The consent forms, including the election of hospice benefits (EOB) agency form signed by the patient dated 6/5/2023, were reviewed on the agency's ShareFile storage and file sharing system that the agency provided access to. The section of the EOB form where the agency's name was inserted had the agency's name typed over correction fluid, obliterating the original entry. There was no documented evidence that the patient elected the current hospice agency. Record 2: The consent forms, including the election of hospice benefits (EOB) agency form signed by the patient dated 6/4/2023, were reviewed on the agency's ShareFile storage and file sharing system that the agency provided access. The section of the EOB form where the agency's name was inserted had the agency's name typed over correction fluid like white out), obliterating the original entry. There was no documented evidence that the patient elected the current hospice agency. During an interview on 6/21/2023 with the Director of Nursing (Record 3), the admitting nurse for all five patients, stated that the patients/representatives were not made to re-sign the consent forms and admissions forms because they discharged and then used the same patients for each of their different agencies for the accreditation process. The Director of Nursing, a hospice consultant, confirmed the forms were manipulated but later denied the use of the correction fluid. She stated using a textbox feature and that they would use DocuSign in the future.

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 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 clinical record review, document review, interview and observation. 2 of 3 (67%) home visits where medication reconciliations were performed revealed the hospice did not ensure the medication profiles were updated and current. Document 3: The agency policy number 3-002.1 titled Medication Profile, with a revision date of January 2023, stated in part under the subtitle Policy...Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. Under the subtitle Procedure...(1) For accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient's current medications ordered for the patient while under the organization's care will be made t those on the list (2) The admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, strength, route, frequency, date and time of administration and a diagnosis, condition, or indication for use for each medication ordered...(3) A drug regimen review will be performed at the time of initial and comprehensive assessment. The review will assist in evaluating effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicative therapy, and noncompliance issues, omissions and unclear information. Home Visit 2: During the visit on 6/21/2023 with the registered nurse and the patient (Record 2) with an election of hospice benefits dated 6/4/2023. The skilled nursing frequency was one time per week (1xW) per the plan of care. The skilled nursing frequency was one time per week (1xW) per the plan of care. A medication comparison was performed by comparing the agency's medication record with the patient's medicine bottles. The patient participated in the review and was knowledgeable of her medication regimen. The review revealed inaccuracies in the medication dosages, frequencies, and missing medications. (1) The profile listed Jardiance 10mg daily; however, the medicine bottle's dosage was 25mg daily. The patient stated the dosage was increased on 5/29/2023, before the start of the care to the agency. (2) The profile listed buspirone 10mg, two tablets by mouth daily; however, the medicine bottle's directions were one tablet twice daily, and the patient confirmed this as accurate. (3) The medication profile listed metoprolol tartrate 100mg by mouth twice a day; however, the medicine bottle listed the frequency as three times a day with an effective date of 2/23/2023, also confirmed as accurate by the patient. (4) The profile listed Lantus subcutaneous 100 Units/mL, inject 11 Units daily. However, the dosage on the injector syringe stated 80 Units daily, which the patient was the accurate dosage. (5) The profile listed pilocarpine 5mg by mouth daily; however, the medicine bottle's instructions were three times daily, which was confirmed correct by the patient. The following medications were not listed on the agency's profile: (6) Digoxin 0.125mg by mouth daily; (7) Diclofenac Sodium Topical Gel 1%, topically three times daily as needed; (8) Novolog 100 Units/ML subcutaneous per sliding scale, three times daily; (9) Multivitamin one tablet by mouth daily; (10) Folic Acid 800mcg by mouth daily; (11) Alendronate 70mg by mouth weekly on Fridays; (12) Torsemide 100mg by mouth daily; (13) Percocet 10mg-325mg by mouth every six hours as needed; (14) Trazadone 50mg by mouth at bedtime; (15) Gabapentin 600mg by mouth three times daily. Additionally, the medication profile listed (16) oxygen 2LPM via nasal cannula as needed; however, the patient stated the oxygen was 3LPM via nasal cannula continuously at night when sleeping and as needed during the day. The patient verbalized not taking the following medications that were listed on the profile: (17) Furosemide 80mg by mouth daily; and (18) Methotrexate Sodium 10mg by mouth daily; both were discontinued before being admitted to the agency on 6/4/2023. Additionally, the patient had a bilateral knee replacement on 6/5/2023, and hydroxychloroquine sulfate 200mg by mouth daily was placed on hold a month ago due to the surgery. There was no documented evidence that the medication reviews completed by the hospice included the medications that were missing from the medication profiles. The registered nurse witnessed the medication reconciliation and confirmed the agency's medication profile was inaccurate. Home Visit 4: The patient's mother was interviewed during the home visit on 6/22/2023, with the chaplain and the patient (Record 1) with a primary diagnosis of cerebral palsy and an election of hospice benefits on 6/5/2023. The skilled nursing frequency was one time per week (1xW) per the plan of care. The patient was wheelchair-bound, and the mother and her met the chaplain at the patient's grandparent's home due to issues with flooding in their apartment. The mother provided a brief history of the patient's condition and current status. She stated that the patient had problems with urine retention, which causes pain. The patient was on a new medication that the mother called a "blue pill" that the neurologist started approximately a month ago. The mother could not recall the name of the drug, and it was not listed on the agency's medication profile. The patient had three medications listed: Baclofen 20mg by mouth five times per day; MiraLAX Powder 17gm/scoop, take 17 grams by mouth daily as needed for constipation; and Baclofen Intrathecal Pump (4000mcg/20mL prefilled syringe), 40mL per day, managed by a neurologist. The mother stated she would call the agency to notify them of the details of the medication for urine retention to be added to the medication profile. There was no documented evidence that the medication reviews completed by the hospice included the medications that were missing from the medication profiles.

It is required that the designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization. THIS IS A CMS CONITION LEVEL FINDING. This CONDITION was not met as evidenced by clinical record review and interview, which revealed issues with the provision of care and services to meet the patient's needs as follows: Failure to include pain management and symptom management interventions on the plan of care (33%) [HCPC.21.I/418.56(c)(1)L546]; Failure to provide the necessary drugs to meet the patient's needs (33%) [HCPC.21.I/418.56(c)(4)/L549]; and Failure to include all DME on the plan of care (20%) HCPC.21.I/418.56(c)(5)/L550]. The cumulative effect of these findings could negatively impact the organization's ability to develop, update, and implement plans of care to ensure services are provided that will meet the care needs of patients.

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 intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review, interview and observation. 1 of 3 (33%) home visits where the patients and/or caregivers verbalized symptom management problems and participated in developing the plan of care revealed the hospice did not ensure the plan of care included the patient's current and ongoing symptom management problems. Document 4: The agency policy number 2-044.2 with a revision date of January 2023, titled The Plan of Care, stated in part under the subtitle Procedure...(4) The plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief. If must state in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs. Clinical Record 1: During the home visit (Home Visit 4) on 6/22/2023 with the patient with an election of hospice benefit dated 6/5/2023 and a primary diagnosis of cerebral palsy, the mother described in detail issues with urine retention, where the patient did not or was unable to urinate, resulting in lower abdominal pain and anxiety. The Plan of Care order dated 6/16/2023 for the benefit period 6/5/2023 through 9/2/2023 documented the Care Plan problem of incontinence of bowel and bladder identified on 6/5/2023 documented interventions of (1) assessing skin for breakdown and notifying physician of an skin integrity changes; monitor bowel movement activity and notify physician if no bowel movement past three days; (3) Assess need for/educate on increased fluid intake; (4) Assess for signs and/or symptoms of urinary tract infection. (5) Instruct caregiver(s) on urinary incontinence care; (6) Provide and/or educate patient and /or caregiver(s) on proper cleaning of peri area. The Plan of Care Order dated 6/16/2023 was missing the problem and interventions for urine retention despite the mother stating it had been an ongoing current problem for the last month and the new medication had not helped much.

It is required that each patient’s individualized written plan of care, and 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 reviews and interview. 1 of 3 (33%) of home visits revealed that the agency did not provide drugs and treatment necessary to meet the needs of the patient. Home Visit 4: During the visit on 6/22/2023 with the chaplain and the patient (Record 1) with an election of hospice benefits dated 6/5/2023, had the skilled nursing frequency of weekly on the written plan of care order dated 6/16/2023.The mother and the patient met the chaplain at the patient's grandparent's home for this visit due to issues with flooding in their apartment. The patient's mother was interviewed during the home visit on 6/22/2023 since she was the primary caregiver and was knowledgeable of the patient’s history and current health status. The mother provided a brief history of the patient's condition and detailing issues with urine retention, where the patient did not or was unable to urinate, resulting in lower abdominal pain and anxiety. The patient was on a new medication that the mother called a "blue pill" that the neurologist started approximately a month ago. The mother could not recall the name of the drug. There was no documented evidence the medication was listed on the agency's medication profile and it was not listed on the Plan of Care dated 6/16/2023. The patient had only three medications listed: Baclofen 20mg by mouth five times per day; MiraLAX Powder 17gm/scoop, take 17 grams by mouth daily as needed for constipation; and Baclofen Intrathecal Pump (4000mcg/20mL prefilled syringe), 40mL per day, managed by a neurologist. The mother stated the the new medication started prior to the start of care, "had not helped much". She remarked that she would call the agency to notify them of the details of the medication for urine retention to be added to the plan of care.

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 medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) records reviewed revealed the agency did not include all the durable medical equipment (DME) in the written plan of care. Clinical Record 2: The patient, with an election of hospice benefits dated 6/4/2023, had a primary diagnosis of unspecified diastolic (congestive) heart failure. The record review revealed the oxygen concentrator and setup were missing from DME on the Plan of Care Order dated 6/16/2023. The Plan of Care order dated 6/16/2023 for the benefit period 6/4/2023 through 9/1/2023 documented the following DME: Shower bench, cane, walker & wheelchair, and hospital bed. The care plan problem documented "shortness of breath, decreased cardiac perfusion identified 6/4/2023, with interventions of administering supplemental oxygen. The medication profile listed "O2 nasal cannula concentrate 2LPM with frequency as needed for shortness of breath, and instructions continuously via nasal cannula. The certification narrative signed by the medical director on 6/4/2023 documented that the "patient is dependent on 5/6 ADLs. Uses oxygen most of the day and at times, 24 hours per day. Disabling dyspnea at rest." The IDT Meeting note dated 6/16/2023 documented "uses oxygen most of the day and at times 24 hours/day...DME in the home shower bench, cane, walker and wheelchair, and hospital bed." There was no documented evidence that the agency provided the oxygen concentrator. During the home visit (HOME VISIT 2) on 6/21/2023, the patient was interviewed and verbalized having an oxygen concentrator in the bedroom, because she uses 3LPM via nasal cannula at night when she sleeps, and as needed during the day. During the home visit on 6/22/2023, when the patient was present, it was asked if the hospice agency provided the oxygen concentrator, and she stated "no" and that she had the oxygen concentrator before getting onto service.

It is required that bereavement services are supervised by a qualified professional with experience or education in grief or loss counseling. This standard was not met as evidenced by document review, personnel record review, and interview. 1 of 8 (12%) personnel records reviewed revealed the hospice did not ensure that the employee was qualified for the bereavement coordinator position per the qualification requirements of the agency's job description. Personnel Record 5: The employee with a date of hire of 12/26/2023 had a completed and signed job description for the bereavement coordinator, alternate administrator and chaplain. The qualification listed on the agency's job description for the bereavement coordinator included (1) Experience with counseling individuals and/or groups. (2) A qualified professional with experience or education in grief or loss counseling. (3) Two years of related experience preferred. The employee's resume was reviewed for grief counseling experience or education; however, there was no corresponding experience listed. The resume included experience as a business consultant, a finance manager, a new car sales manager, and a USAF jet engine mechanic, but no experience with grief counseling or pastoral, spiritual experience. Additionally, there was no evidence of training or certifications in grief counseling in the personnel record. During an interview on 6/22/2022, the bereavement coordinator confirmed that his resume did not reflect the required education and experience.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by clinical record review and interview. 4 of 5 (80%) clinical records reviewed revealed the hospice did not ensure the consents and the election statements were authenticated and dated as consistent with the acceptable documentation standards of practice on medical legal documents. Record 1: The consent forms, including the election of hospice benefits (EOB) agency form signed by the patient's POA dated 6/5/2023, were reviewed on the agency's ShareFile storage and file sharing system that the agency provided access. The section of the EOB form where the agency's name was inserted had the agency's name typed over correction fluid, obliterating the original entry. Additionally, the signature section of the EOB form had signature dates handwritten over whiteout. Record 3: The consent forms, including the election of hospice benefits (EOB) agency form signed by the patient dated 6/4/2023, were reviewed on the agency's ShareFile storage and file sharing system that the agency provided access. The section of the EOB form where the agency's name was inserted had the agency's name typed over correction fluid like white out), obliterating the original entry. Record 4: The consent forms, including the election of hospice benefits (EOB) agency form signed by the patient was dated 6/5/2023, were reviewed on the agency's ShareFile storage and file sharing system that the agency provided access to. The section of the EOB form where the agency's name was inserted had the agency's name typed over correction fluid, obliterating the original entry. Record 2: The consent forms, including the election of hospice benefits (EOB) agency form signed by the patient dated 6/4/2023, were reviewed on the agency's ShareFile storage and file sharing system that the agency provided access. The section of the EOB form where the agency's name was inserted had the agency's name typed over correction fluid like white out), obliterating the original entry. 5 of 5 (100%) clinical records reviewed revealed the hospice did not ensure that electronic signatures were included timestamps to establish the integrity and authenticity of the signatures. Record 5: The consent forms, including the election of hospice benefits (EOB) agency form signed by the patient dated 6/5/2023, were reviewed on the agency's ShareFile storage and file sharing system that the agency provided access to. The CTI and visit notes did not include a date and a timestamp. The signature section of the EOB form had the signature dates typed in a large and bolded highlighted font. During the record review, all electronic signatures, including the physician and registered nurses, missed a timestamp with the date to indicate the exact date and time when the digital signature was applied to the documents. Record 4: The consent forms, including the election of hospice benefits (EOB) agency form signed by the patient dated 6/5/2023, were reviewed on the agency's ShareFile storage and file sharing system that the agency provided access to. The section of the EOB form where the agency's name was inserted had the agency's name typed over correction fluid, obliterating the original entry. During the record review, all electronic signatures, including the physician and registered nurses, missed a timestamp with the date to indicate the exact date and time when the digital signature was applied to the documents. Clinical Record 3: The consent forms, including the election of hospice benefits (EOB) agency form signed by the patient dated 6/4/2023, were reviewed on the agency's ShareFile storage and file sharing system that the agency provided access to. The section of the EOB form where the agency's name was inserted had the agency's name typed over correction fluid, obliterating the original entry. During the record review, all electronic signatures, including the physician and registered nurses, missed a timestamp with the date to indicate the exact date and time when the digital signature was applied to the documents. Record 2: The consent forms, including the election of hospice benefits (EOB) agency form signed by the patient dated 6/4/2023, had the agency's name typed and the signature dates typed in the same typed font. During the record review, all electronic signatures, including the physician and registered nurses, missed a timestamp with the date to indicate the exact date and time when the digital signature was applied to the documents. Record 1: The consent forms, including the election of hospice benefits (EOB) agency form signed by the patient's POA dated 6/5/2023, were reviewed on the agency's ShareFile storage and file sharing system that the agency provided access to. The section of the EOB form where the agency's name was inserted had the agency's name typed over correction fluid, obliterating the original entry. Additionally, the signature section of the EOB form had the signature dates handwritten over whiteout. During the record review, all electronic signatures, including the physician and registered nurses, missed a timestamp with the date to indicate the exact date and time when the digital signature was applied to the documents. During an interview on 6/21/2023 with the Director of Nursing (Record 3), the admitting nurse for all five patients, stated that the patients/representatives were not made to re-sign the consent forms and admissions forms because they discharged and then used the same patients for each of their different agencies for the accreditation process. The Director of Nursing, a hospice consultant, confirmed the forms were manipulated but later denied the use of the correction fluid. She stated using a textbox feature and that they would use DocuSign in the future.