Every finding on record at Hospice Care Team, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure that the hospice Interdisciplinary Group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the patient elected hospice care. Clinical Record 2: The patient elected the hospice benefit on 04/08/2024. The Social Worker completed the initial psychosocial assessment on 04/16/2024 (day 8). The Chaplain completed the initial spiritual assessment on 05/20/2024 (day 42). There was no documented evidence of a missed visit or reason for the delay. Clinical Record 4: The patient elected the hospice benefit on 01/25/2024. The Social Worker completed the initial psychosocial assessment on 01/31/2024 (day 6). The Chaplain completed the initial spiritual assessment on 01/31/2024 (day 6). There was no documented evidence of a missed visit or reason for the delay. Clinical Record 5: The patient elected the hospice benefit on 05/22/2024. The Social Worker completed the initial psychosocial assessment on 06/12/2024 (day 21). The Chaplain completed the initial spiritual assessment on 06/03/2024 (day 12). There was no documented evidence of a missed visit or reason for the delay. Clinical Record 6: The patient elected the hospice benefit on 07/31/2024. The Chaplain completed the initial spiritual assessment on 08/08/2024 (day 8). There was no documented evidence of a missed visit or reason for the delay. During a joint record review and interview on 11/08/2024, the Director of Clinical Services stated, “These should have been completed in the first five days, and they weren't. We have identified this problem and are working on it.”

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #HR.115(state) "Background Checks" stated in part, "Background and criminal history checks will be performed as follows: An individual, who will have direct access to patients either as an employee or as an independent contractor with the Hospice, will give written consent at the time of application to conduct a criminal history check, including a state and Federal Bureau of Investigation (FBI) finger-print based check." Agency policy #HR.115 "Background Checks" stated in part, "A criminal history check will be obtained prior to employment on all Hospice employees and contractors that have direct contact with patients or access to patient records." In 2 of 9 (22%) personnel records reviewed of hospice staff with direct patient contact or access to patient records, the agency did not ensure that a criminal background check was obtained. Personnel Record 5: The Hospice Medical Director hired on 01/24/2023, who has access to the patient's medical records, did not have documentation of a criminal background check. Personnel Record 6: The Associate Medical Director hired on 01/29/2024, who has access to the patient's medical records, did not have documentation of a criminal background check. During a joint review of the employee's file and interview on 11/07/2024, the Business Office Manager stated, "I do not see a background check for either of them." No further documentation was provided before the survey exit. During an interview on 11/08/2024, the Executive Director stated, "They should have been completed upon hire, but we cannot find a background check for either physician. I checked with Human Resources and Corporate, and they did not have one." No further documentation was provided before the survey exit.

Based on record review and interview, the hospice agency failed to ensure that nursing services met the needs of the patient as identified in the updated assessment in 1 of 4 records reviewed resulting in lack of nursing oversight for needs of the patient and the potential for a poor outcome for this patient. Findings include: --- Agency policy titled ";Implementing Care and Treatment", PC.35 was reviewed on 8/20/24. On page 2., it stated ";V. If there is a change in the schedule of care, the patient and or caregiver are notified prior to the scheduled time (if possible) by the appropriate discipline. Vl. When provision of care/treatment cannot be implemented as established on the care planning document(s), the patients physician will be notified. The appropriate documentation will be completed and submitted by the assigned discipline or Clinical Manager." P-1: This 84-year-old was admitted to the hospice agency on 4/29/23 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (progressive lung disease). The medical record was reviewed on 8/19/24. The plan of care update for the certification period of 6/22/24- 8/20/24 included a registered nurse (RN) visit frequency of 1 time per week (effective 6/20/24). There was no RN visit the week of 6/16/24- 6/22/24. There were no RN visits made to P-1 between 6/28/24 and 7/17/24 (20 days). There was a "Missed Visit" note signed by the RN case manager (Staff C) on 7/19/24 for a missed visit which occurred on 6/21/24 (28 days earlier). On the note, under ";Missed Visit Details", the reason for the missed visit was documented as ";Patient/Family Not at Home" and no other comments regarding the visit were included. There was no documentation that a message was left for P-1 or the family regarding the missed visit. It was not documented if contact was ever established regarding the visit, or if options for other days or times in the week were offered. There was no documentation that P-1 or the family were aware that the visit would be missed. There was no documentation that the physician was notified that the weekly RN frequency visit had been missed. There was a ";Missed Visit" note signed by the RN case manager (Staff C) on 7/19/24 for a missed visit which occurred on 7/3/24 (16 days earlier). On the note, under ";Missed Visit Details", the reason for the missed visit was documented as ";Patient/Family Not at Home" and included the following comments: ";called family to let them know that because of holiday being on the 4th which is a thurs but no one answered" [sic]. There was no documentation that a message was left for P-1 or the family regarding the missed visit. It was not documented if contact was ever established regarding the visit, or if options for other days or times in the week were offered. There was no documentation that P-1 or the family were aware that the visit would be missed. There was no documentation that the physician was notified that the weekly RN frequency visit had been missed. There was a ";Missed Visit" note signed by the Clinical Manager, Staff B on 7/19/24 for a missed visit which occurred on 7/11/24 (8 days earlier). On the note, under ";Missed Visit Details", the reason for the missed visit was documented as ";Patient/Family Refused Visit" and included the comment, ";per" the RN (Staff F), no visit was ";needed" per family request. It was unclear why Staff B (not Staff F) entered the ";Missed Visit" note. It was unclear if ";family" or P-1 refused the visit or if Staff F was just not able to make the scheduled visit (see below). No documentation was noted that other day/time options were given to P-1 or family so that P-1 would still have a visit in the week. It was unclear whether the ";Missed Visit" note was entered on 7/11/24, or if it was entered on the same day it was signed (7/19/24). There was no documentation that the physician was notified that the weekly RN frequency visit had been missed. On 8/19/24, hospice after-hours triage logs for July 2024 were requested and reviewed. It was notes that hospice daily ";Stand-up" meeting notes were included and had a list of staff members who were present for the meeting, and who was working each day. On the date of 7/11/24 (the day the ";Missed Visit" note was entered by Staff B), documentation under Staff Fs name indicated that Staff F had ";called off" that day. On 8/20/24 at 8:45 a.m., Staff B stated that ";Stand-up" notes were completed in the morning during the daily hospice meeting with staff. On 8/20/24 at 1035 a.m., interview was conducted with the Administrator (Staff A), and Staff B. During the interview, Staff A was queried to whether P-1 or the family were aware that no RN visit would occur on 6/21/24 and that no RN visits would occur between 6/28/24- 7/17/24. Staff A agreed that documentation did not reflect if P-1 or the family were made aware of the missed visits on the day that they occurred. Staff A agreed that documentation did not reflect if another option for day/time were offered to P-1 or the family when the missed visits occurred. Staff A was queried to whether the ";Missed Visit" notes were entered on the day of the missed visit or if they were entered on the day they were signed (7/19/24). Staff A stated that there was no way of determining what day the notes were entered into the medical record but that the agency does quality reviews prior to pay days for notes with missing signatures. Staff B did not offer explanation to why all the missed visit notes were signed on 7/19/24. The hospice failed to ensure nursing services met the needs of this patient as identified in the updated assessment (RN frequency of 1 time weekly).

Based on record review and interview, the hospice failed to ensure the clinical notes reflected communication and coordination of care regarding pain medications and pain control for 1 of 4 (P-3) records reviewed, resulting in patient pain and discomfort. Findings include: --- P-3: This patient was admitted to hospice on 9/18/23 with a diagnosis of Alzheimer's disease. The patient resided in a skilled facility. During record review on 8/19/24, the following was noted regarding patient pain over several days: 7/26/24 - The hospice nurse made a prn (as needed) visit due to reports of pain by the patient's daughter. The nurse notes that the daughter states the patient was in pain all day yesterday. The nurse notes no signs of pain during the visit. The patient is currently receiving Tramadol. No new orders at this time. There was no documentation to indicate the nurse coordinated care with the facility nurse to ensure the patient's pain was being controlled with Tramadol. 7/28/24 - The nurse made a prn visit after receiving a call that the patient was having pain issues and comfort medications not in place. The nurse documented that the hospice medical director was notified of the patient pain/discomfort. New orders for scheduled morphine and scheduled Ativan received. Order sent over to pharmacy for stat (immediate) delivery of medications. The patient was mostly non-verbal and the nurse notes that the patient had occasional grimace or frown. A review of physician orders indicates the physician ordered to start morphine sulfate 20 mg/ml oral concentration, give 5 mg sublingual (under the tongue) every 4 hours scheduled for pain, and give 5 mg sublingual every 4 hours as needed for breakthrough pain. There was no new order for Ativan. There was no documentation to indicate the nurse communicated with the skilled facility to ensure pain medications were received or coordinated care to ensure the patient's pain was controlled. 7/29/24 - The aide documents a nursing summary note that states according to patient's daughter, when family is present the patient seems to be having discomfort. There was no documentation on this day to indicate the nurse communicated with the skilled facility to ensure pain medications were received or coordinated care to ensure the patient's pain was controlled. 7/30/24 - The nurse conducts a scheduled visit and documents no sign of pain at this time. Patient appears comfortable. Daughter and spouse at bedside state that patient has been grimacing and clenching fists. Morphine orders clarified with facility nurse who states that there are no orders for morphine. The daughter filed a complaint with the hospice that day regarding the patient not receiving medications. The patient passed away the next day. It was unclear why the pain medications ordered for the patient were not available. There was no documentation on this day to indicate the nurse communicated with the skilled facility to ensure pain medications were received or coordinated care to ensure the patient's pain was controlled. The findings were reviewed with the administrator (Staff A) and the clinical manager (Staff B) during an interview on 8/20/24 at 11:35 a.m. Staff A reviewed the medical record and stated that the comfort medications were ordered on July 19th. This does not mean the medications were available. Staff A explained that she remembered that there was difficulty with the pharmacy and the skilled facility in obtaining the morphine sulfate. Paperwork had to be obtained and signed and then the morphine could be obtained from floor stock at the skilled facility. There was no documentation of the efforts to obtain the morphine and ensure the patient's pain and discomfort were controlled.

Based on record review and interview, the hospice failed to obtain drugs from community or institutional pharmacists or stock drugs in a timely manner for 1 of 4 (P-3) records reviewed, resulting in patient discomfort or pain (See L691); and failed to ensure the interdisciplinary group, as part of the plan of care, determined ability of the patient and/or family to safely self-administer drugs to the patient in their home in 1 (P-1) of 4 records reviewed potentially resulting in missed or improper dosing by the patient (See L692). --- The cumulative effect of these systemic problems resulted in the Hospice agency's inability to ensure the provision of quality Hospice care at the end of life, in a safe environment for the Condition of Participation: 42 CFR §418.106: Drugs and biologicals, medical supplies, and durable medical equipment.

Based on record review and interview, the hospice failed to obtain drugs from community or institutional pharmacists or stock drugs in a timely manner for 1 of 4 (P-3) records reviewed, resulting in patient discomfort or pain. Findings include: --- P-3: This patient was admitted to hospice on 9/18/23 with a diagnosis of Alzheimer's disease. The patient resided in a skilled facility. During record review on 8/19/24, the following was noted: 7/26/24 - The hospice nurse made a prn (as needed) visit due to reports of pain by the patient's daughter. The nurse notes that the daughter states the patient was in pain all day yesterday. The nurse notes no signs of pain during the visit. The patient is currently receiving Tramadol. No new orders at this time. 7/28/24 - The nurse made a prn visit after receiving a call that the patient was having pain issues and comfort medications not in place. The nurse documented that the hospice medical director was notified of the patient pain/discomfort. New orders for scheduled morphine and scheduled Ativan received. Order sent over to pharmacy for stat (immediate) delivery of medications. The nurse noted the patient had occasional grimace or frown. A review of physician orders indicates the physician ordered to start morphine sulfate 20 mg/ml oral concentration, give 5 mg sublingual (under the tongue) every 4 hours scheduled for pain, and give 5 mg sublingual every 4 hours as needed for breakthrough pain. There was no new order for Ativan. 7/29/24 - The aide documents a nursing summary note that states according to patient's daughter, when family is present the patient seems to be having discomfort. 7/30/24 - The nurse documents no sign of pain at this time. Patient appears comfortable. Daughter and spouse at bedside state that patient has been grimacing and clenching fists. Morphine orders clarified with facility nurse who states that there are no orders for morphine. The daughter filed a complaint with the hospice that day regarding the patient not receiving medications. The patient passed away the next day. It was unclear why the pain medications ordered for the patient were not available. The findings were reviewed with the administrator (Staff A) and the clinical manager (Staff B) during an interview on 8/20/24 at 11:35 a.m. Staff A reviewed the medical record and stated that the comfort medications were ordered on July 19th. This does not mean the medications were available. Staff A explained that she remembered that there was difficulty with the pharmacy and the skilled facility in obtaining the morphine sulfate. Paperwork had to be obtained and signed and then the morphine could be obtained from floor stock at the skilled facility. There was no documentation of the efforts to obtain the morphine and ensure the patient's pain and discomfort were controlled. The hospice failed to follow its own policy, Pain and Symptom Management (102022) which states, when medication changes occur in relation to pain and symptom management, timely follow up by the nurse will be made to determine the effectiveness of those changes.

Based on record review and interview, the hospice failed to ensure the interdisciplinary group, as part of the plan of care, determined ability of the patient and/or family to safely self-administer drugs to the patient in their home in 1 (P-1) of 4 records reviewed potentially resulting in missed or improper dosing by the patient. Findings include: --- Agency policy titled ";Medication List and Monitoring", PC.85 was reviewed on 8/20/24. On page 1., it stated ";l. The Hospice Registered Nurse (RN) will be responsible for coordinating the efforts of monitoring the medication regimen by compiling assessment data through a collaborative effort of all hospice staff involved in the patients care, including the pharmacist." On page 2., it stated ";V. The Hospices nursing staff will assess on an ongoing basis the patients medication safety as well as their response to the medication and the patient and/or caregivers compliance with the medication regimen." During investigation of complaint intake #108452, interview was conducted with the complainant (Com-1) on 8/15/24 at 2:52 p.m. to review the allegations. Com-1 stated that the agency had to be called on multiple occasions to get medication refills. Com-1 stated that P-1 had symptoms which were not being managed because of not receiving the medications timely and the patient often had difficulty breathing, anxiety and pain. On 8/19/24, the hospice after-hours triage logs for July 2024 were requested and reviewed. During review, the following calls were noted: On 6/21/24 at 7:00 p.m., Com-1 called the agency and stated P-1 had only 1 dose of some of medications but could not confirm on the phone which medications were needed. The on-call staff called the pharmacy where the medications could be filled and requested all medications due for refill to be filled and sent next day for immediate delivery in the morning. On 6/29/24 at 10:37 a.m., Com-1 called the agency and stated that P-1 was almost out of some of her meds and please call her back. On 6/29/24 at 2:53 p.m., Com 1 called back stating that P-1 still had not received Prednisone. On-call staff called the pharmacy, and it was noted that Prednisone had already been filled on 6/21/24 and it was too early for the fill. The on-call staff member documented that she called Com-1 and left message with the details above 7/15/24 at 5:55 p.m., Com-1 called and stated that patient is out of medications and wanted refills for all medications that could be refilled. On-call staff called the pharmacy to have medications refilled. On 8/19/24, P-1s medical record was reviewed for medication refills. The following were noted: On 6/21/24, the following were ordered: Amlodipine Besylate, (for high blood pressure); Fluticasone/Vilanterol inhaler (inhaled steroid bronchodilator to ease shortness of breath); Albuterol Sulfate nebulizer vials, (inhaled used to treat and prevent bronchospasms); Prednisone, (steroid used in this case to ease shortness of breath). On 7/1/24, the following were ordered: Amlodipine Besylate and Prednisone. On 7/15/24, the following were ordered: Amlodipine Besylate; Albuterol Sulfate vials; Diazepam 10 mg (anti-anxiety); Diazepam 2 mg; Fluticasone/Vilanterol inhaler; and Prednisone. On 8/20/24 during interview at 10:35 a.m. with the Administrator (Staff A) and the Clinical Manager (Staff B), Staff A stated that hospice pays for a 15-day supplies of medications each time they are refilled. Staff B stated that P-1 or the family would request refills early because P-1 would keep unopened bags with medications from the pharmacy stashed away and would not allow staff to look in the bags. Staff B was queried to whether this was documented in P-1s medical record or if it was care planned as an intervention for nurses to monitor/educate P-1 and family. Staff B stated that she documented the behavior last year some time but that it had not been carried through as an updated care plan issue. The hospice failed to ensure the interdisciplinary group, as part of the plan of care, determined ability of the patient and/or family to safely self-administer drugs to the patient in their home.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by review of clinical record, document review and interview that 1 of 11 (09%) records failed to document a plan that included all care and services specific to needs identified in the initial comprehensive assessment. Agency Policy PC.6, Plan of Care Process (Revised 05/01/2020) stated in part, "The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments." Record #36382: Initial comprehensive assessment completed 11/17/2021 identified, but not limited to, hypertension, depression, agitation with associated medications to treat. Plan of care, reviewed 11/22/2021 failed to document interventions and goals for these identified problems. Interview with the administrator and director of clinical services 11/23/2021 stated, the nurse updated the plan of care to include interventions for agitation, depression and hypertension as of 11/24/2021.

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: Measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by review of clinical record, document review and interview that in 2 of 11 (18%) records failed to document measurable goals on the individualized plan of care. Agency Policy PC.6, Plan of Care Process (Revised 05/01/2020) stated in part, " The plan of care includes, .... measurable outcomes anticipated from implementing and coordination the plan of care." Record #38102: Admitted 11/09/2021 with updated plan of care 11/12/2021 failed to document measurable goal for incontinence and social work goal. Incontinence goal: "Patient will maintain optimal urinary and fecal elimination patterns, skin integrity and dignity related to incontinence." (optimal is not measurable) Social work goal: "To make decision and have appropriate documentation/plan completed. " (appropriate is not measurable) Record #36382: Admitted 11/17/2021 with plan of care 11/18/2021 failed to document measurable goal for Incontinence, Nutrition and social work. Incontinence goal: " Patient will maintain optimal urinary and fecal elimination patterns, skin integrity and dignity related to incontinence." (optimal is not measurable) Nutrition goal: "Patient will maintain optimal nutrition and hydration." (optimal is not measurable) Social work goal: "To make decision and have appropriate documentation/plans completed." (appropriate is not measurable) Interview with the administrator and director of clinical services on 11/23/2021 stated that work is being done with staff for goal writing.

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 review of clinical record, document review and interview that in 1 of 1 (100%) records in which a patient was discharged to a facility failed to provide evidence that a discharge summary was sent to the receiving facility. Record #91960: Admitted 08/21/2021 with primary diagnosis of malignant lung cancer and taken to the hospital on 09/08/2021. No documentation provided evidence that the discharge summary or any part of the clinical record was sent to the facility, as of review date 11/23/2021. Interview on 11/23/2021 with the administrator and director of clinical services agreed that evidence of the summary sent to the hospital is not available.