Every finding on record at Hospice Advantage, 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. 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. Agency policy #C_15C, "Medication Reconciliation" (revised 1/30/2019), stated in part, "Regardless of the setting, it is the responsibility of the registered nurse performing the admission visit to complete a comprehensive medication review and reconciliation according to the following step...Perform a comprehensive clinical assessment and identify whether medication changes or new interventions are needed to manage the patient's symptoms or comfort...Review current MAR at the medication cart...Note whether there are any new medications or changes documented on the MAR... If so, document on the nursing visit note what the medication changes are...Review the hospice patient's facility record and look for orders to support the medication changes...For patients residing in their residence, it is the responsibility of the hospice RN to perform the following at every scheduled nursing visit...Obtain the most current copy of the medication list (whether this is in the EMR or on paper)….Nurses visually review the patient's medication list in the Home, comparing it to the medication list from the medical record...If the medication list does not match, the nurse promptly updates the incorrect list to reflect the current orders, and the medication reconciliation is completed." Agency policy # C_08C "Initial and Comprehensive Assessment" (revised 7/26/2021) stated in part, "The comprehensive assessments are... updated by the RN at least every fourteen (14) days...used to revise the patient's plan of care, (g) includes all elements, (ix) drug profile." In 3 of 3 (100%) home visits observed, the hospice did not ensure that the comprehensive assessment included a drug profile containing the patient's current medication regimen. Home Visit 1/Clinical Record 2: The patient elected hospice care on 12/18/2023 and resided in a Skilled Nursing Facility (SNF). A medication reconciliation was performed during the home visit with the Registered Nurse (RN) [Personnel Record 3] on 1/30/2024, comparing the hospice medication profile to the patient's SNF medication administration record (MAR)/medication list. The hospice medication profile dated 1/30/2024 for the benefit period dated 12/18/2023 through 2/15/2024 documented, "Order date 1/1/2024-Vitamin D3 capsule 25 mcg, take three (3) capsules daily for Vitamin D deficiency. Order date 12/22/2023- Levothyroxine 88 mcg, take one (1) capsule every morning for hypothyroidism. Order date 1/1/2024-Lorazepam one (1) mg, take one (1) tablet every four (4) hours as needed (PRN) for anxiety." The SNF MAR did not include documentation of Vitamin D3, Levothyroxine, or Lorazepam. During an interview and joint record review, the Director of Clinical Services (DCS), who was present for the home visit, confirmed that the hospice medication profile did not match the patient's SNF medication regimen. Home Visit 2/Clinical Record 1: The patient elected hospice care on 2/16/2023. A medication reconciliation was performed during the home visit with the Hospice Aide (HA) [Personnel Record 5], comparing the hospice medication profile to the patient's medication regimen. The hospice medication profile dated 1/30/2024 for the benefit period 12/13/2023 through 2/10/2024 documented, "Ondansetron 8 mg, take one (1) tablet by mouth every six (6) hours as needed (PRN) for nausea". The caregiver confirmed the patient did not take Ondansetron, stating, "We don't have any medication here for nausea." The medication profile documented, "Hydrocodone 10 mg/Acetaminophen 325 mg, take one (1) tablet by mouth every morning (order dated 2/16/2023)." The medication bottle with an order/fill date of 8/30/2023 read, "Hydrocodone 10 mg/Acetaminophen 325 mg, take one (1) tablet every eight (8) hours as needed (PRN) for pain." The caregiver reported the patient's current regimen was to take the Hydrocodone 10mg/Acetaminophen 325 mg, one (1) tablet every other day. The caregiver stated they were trying to taper off the Hydrocodone/Acetaminophen since the patient was started on a Fentanyl patch. Additionally, the medication profile documented, "Docusate sodium 250 mg, take one (1) capsule in the morning." The medication in the home was Docusate Sodium,100 mg. The caregiver confirmed the patient took one (1) Docusate 100 mg capsule every morning. During an interview and joint record review, the Director of Clinical Services (DCS), who was present for the home visit, confirmed that the hospice medication profile did not match the patient's SNF medication regimen. Home Visit 3/Clinical Record 3: The patient elected hospice care on 11/10/2022. A medication reconciliation was performed during the home visit with the Medical Social Worker (MSW) [Personnel Record 7], comparing the hospice medication profile dated 1/30/2024 to the patient's medication regimen. The patient was taking the medication Austedo 12 mg, take one (1) tablet two (2) times daily. The patient took an additional Austedo six (6) mg at night; the bedtime dose of Austedo was 18 mg. The caregiver confirmed the patient had been on the medication for several years. During an interview and joint record review, the Director of Clinical Services (DCS), who was present for the home visit, and the RN Case Manager confirmed that the hospice medication profile did not match the patient's. They stated, "I knew he was taking Austedo, but I forgot to get that on the med list."

It is required that each patient’s individualized written plan of care: reflects patient and family goals: 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, document review, and interview. Agency policy #C_09A, "Individualized Plan of Care" (revised 1/1/2024) stated in part, "Development of the initial plan of care (a) The RN performs an initial assessment at the time of admission and identifies the immediate physical needs to provide a safe plan of care for the immediate support of the patient and family." In 2 of 14 (14%) clinical records reviewed, the hospice did not ensure that the written plan of care contained goals and interventions based on problems identified in the initial and updated comprehensive assessment. Clinical Record 2: The patient elected hospice care on 12/18/2023. The initial comprehensive assessment completed by the Registered Nurse (RN) on 12/18/2023 documented the patient had one (1) wound to the right upper arm and "Dressing, intact and changed today per facility staff. The patient resided in a nursing facility. Facility nurse will complete wound care with hospice support...fell out of bed a month ago and sustained a laceration to left lower forearm. Injury currently covered with dressing by facility staff." The initial plan of care did not contain a wound care order or problems, goals, or interventions related to a wound. The RN documented the wound healed on 12/21/2023 (3 days after admission) that, and there was only bruising. During a joint record review and interview on 1/29/2024 the Director of Clinical Services confirmed the plan of care did not include problems, goals and interventions for the wound care. Clinical Record 10: The patient elected hospice care on 8/30/2023. The initial comprehensive assessment completed by the RN on 8/30/2023 documented the patient had a colostomy. The initial plan of care dated 8/30/2023 through 10/1/2023 did not contain any problems, goals, or interventions related to the colostomy. During a joint record review and interview on 1/30/2024, the Director of Clinical Services confirmed the initial plan of care did not list any problems, goals, or interventions related to the colostomy. The Director of Clinical Services stated, "The patient was initially in a Skilled Nursing Facility, and the Skilled Nursing Facility managed the colostomy."

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: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, interview and observation. Agency policy #C_09A "Individualized Plan of Care" (revised 1/1/2024) stated in part, "Content of the Plan of Care is to include (e) Drugs and treatments necessary to support patient care needs." In 3 of 14 (21%) clinical records reviewed and home visits observed, the hospice did not ensure the patient's plan of care identified all drugs and treatments necessary to meet the patient's needs. Clinical Record 2: The patient elected hospice care on 12/18/2023. The initial comprehensive assessment completed by the Registered Nurse on 12/18/203 documented the patient had one (1) wound to the right upper arm and "Dressing intact and changed today per facility staff. The patient resided in a nursing facility. Facility nurse will complete wound care with hospice support...fell out of bed a month ago and sustained a laceration to left lower forearm. Injury currently covered with dressing by facility staff." The initial plan of care did not contain a wound care order. The RN documented the wound healed on 12/21/2023 (3 days after admission) that, and there was only bruising. A joint record review and interview with the Director of Clinical Services on 1/29/2024 confirmed the record did not contain a physician order for wound care. Clinical Record 3/Home Visit 3: The patient elected hospice care on 11/10/2022. A medication reconciliation was performed during the home visit on 1/30/2024, comparing the hospice medication profile dated 1/30/2024 to the patient's medication regimen. The patient was taking the medication Austedo 12 mg, take one (1) tablet two (2) times daily. The patient took an additional Austedo six (6) mg at night; the bedtime dose of Austedo was 18 mg. The caregiver confirmed the patient had been on the medication for several years. During an interview and joint record review, the Director of Clinical Services (DCS), who was present for the home visit, and the RN Case Manager confirmed that the hospice plan of care dated 1/4/2024 through 3/3/2024 did not contain the medication. They stated, "I knew he was taking Austedo, but I forgot to get that on the med list." Clinical Record 10: The patient elected hospice care on 8/30/2023. The initial comprehensive assessment completed by the RN on 8/30/2023 documented the patient had a colostomy. The updated Interdisciplinary Group (IDG) plan of care (POC) dated 10/2/2023 documented, "Problem: need for skilled teaching related to ostomy care." The POC documented the goal: "Patient's caregiver to verbalize and demonstrate the ability to remove, clean, dispose of, and reapply the ostomy appliance." The POC documented the intervention: "instructed regarding the use of ostomy equipment." The plan of care did not provide specific instructions or physician's orders as to what colostomy care was to be provided. During a joint record review and interview on 1/30/2024, the Director of Clinical Services confirmed the record did not contain the physician's order for colostomy 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 following: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and observation. Agency policy #C_09A, "Individualized Plan of Care" (revised 1/1/2024), stated in part, "Content of the Plan of Care is to include...Medical supplies and appliances/DME needed to support patient care needs." In 1 of 14 (7%) clinical records reviewed, the hospice did not ensure that the written plan of care included all medical supplies and appliances necessary to meet the patient's needs. Clinical Record 10: The patient elected hospice care on 8/30/2023. The initial comprehensive assessment completed by the RN on 8/30/2023 documented the patient had a colostomy. The updated Interdisciplinary Group (IDG) plan of care (POC) dated 10/2/2023 documented, "Problem: need for skilled teaching related to ostomy care." The POC documented the goal: "Patient's caregiver to verbalize and demonstrate the ability to remove, clean, dispose of, and reapply the ostomy appliance." The POC documented the intervention: "instructed regarding the use of ostomy equipment." The plan of care dated 8/30/2023 through 11/27/2023 did not contain colostomy supplies for the ostomy care. During a joint record review and interview on 1/30/2024, the Director of Clinical Services confirmed the plan of care did not list any colostomy supplies.

It is required that each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy# C31 "Clinical Records" (revised 1/25/2023) stated in part, "Elements of a complete medical record include, "(j) Physicians orders." In 2 of 14 (14%) clinical records reviewed, the hospice did not ensure the patient's clinical record contained all physician's orders. Clinical Record 5: The patient elected hospice care on 11/16/2023 and resided in a Skilled Nursing Facility (SNF). On 11/17/2023 the physician ordered, "D/C PICC (peripherally inserted central catheter) after antibiotic completion on 11/18/2023." The Registered Nurse (RN) completed a comprehensive assessment on 11/22/2023, documenting that the PICC line had not been removed. The hospice RN coordinated with the physician and SNF on 11/22/2023 to remove the PICC line. On 11/22/2023, a clarification physician order was documented: "Remove PICC as previously ordered." The RN comprehensive assessment on 11/26/2023 stated in part, "PICC removed bandaid to area above left antecubital in place." During a joint record review and interview on 1/29/2024, the Director of Clinical Services confirmed the physician order dated 11/17/2023 did not specify if the SNF or the hospice RN would remove the PICC. Clinical Record 7: The patient elected hospice care on 1/17/2024. The comprehensive assessment completed by the RN on 1/18/2024 documented, "PICC dressing removed per patient request. A small amount of blood oozing from the site. Covered with sterile gauze and Tegaderm, as the patient stated he would take a shower." A clinical record review revealed no documented physician's order for sterile gauze and Tegaderm. During a joint record review and interview on 1/30/2024, the Director of Clinical Services confirmed the clinical record did not contain a physician's order for sterile gauze and Tegaderm.