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 medication review process includes the identification of the following: 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. Agency policy #C8, "Initial and Comprehensive Assessment" (revised 1/22/2021) sub-section two (2) stated in part, "The comprehensive assessments are" (e) updated by the RN at least every fourteen (14) days. (f) used to revise the patient's plan of care, (g) includes all elements, (ix) drug profile." Agency policy # C_15C, "Medication Reconciliation" (revised 1/30/2019) sub-section procedure 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... identify whether medication changes or new interventions are needed to manage the patient's symptoms or comfort...Review current MAR at the medication cart. (3) Note whether there are any new medications or changes documented on the MAR. Four (4) If so, document on the nursing visit note what the medication changes are. Five (5) 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)….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." In 3 of 19 (16%) clinical records reviewed and home visits observed, the hospice did not ensure that the comprehensive assessment included a review of the patient's current medications. Home Visit 2/Clinical Record 2: The patient elected hospice care on 12/27/2023. Medication reconciliation was performed during the home visit on 2/13/2024, comparing the hospice medication profile to the patient's medication regimen. The hospice medication profile dated 2/13/2024 documented, "Baclofen 5 mg., take one (1) tablet three (3) times a day. The caregiver reported the patient's current medication regimen was Baclofen 5 mg. take one (1) tablet two (2) times a day. The caregiver reported the patient took Baclofen twice a day "since before admission to hospice." The medication bottle in the home read in part, "Baclofen 5 mg, take one (1) tablet two (2) times a day." Additionally, the Register Nurse (RN) assessment completed on 2/6/2023 documented, "New medication Lomotil as needed (PRN) order sent to the pharmacy." The medication profile did not contain the medication Lomotil. During a joint record review and interview on 2/12/2024, the Director of Clinical Services confirmed the medication list or plan of care did not contain Lomotil. There was no evidence that Lomotil was reviewed during the patient's medication regimen review. Home Visit 3/Clinical Record 3: The patient elected hospice care on 9/20/2023 and resided in a skilled nursing facility (SNF). Medication reconciliation was performed during the home visit on 2/13/2024, comparing the hospice medication profile to the patient's SNF medication profile/administration record (MAR) dated 2/13/2024. The hospice medication profile dated 2/13/2024 documented, "1/4/2024-2/13/2024 hydrocodone 7.5/acetaminophen 325, take one (1) tablet three (3) times a day for pain." The MAR documented, "Start date, 1/17/2024 hydrocodone 7.5/acetaminophen 325, take one (1) tablet four (4) times a day for pain." The SNF MAR documented, "Geri-Lanta Oral Suspension 200-200-20 per 5 ml give ten ml every four (4) hours as needed (PRN) for indigestion," start date 2/1/2024. The hospice medication profile did not include documentation of Geri-Lanta Oral Suspension. There was no evidence that Geri-Lanta Oral Suspension was reviewed during the patient's medication regimen review. Clinical Record 5: The patient elected hospice care on 2/24/2023 and resided in a Skilled Nursing Facility (SNF). The comprehensive assessment completed by the RN dated 2/05/2024 documented, "Norco 5/325 scheduled three (3) times a day for generalized pain." A review of the patient's SNF medication list dated 2/13/2024 documented "Norco (Hydrocodone) 5 mg/Acetaminophen 325 mg, give one (1) tablet three (3) times daily." The medication profile and plan of care did not document Norco. There was no evidence Norco was reviewed during the patient's medication regimen review. During a joint record review and interview on 2/12/2024, the Director of Clinical Services confirmed that the hospice medication profile and plan of care did not contain Norco. During a joint record review, observation, and interview on 2/13/2024, the Director of Clinical Services, who was present at the home visits, confirmed the hospice medication profiles did not match the patient's current medication regimens.

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, document review, interview, and observation. Agency policy # C_09A, "Individualized Plan of Care" (revised 1/1/2024) sub-section two (2) stated in part, "Contents of the Plan of care include (b) interventions to manage pain and symptoms, (i) medications, (ii) non-pharmacological interventions, and (iii) training for the patient and caregiver... 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 1 of 19 (5%) clinical records reviewed, the hospice did not ensure the plan of care contained all problems, goals, and interventions necessary for the palliation of the patient. Clinical Record 2/Home Visit 2: The patient elected hospice care on 12/27/2023 with the terminal diagnosis of cerebral vascular disease with sequelae following a cerebral vascular accident, or "stroke." The Certificate of Terminal Illness (CTI) documented, "had a prior stroke that resulted in right hemiparesis on left-sided weakness." The initial Registered Nurse (RN) assessment dated 12/27/2023 documented, "The patient has been getting weaker on the left side. Yesterday, the patient would not open their mouth to take pills, and the daughter reports that the pills had to be removed because the patient was unable to swallow." The initial plan of care dated 12/27/2023 through 3/25/2024 did not include documentation of goals or interventions for the problem of left-sided weakness or dysphagia. The updated interdisciplinary group (IDG) plan of care dated 1/10/2024 did not include documentation of goals or interventions for the problem of left-sided weakness or dysphagia. The current plan of care dated 2/12/2024 did not include documentation of goals or interventions for the problem of left-sided weakness or dysphagia. During the home visit on 2/13/2024, the patient was bed-bound with left-sided weakness. During a joint record review and interview on 2/12/2024, the Director of Clinical Services, who was present at the home visit, confirmed the hospice plan of care did not contain any goals or interventions related to hemiplegia/left-sided weakness or dysphagia, even though the RN identified those two (2) problems on the assessment completed 12/27/2023.

It is required that each patient’s individualized written plan of care includes all drugs and treatments 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) sub-section two (3), 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 19 (16%) clinical records reviewed and home visits observed, the hospice did not ensure that the patient's written plan of care contained all drugs needed to meet the patient's needs. Clinical Record 2/Home Visit 2: The patient elected hospice care on 12/27/2023. The comprehensive assessment completed by the Registered Nurse (RN) dated 2/6/2023 documented, "New medication Lomotil as needed (PRN) order sent to the pharmacy." The plan of care dated 12/27/2023 through 3/6/2024 did not document Lomotil. During a joint record review and interview on 2/12/2024, the Director of Clinical Services confirmed the medication list and plan of care did not contain Lomotil. Clinical Record 3/Home Visit 3: The patient elected hospice care on 9/20/2023 and resided in a skilled nursing facility (SNF). Medication reconciliation was performed during the home visit on 2/13/2024, comparing the hospice medication profile to the patient's SNF medication profile/administration record (MAR) dated 2/13/2024. The SNF MAR documented, "Geri-Lanta Oral Suspension 200-200-20 per 5 ml give ten ml every four (4) hours as needed (PRN) for indigestion," start date 2/1/2024. The hospice plan of care dated 12/20/2024 through 3/18/2024 did not document Geri-Lanta Oral Suspension. During a joint record review, observation, and interview on 2/13/2024, the Director of Clinical Services, who was present at the home visit, confirmed that the plan of care did not include Geri-Lanta Oral Suspension. Clinical Record 5: The patient elected hospice care on 2/24/2023 and resided in a Skilled Nursing Facility (SNF). The comprehensive assessment completed by the RN dated 2/05/2024 documented, "Norco 5/325 scheduled three (3) times a day for generalized pain." A review of the patient's SNF medication list dated 2/13/2024 documented "Norco (Hydrocodone) 5 mg/Acetaminophen 325 mg, give one (1) tablet three (3) times daily." The plan of care did not document Norco. During a joint record review and interview on 2/12/2024, the Director of Clinical Services confirmed that the hospice medication profile and plan of care did not contain Norco.

It is required written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C9 "Written Interdisciplinary Plan of Care" (revised 9/27/2019) sub-section two, stated in part, "Care is provided to the patient in accordance with the plan." In 2 of 15 (13%) clinical records reviewed where hospice aide services were accepted, the hospice did not ensure that the Hospice Aide (HA) received specific patient care instructions. Clinical Record 9: The patient elected hospice care on 1/15/2024. The HA care plan dated 1/15/2024 through 3/31/2024 ordered HA services two (2) times per week and assigned the HA the tasks, "Bathing/shower weekly, skin care weekly, apply moisture barrier as needed, shampoo weekly, and change linens weekly." The HA care plan did not specify what day of the week the patient was to receive a shower and have linens changed. During a joint record review and interview on 2/14/2024, the Area Executive Director of Clinical Operations confirmed the HA care plan did not provide specific instructions to the HA regarding the shower and linen change. Clinical Record 11: The patient elected hospice care on 10/16/2023 with the terminal diagnosis of Huntington's disease. The patient lived in a Skilled Nursing Facility (SNF). On 2/12/2023, the patient fell. The fall report completed by the hospice Registered Nurse (RN) documented, " Facility called and stated patient rolled out of bed had had two (2) small abrasions to left eyebrow. The staff nurse stated that the CNA did not put the patient's wedge in bed as ordered when the patient was in bed. The Facility stated CNAs were educated about patients needing wedges when in bed." The HA care plan dated 1/14/2024 through 4/12/2024 did not assign the HA the task of "placing the wedge in the bed while the patient is in bed." The Area Executive Director of Clinical Services reported that since the HA did not complete a visit on 2/12/2024, it was assumed the SNF aide forgot to place the wedge beside the patient while the patient was in bed. During a joint record review and interview on 12/14/2024, the Area Executive Director of Clinical Services confirmed the HA care plan dated 1/14/2024 through 4/12/2024 did not assign the HA a task to place the wedge in the bed while the patient was in the bed.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; [and] included in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C9, "Written Interdisciplinary Plan of Care" (revised 9/27/2019) sub-section two, stated in part, "Care is provided to the patient in accordance with the plan." In 3 of 15 (20%) clinical records reviewed where hospice aide services were accepted, the hospice did not ensure the Hospice Aide (HA) provided services included in the plan of care. Clinical Record 4: The patient elected hospice care on 9/13/2023. The HA care plan ordered Hospice Aide services two (2) times a week and assigned the HA the tasks: "Oral care every visit, and wash linens every visit." The week of 1/28/2024 through 2/3/2024, the HA visit notes dated 1/30/2024 and 2/1/2024 documented the assigned tasks oral care and wash linen were not completed. There was no evidence the HA updated the Registered Nurse (RN) about the tasks not provided. The week of 2/4/2024 through 2/10/2024, the HA visit notes dated 2/6/2024 and 2/8/2024 documented the assigned tasks oral care and wash linen were not completed. There was no evidence the HA updated the RN about the tasks not provided. Clinical Record 7: The patient elected hospice care on 9/12/2022. The HA care plan dated 1/5/2023 through 3/4/2024 ordered Hospice Aide services one (1) time a week and assigned the HA the tasks: "Oral care every visit and turn and position patient in bed every visit." The week of 1/28/2023 through 2/3/2024, the HA visit note dated 1/31/2024 documented the assigned tasks oral care and turning and positioning in bed were not completed. The week of 2/4/2024 through 2/10/2024, the HA visit note dated 2/6/2024 documented the assigned tasks oral care and turning and positioning in bed were not completed. Clinical Record 9: The patient elected hospice care on 1/15/2024. The HA care plan dated 1/15/2024 through 3/31/2024 ordered Hospice Aide services two (2) times per week and assigned the HA the tasks: "Bathing/shower weekly, skin care weekly, apply moisture barrier as needed, shampoo weekly, and change linens weekly." The week of 2/4/2024 through 2/10/2024, the HA visit notes dated 2/6/2024 and 2/8/2024 documented the assigned tasks "Bathing/Showering " task was not completed. There was no evidence the HA updated the RN about the tasks not provided. During a joint record review and interview on 2/13/2024, the Director of Clinical Services confirmed the HA did not follow the care plans.

It is required that hospice aides report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 3 of 15 (20%) clinical records reviewed in which Hospice Aide services were accepted, the hospice did not ensure the HA reported changes in the patient's care needs to the Registered Nurse (RN) as the changes related to the plan of care. Clinical Record 4: The patient elected hospice care on 9/13/2023. The HA care plan ordered Hospice Aide services two (2) times a week and assigned the HA the tasks: "Oral care every visit, and wash linens every visit." The week of 1/28/2024 through 2/3/2024, the HA visit notes dated 1/30/2024 and 2/1/2024 documented the assigned tasks oral care and wash linen were not completed. There was no evidence the HA updated the Registered Nurse (RN) about the tasks not provided. The week of 2/4/2024 through 2/10/2024, the HA visit notes dated 2/6/2024 and 2/8/2024 documented the assigned tasks oral care and wash linen were not completed. There was no evidence the HA updated the RN about the tasks not provided. Clinical Record 7: The patient elected hospice care on 9/12/2022. The HA care plan dated 1/5/2023 through 3/4/2024 ordered Hospice Aide services one (1) time a week and assigned the HA the tasks: "Oral care every visit, and turn and position patient in bed every visit." The week of 1/28/2023 through 2/3/2024, the HA visit note dated 1/31/2024 documented the assigned tasks oral care and turning and positioning in bed were not completed. The week of 2/4/2024 through 2/10/2024, the HA visit note dated 2/6/2024 documented the assigned tasks oral care and turning and positioning in bed were not completed. Clinical Record 9: The patient elected hospice care on 1/15/2024. The HA care plan dated 1/15/2024 through 3/31/2024 ordered Hospice Aide services two (2) times per week and assigned the HA the tasks: "Bathing/shower weekly, skin care weekly, apply moisture barrier as needed, shampoo weekly, and change linens weekly." The week of 2/4/2024 through 2/10/2024, the HA visit notes dated 2/6/2024 and 2/8/2024 documented the assigned tasks "Bathing/Showering " task was not completed. There was no evidence the HA updated the RN about the tasks not provided. During a joint record review and interview on 2/13/2024, the Director of Clinical Services confirmed the HA did not update the RN about interventions not provided to the patients according to the plan of care.