Every finding on record at Home Health Care Professionals and Hospice

Based on review of hospice policies/procedures and clinical records, and interview with the administrator, the hospice failed to ensure that goals for problems identified during hospice assessments or the hospice interdisciplinary group (IDG) meetings were included on the initial or recertification "Hospice Plan of Care" for twelve (12) of fourteen (14) patients. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #13 and #14) --- Findings include: On August 11, 2023 at approximately 3:47 PM, review of agency policy 1-033, titled "Prioritizing Patient Problems/Needs", revealed the following under "Procedure": 3. Using data obtained during the initial, comprehensive and ongoing assessments, the hospice interdisciplinary group members will develop a list of patient problems and needs, with corresponding goals and anticipated outcomes for reaching those goals... 4. The analysis of data obtained during assessments should facilitate the ongoing and prioritization of patient problems, needs, goals and care. 5. The plan of care should include...B. Goals... Patient #1 (Discharge): Between August 8, 2023 at approximately 11:49 AM and August 9, 2023 at approximately 2:08 PM, review of the clinical record revealed the start of care date was 01/31/2023 and the primary hospice diagnosis was transient cerebral ischemic attack (mini-stroke) as documented on the "Hospice Plan of Care" for the recertification period of 05/01/2023 through 07/29/2023. Review of skilled nursing (SN) assessment documentation dated 05/01, 05/15, 05/22 and 05/30/203 revealed the patient suffered from short-term and/or long-term memory loss. There was no documentation on the "Hospice Plan of Care" which provided evidence neurological goals were included on the "Hospice Plan of Care" for the recertification period of 05/01/2023 through 07/29/2023. Patient #2 (Discharge): Between August 8, 2023 at approximately 12:55 PM and August 9, 2023 at approximately 2:38 PM, review of the clinical record revealed the start of care date was 05/04/2023, the primary hospice diagnosis was heart failure, oxygen (O2) was to be administered continuously, cardiac medications included Metoprolol and that wound care was to be provided as documented on the "Hospice Plan of Care" for the initial certification period ending 07/21/2023. Review of start of care (SOC) SN assessment documentation dated 05/04/2023 revealed the patient required O2 continuously and that SN provided wound care to three (3) pressure wounds. There was no documentation on the "Hospice Plan of Care" which provided evidence cardiopulmonary (heart/lung) nor integumentary (skin) goals were included on the "Hospice Plan of Care" for the initial certification period ending on 07/21/2023. Patient #3 (Discharge): Between August 8, 2023 at approximately 1:43 PM and August 9, 2023 at approximately 2:43 PM, review of the clinical record revealed the start of care date was 07/21/2023, the primary hospice diagnosis was heart failure, O2 was to be administered as needed and that the cardiac medications included Metoprolol as documented on the "Hospice Plan of Care" for the initial certification period of 07/21/2023 through 10/18/2023. Review of SOC SN assessment documentation dated 07/21/2023 revealed cardiac symptoms included fatigue, weakness and irregular heartrate and pulmonary symptoms included shortness of breath. There was no documentation on the "Hospice Plan of Care" which provided evidence cardiopulmonary goals were included on the "Hospice Plan of Care" for the initial certification period of 07/21/2023 through 10/18/2023. Patient #4: On August 10, 2023 at approximately 2:56 PM, review of the clinical record revealed the start of care date was 02/14/2022, the primary hospice diagnosis is heart failure and that O2 is to be administered as needed as documented on the "Hospice Plan of Care" for the recertification period of 08/08/2023 through 10/06/2023. Review of the interdisciplinary group/team meeting minutes dated 08/01/2023 revealed SN assessment findings included a loose cough. There was no documentation on the "Hospice Plan of Care" which provided evidence cardiopulmonary goals were included on the "Hospice Plan of Care" for the recertification period of 08/08/2023 through 10/06/2023. Patient #5: On August 11, 2023 at approximately 9:12 AM, review of the clinical record revealed the start of care date was 05/30/2023, the primary hospice diagnosis is heart failure and that O2 is to be administered as needed as documented on the "Hospice Plan of Care" for the initial certification period of 05/30/2023 through 08/27/2023. Review of the interdisciplinary group/team meeting minutes conducted between 06/06/2023 and 08/01/2023 revealed SN assessment findings included edema of the lower legs and shortness of breath. There was no documentation on the "Hospice Plan of Care" which provided evidence cardiopulmonary goals were included on the "Hospice Plan of Care" for the initial certification period of 05/30/2023 through 08/27/2023. Patient #6: On August 11, 2023 at approximately 9:59 AM, review of the clinical record revealed the start of care date was 06/08/2023, the primary hospice diagnosis is heart failure, O2 is to be administered as needed and that cardiac medications include Metoprolol as documented on the "Hospice Plan of Care" for the initial certification period of 06/08/2023 through 009/05/2023. Review of the interdisciplinary group/team meeting minutes conducted between 07/08/2023 and 08/01/2023 revealed SN assessment findings included shortness of breath and decreased oxygen concentration levels. There was no documentation on the "Hospice Plan of Care" which provided evidence cardiopulmonary goals were included on the "Hospice Plan of Care" for the initial certification period of 06/08/2023 through 009/05/2023. Patient #7: On August 11, 2023 at approximately 10:39 AM, review of the clinical record revealed the start of care date was 03/05/2023, the primary hospice diagnosis is lung cancer and that O2 is to be administered as needed as documented on the "Hospice Plan of Care" for the recertification period of 06/03/2023 through 08/31/2023. Review of the interdisciplinary group/team meeting minutes dated 06/20/2023 and 08/01/2023 revealed SN assessment findings included edema of the lower legs or changes in lung sounds. There was no documentation on the "Hospice Plan of Care" which provided evidence pulmonary goals were included on the "Hospice Plan of Care" for the recertification period of 06/03/2023 through 08/31/2023. Patient #8 (Discharge): On August 11, 2023 at approximately 11:30 AM, review of the clinical record revealed the start of care date was 06/29/2022, the primary hospice diagnosis was chronic congestive (systolic) heart failure, that O2 was to be administered as needed and that cardiac medications included Metoprolol as documented on the "Hospice Plan of Care" for the initial certification period of 06/29/2022 through 09/26/2022. Review of SOC SN documentation dated 06/29/2023 revealed SN assessment findings included that lung sounds were diminished. There was no documentation on the "Hospice Plan of Care" which provided evidence cardiopulmonary goals were included on the "Hospice Plan of Care" for the initial certification period of 06/29/2022 through 09/26/2022. Patient #10: On August 11, 2023 at approximately 1:16 PM, review of the clinical record revealed the start of care date was 01/04/2023, the primary hospice diagnosis is pulmonary fibrosis (lung disease) and that respiratory medication included nebulizer (breathing) treatments to be administered as needed as documented on the "Hospice Plan of Care" for the recertification period of 07/03/2023 through 08/31/2023. Review of the interdisciplinary group/team meeting minutes dated 07/18/2023 and 08/01/2023 revealed SN assessment findings included shortness of breath or that the patient required use of an inhaler as needed. There was no documentation on the "Hospice Plan of Care" which provided evidence pulmonary goals were included on the "Hospice Plan of Care" for the recertification period of 07/03/2023 through 08/31/2023. Patient #11: On August 11, 2023 at approximately 1:43 PM, review of the clinical record revealed the start of care date was 02/10/2022, the primary hospice diagnosis is heart failure and that O2 is to be administered as need as documented on the "Hospice Plan of Care" for the recertification period of 07/16/2023 through 09/13/2023. Review of the interdisciplinary group/team meeting minutes dated 08/01/2023 revealed SN assessment findings included cough with thick mucus. There was no documentation on the "Hospice Plan of Care" which provided evidence cardiopulmonary goals were included on the "Hospice Plan of Care" for the recertification period of 07/16/2023 through 09/13/2023. Patient #13: On August 11, 2023 at approximately 2:17 PM, review of the clinical record revealed the start of care date was 04/04/2022, the primary hospice diagnosis is chronic obstructive pulmonary disease (COPD) and that respiratory medications include inhalers and cough syrup to be administered as needed as documented on the "Hospice Plan of Care" for the recertification period of 07/28/2023 through 09/25/2023. Review of SN assessment documentation dated 07/31/2023 revealed oxygen was being administered at 4 liters per minute and that wheezing was present. There was no documentation on the "Hospice Plan of Care" which provided evidence pulmonary goals were included on the "Hospice Plan of Care" for the recertification period of 07/28/2023 through 09/25/2023. Patient #14: On August 11, 2023 at approximately 2:37 PM, review of the clinical record revealed the start of care date was 07/31/2023, the primary hospice diagnosis is COPD and that O2 is to be administered as needed as documented on the "Hospice Plan of Care" for the initial certification period of 07/31/2023 through 10/28/2023. Review of SOC SN documentation dated 07/31/2023 revealed SN assessment findings included dyspnea (shortness of breath). There was no documentation on the "Hospice Plan of Care" which provided evidence pulmonary goals were included on the "Hospice Plan of Care" for the initial certification period of 07/31/2023 through 10/28/2023. During interview conducted on August 11, 2023 at approximately 3:25 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence that goals for hospice problems identified during SN assessments had been included on the "Hospice Plan of Care" for the above identified patients.

Based on review of hospice policies/procedures and clinical records, and interview with the administrator, the hospice failed to ensure verbal orders were documented on a written "Physician Order" form was for three (3) of four (4) patients for whom verbal medication order was obtained by a registered nurse (RN). (Patients #7, #9 and #13) --- Findings include: On August 11, 2023 at approximately 3:49 PM, review of agency policy 1-010, titled "Monitoring Patient's Response/Reporting to Physician", revealed the following under "Procedure": 6. Based on communication with the physician, a verbal order will be obtained for any change in the plan of care... Patient #7: On August 11, 2023 at approximately 10:39 AM, review of the clinical record revealed the start of care date was 03/05/2023 and that the primary hospice diagnosis is lung cancer as needed as documented on the "Hospice Plan of Care" for the recertification period of 06/03/2023 through 08/31/2023. Review of skilled nursing (SN) assessment documentation dated 07/10/2023 revealed the RN (Employee #3) obtained a verbal physician order for Bactrim DS (antibiotic). The RN failed to document the dose, route and duration Bactrim DS which was to be administered. There was no documentation which provided evidence Bactrim DS was included on the "Medication Profile" in the electronic clinical record. There was no documentation in the clinical record which provided evidence the RN documented the verbal order on a written "Physician Order" form for the verbal order obtained on 07/10/2023. Patient #9: On August 11, 2023 at approximately 12:33 PM, review of the clinical record revealed the start of care date was 07/15/2023 and that he primary hospice diagnosis is secondary brain cancer as documented on the "Hospice Plan of Care" for the initial certification period of 07/15/2023 through 10/12/2023. Review of electronic infection "Communication Note" dated 07/24/2023 revealed the RN (Employee #3) documented that a verbal order was obtained for Cipro 500 milligrams (mg) to be administered orally (po) twice a day for seven days. There was no documentation in the clinical record which provided evidence the RN documented the verbal order on a written "Physician Order" form for the verbal order obtained on 07/24/2023. Patient #13: On August 11, 2023 at approximately 2:17 PM, review of the clinical record revealed the start of care date was 04/04/2022, the primary hospice diagnosis is chronic obstructive pulmonary disease (COPD) and that respiratory medications include inhalers and cough syrup to be administered as needed as documented on the "Hospice Plan of Care" for the recertification period of 07/28/2023 through 09/25/2023. Review of SN visit documentation dated 07/31/2023 revealed the RN (Employee #5) documented that a verbal order was obtained for Zpack (antibiotic) 500 mg daily for five (5) days. There was no documentation in the clinical record which provided evidence the RN documented the verbal order on a written "Physician Order" form for the verbal order obtained on 07/31/2023. During interview conducted on August 11, 2023 at approximately 3:25 PM, the administrator confirmed verbal medication orders were not documented on a written "Physician Order: form for the above identified patients.