Every finding on record at Hoag 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. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 6 (50%) home visits revealed the agency did not ensure the drug profile contained the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1: During Home Visit 1 (Clinical Record 1) on 10/01/2024 to observe the Hospice Aide (Personnel Record ), the hospice medication list dated 09/30/2024 was compared to the assisted living facility (ALF) medication list dated 10/01/2024. The ALF list included the following medication(s) not listed on the hospice list: 09/27/2024 Amoxicillin 500 mg capsule. Take 4 capsules by mouth four hours prior to procedures as needed. Haldol 0.5 mg tablet. Take 1 tablet by mouth every 6 hours as needed for for agitation. Morphine ER 15 mg tablet. Take 1/2 tablet every 4 hours as needed for pain or shortness of breath. The hospice medication list indicated Haldol liquid 2mg/ml instead of the tablet. Directions take 0.5 ml every 4 hours as needed for agitation. The hospice medication list indicated Roxanol (liquid Morphine) take 0.25 ml every 4 hours as needed for pain or shortness of breath instead of the tablet. Home Visit 2: During Home Visit 2 (Clinical Record 2) on 10/01/2024 to observe the Hospice Aide (Personnel Record 7), the hospice medication list dated 09/30/2024 was compared to the skilled living facility (SNF) medication list dated 10/01/2024. The SNF list included the following medication(s) not listed on the hospice list: 07/27/2024 Fleet enema. Insert 1 daily as needed for constipation. 07/30/2024 Boost supplement drink. 1 can daily. The hospice medication list contained the following medications not listed on the SNF list: 07/27/2024 Albuterol Inhaler. 1 puff every 4 hours as needed. 08/07/2024 Duoneb Inhaler. Inhale 1 vial every 6 hours as needed. 09/19/2024 Immodium 2 mg. Take 1 tablet daily as needed for diarrhea. 09/28/2024 Benadryl 25 mg. Take 1 tablet every 6 hours as needed for itching. Home Visit 4: During Home Visit 4 (Clinical Record 4) on 10/01/2024 to observe the Registered Nurse (Personnel Record 4), the hospice medication list dated 09/30/2024 was compared to the skilled living facility (SNF) medication list dated 10/01/2024. The hospice list included the following medication(s) not listed on the SNF list: 04/08/2024 Cardizem 60 mg tablet three times daily, Ambien 5 mg 1 tablet nightly as needed, Albuterol nebulizer every 6 hours as needed, Haldol 2mg/ml give 0.5 ml every four hours as needed, Ativan 0.5 mg every 6 hours as needed, Morphine 0.25 ml every four hours as needed, Hyoscyamine 0.125 mg every four hours as needed, Dulcolax 10 mg daily as needed. During an interview and joint record review with the Director of Patient Care Services on 10/02/2024, the medication list differences were confirmed and she agreed the lists needed to be reconciled.

It is required that each patient’s individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 7 of 27 (26%) clinical records reviewed revealed the agency did not ensure the patient's individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plans of care. Clinical Record 1: The patient elected the hospice benefit on 04/24/2024 for the diagnosis of Parkinson's disease. The Plan of Care dated 04/24/2024 included the problem "Nutrition: Patient will have adequate nutrition as long as possible." This did not include a measurable outcome for "adequate nutrition." Clinical Record 11: The patient elected the hospice benefit on 09/26/2024 for the diagnosis of Huntington's disease. The Plan of Care dated 09/26/2024 included a Respiratory Goal stated "Patient will have palliation of respiratory symptoms as desired." Initial nursing assessment dated 09/26/2024 documented "recent covid, pneumonia, respiratory distress." The Plan of Care did not include measurable outcomes for the palliation of these respiratory diseases nor describe what the patient "desired." Clinical Record 12: The patient elected the hospice benefit on 01/19/2024 for the diagnosis of ALS. The Plan of Care dated 01/19/2024 included the following "Goal Pain will be at patient's acceptable level within 1 hour." The Plan of Care did not include a measurable level of pain or describe what was "acceptable" to the patient. Clinical Record 13: The patient elected the hospice benefit on 01/06/2024 for the diagnosis of cerebral infarction. The Plan of Care dated 01/06/2024 included the Goal: "Patient will have less distressing symptoms as it relates to their mortality." The Plan of Care did not include measurable outcomes or descriptions of the "distressing symptoms." Clinical Record 19: The patient elected the hospice benefit on 10/12/2023 for the diagnosis of atherosclerotic heart disease. The Plan of Care dated 10/12/2023 included the following: "Problem Respiratory: Patient will have palliation of symptoms as they desire." The Plan of Care did not include measurable outcomes for the palliation of these respiratory diseases nor describe what the patient "desired." Clinical Record 26: The patient elected the hospice benefit on 08/12/2024 for the diagnosis of AML. The Plan of Care included the following: "Pain Problem. Pain as evidenced by: (left blank) Goal: Pain control will be at the patient's acceptable level within hours of identification. The Plan of Care did not include a measurable level of pain or describe what was "acceptable" to the patient. The Chief Operating Officer stated in an interview on 10/03/2024 during a joint clinical record review that the plan of care interventions and goals had not been developed with measurable outcomes or individualized.

It is required that a hospice aide provides services Included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 2 (50%) home visits with hospice aide services revealed the agency did not ensure that the hospice aide provided services included in the plan of care. Home Visit 1: During Home Visit 1 on 10/01/2024, the Hospice Aide (Personnel Record 11) was observed to perform a shower instead of a bed bath. The shower was not listed on the aide care plan dated 04/24/2024 which had the aide visit frequency of "two times per week and the bed bath to be provided every visit." During an interview with the Director of Patient Care Services on 10/03/2024, it was confirmed the hospice aide care plan had not been followed.

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 a joint review of clinical records and through interview with the Director of Patient Care Services (DPCS), in which 1 of 4 (25%) of applicable clinical records revealed that a bereavement plan of care was not initiated after a patient’s death. Patient Record #79562 - During review of the clinical record, the DPCS stated that she was unable to locate a bereavement Plan of Care initiated with the identified bereaved after the patient’s death on 8/31/21. There was an identified problem titled Grief that indicated that the Bereavement Coordinator would contact the bereaved to offer condolences and to initiate the Bereavement plan of care, but there was no documented attempts at communication or refusal of the program by the bereaved.

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 a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by a joint review of clinical records and interview with the Director of Patient Care Services (DPCS), in which 3 of 12 (25%) applicable clinical records revealed that orders on the plan of care for spiritual counseling visits were not updated to reflect the visits ordered by the IDT in accordance with the patient’s and family’s acceptance of the services. Patient Record #32701 - The plan of care dated to begin 8/29/21 included orders for one spiritual counselor visit each week. Clinical documentation revealed spiritual counselor visits were not completed during the weeks ending 10/9/21, 10/16/21, and 10/31/21. The DPCS stated that the frequency of spiritual counselor visits ordered by the IDT in accordance with the patient’s and family’s acceptance of the services was one spiritual counseling visit per month. Patient Record #52886 - The plan of care dated to begin 11/21/21 included orders for one to two spiritual counselor visits each week. Clinical documentation revealed missed spiritual counselor visits the weeks ending 11/27/21 and 12/4/21. The DPCS stated that the frequency of spiritual counselor visits ordered by the IDT in accordance with the patient’s and family’s acceptance of the services was one to two spiritual counseling visits per month. Patient Record #96700 - The plan of care dated to begin 11/10/21 included orders for one to two spiritual counselor visits each week. Clinical documentation revealed missed spiritual counselor visits the weeks ending 11/20/21, 11/27/21, 12/4/21 and 12/11/21. The DPCS stated that the frequency of spiritual counselor visits ordered by the IDT in accordance with the patient’s and family’s acceptance of the services was one to two spiritual counseling visits per month.

It is required each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by evidenced by a joint review of clinical records and interview with the Director of Patient Care Services (DPCS), in which 4 of 5 (80%) applicable clinical records of patients who received oxygen were missing documentation of complete, updated orders for oxygen on the plans of care. Patient Record #77263 - The plan of care (POC) dated 7/25/21 included orders for administration of supplemental O2 as ordered. The DPCS was unable to identify specific oxygen orders included in POC and/or POC updates. Patient Record #79562 - The POC dated 8/26/21 included orders for administration of supplemental O2 as ordered. The DPCS was unable to identify specific oxygen orders included in POC and/or POC updates. Patient Record #72244 - The DPCS stated that skilled nurse visit notes revealed that the patient was using oxygen at 4L/minute per nasal cannula. The DPCS was unable to identify oxygen orders included in the POC dated 8/8/21 or any POC updates. Patient Record #52381 - The DPCS stated that the patient’s medication list, POC dated 8/13/21, and POC updates stated that the patient was using Oxygen at 3L/minute per nasal cannula. However, skilled nurse visit notes revealed that the patient was using Oxygen at 4L/minute per nasal cannula and there was no evidence that orders were updated by the IDG.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 41.I and the patient’s record, if requested. This standard was not met as evidenced by evidenced by a joint review of clinical records and interview with the Director of Patient Care Services (DPCS), in which 2 of 3 (67%) applicable discharged clinical records revealed that the hospice did not forward the receiving facility a copy of the hospice discharge summary. Patient Record #99750 - The patient was a live discharge to hospital on 10/24/21. The DPCS stated that she was unable to locate documentation in the clinical record that indicated that the hospice forwarded a discharge summary to the hospital after documented discovery of the patient’s admission. Patient Record #49413 - The patient revoked hospice to seek aggressive treatment in the hospital on 11/3/21. The DPCS stated that she was unable to locate documentation in the clinical record that indicated that the hospice forwarded a discharge summary to the hospital.

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 evidenced by a joint review of clinical records and interview with the Director of Patient Care Services (DPCS), in which 3 of 5 (60%) applicable discharged clinical records revealed that the hospice did not document a hospice discharge summary that included a summary of: the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s plan of care; the patient’s latest physician orders; or any other documentation that would assist in the post-discharge continuity of care. The DPCS stated that she was unable to locate a completed discharge summary of the patient’s hospice stay in the clinical records [Record #99750 (Live discharge to hospital on 10/24/21); Record #32701 (Live discharge for extended prognosis on 11/3/21); Record #49413 (Revocation to seek aggressive treatment in the hospital on 11/3/21)].