Every finding on record at Hospice 365 LLC

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address the development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment which includes information provided to facilitate patient evacuation and transportation including if the patient is mobile or not, if the patient has life-dependent equipment, and if so, is it able to be transported (e.g. battery operated, size, condition, etc.), and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g. deaf, non-English speaking, etc.). This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed, the agency did not ensure the patient's emergency plan was individualized to the needs of the patient. Clinical Record 4: The patient elected the hospice benefit on 11/10/2023. The "Patient's Emergency Plan" form completed and signed on 11/10/2023 documented that the patient had special needs indicated by a box checked "yes." The Registered Nurse's Admission Assessment documented the patient had a gastric and jejunal tube through which medications and continuous feedings were administered via a feeding pump at 65cc/hour. This information was not included in the Patient's Emergency Plan Assessment. On 11/21/2023 it was discussed and confirmed with the Alternate Administrator (Staff 2) that the patient's individualized emergency plan did not contain the pertinent information about the gastric and jejunal tube, gastric feeding pump, and continuous feedings needed in order to provide emergency personnel information in the event the patient needed evacuation.

It is required that each patient’s individualized written plan of care includes 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 document review, clinical record review, and interview. In 3 of 7 (43%) clinical records reviewed, the agency did not ensure the patient's individualized written plan of care included a frequency of services necessary to meet the specific patient and family needs. Agency policy PE.1 Patient Assessments, dated 09/01/2019, stated in part, "Updates to the Comprehensive Health Assessment will be accomplished by the IDG... to include but not be limited to ...services and frequency of services to be provided." Clinical Record 2: The patient elected the hospice benefit on 10/30/2023. The plan of care dated 10/30/2023 through 01/27/2024 included an order for an initial Social Work (SW) and Chaplain evaluation. A physician order dated 11/05/2023 ordered SW visits weekly and every other week for Chaplain visits. A physician order dated 11/09/2023 discontinued weekly SW visits and included an order for one PRN (as needed) SW visit. The updated Plan of Care/Interdisciplinary Group (IDG) meeting dated 11/16/2023 included the one PRN SW visit but did not include the circumstances or reason for the PRN visit. Clinical Record 5: The patient elected the hospice benefit on 10/05/2023. The plan of care dated 10/05/2023 through 01/02/2024 included an order for an initial Social Work and Chaplain evaluation. A physician order dated 10/20/2023 documented the patient declined Social Work visits. The Updated Plan of Care/IDG meeting dated 10/20/2023 included four PRN visits for the Chaplain and the Social Worker. The updated POC orders did not include the circumstances or reasons for the PRN visits and did not include a frequency for the PRN visit. Clinical Record 6: The patient elected the hospice benefit on 10/19/2023. The plan of care dated 10/19/2023 through 01/16/2024 included an order for an initial Social Worker and Chaplain evaluation. A physician order dated 10/23/2023 ordered SW visits monthly and 4 PRN Chaplain visits but did not include the circumstances or reasons for the PRN visits and did not include a frequency for the PRN visits. During an interview on 11/22/2023, the Alternate Administrator (Staff 2) and the Alternate Director of Nursing (Staff 3) agreed that no specific visit frequency or reason was included for the PRN visits include in the plans 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 measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 7 (29%) clinical records reviewed, the agency did not ensure that the patient's plan of care included measurable outcomes based on care implemented by the hospice agency. Agency policy PE.1 Patient Assessments, dated 9/1/2019, stated in part, "Updates to the Comprehensive Health Assessment will be accomplished by the IDG [interdisciplinary group] ...to include...reassessment of the patient's response to care." Agency policy PC.6 Plan of Care Process, dated 5/1/2019, stated in part, "The update of the comprehensive assessment will be accomplished by the IDG ...and will evaluate changes that have taken place since the initial assessment ...updates will include progress toward desired outcomes, as well as a reassessment of the patient's response to care. The POC includes but is not limited to ... measurable outcomes anticipated from implementing and coordinating the POC." Clinical Record 2: The patient elected the hospice benefit on 10/30/2023. The Registered Nurse (RN) documented on the Nursing Clinical Progress Note dated 11/02/2023 that the patient's "Left ac [antecubital space] where the IV [intravenous line] was placed during hospitalization appears infected: red, swollen, and painful." The nurse obtained an order from the physician for Bactrim DS [antibiotic] for seven days. Then, on 11/04/2023, the nurse noted, in addition to the infected IV site, that the left lower extremity had symptoms of cellulitis. There was no related goal or measurable progress reflected in the patient's updated plan of care for the left arm and left lower leg infection treatment. Clinical Record 6: The patient elected the hospice benefit on 10/19/2023. The RN documented on the admission assessment that the patient was anxious. The physician's order at admission was for Lorazepam 0.5mg every four hours as needed for anxiety. A communication note documented by the RN on 10/22/2023 stated in part that the patient needed a refill of the Lorazepam, and after conferring with the physician, an order was received to schedule the Lorazepam 0.5mg by mouth three times daily. There was no related goal or measurable progress reflected in the patient's updated plan of care for the patient's identified anxiety. During interviews on 11/22/2023, the Alternate Administrator and the Alternate Director of Nursing confirmed the patient’s plans of care did not include goals related to the infection for record 2 and anxiety for record 6.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with a live discharge, the agency did not ensure the patient's attending physician received a copy of the hospice discharge summary. Clinical Record 7: The patient elected the hospice benefit on 10/05/2023 and signed the revocation form on 10/22/2023. A review of the discharge summary, communication notes, and scanned documents revealed no documented evidence that the discharge summary was provided to the patient's physician. During an interview and record review on 11/22/2023, the Alternate Administrator and Alternate Director of Nursing confirmed the discharge summary was not sent.

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 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 and interview. In 1 of 1 (100%) clinical record reviewed with a live discharge, the agency did not ensure that the patient's discharge summary included the patient's plan of care, medication list, or physician orders. Clinical Record 7: The patient elected the hospice benefit on 10/05/2023 and signed the revocation form on 10/22/2023. Review of the hospice discharge summary revealed it did not include the patient's medication list, plan of care, or the latest physician orders. During interviews on 11/22/2023, the Alternate Administrator and the Alternate Director of Nursing confirmed the discharge summary did not contain information related to the patient's symptom management, current plan of care, or latest physician orders.