Every finding on record at Hospice of Midland, Inc.

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, interview, and observation. In 2 of 19(11%) home visits and clinical records reviewed revealed that the agency did not ensure that the drug profiles were updated and current. Agency policy titled, "Medication Profile" Policy No. 2 - 004 revised 03/21/2024 read in part, A drug regimen review will be done at the time of initial and comprehensive assessment and when updates to the comprehensive assessment are performed. During subsequent home visits, the medication profile will be used as a care planning and teaching guide. Home Visit 1: During a home visit (Home Visit 1) on 12/10/2024 with the registered nurse (RN) (Personnel Record 1) during the RN. The clinical record (Clinical Record 1) and plan of care dated 10/27/2024 indicated that the patient was prescribed Lisinopril 40 mg 1 tab once a day beginning 08/06/2024. The patient fills a 28-day mediset. A bottle of Lisinopril in the patient's drawer that the patient stated was a current prescription bottle and dated 10/18/2024 read, Lisinopril 10 mg 1 tablet daily. The patient also reported that he breaks the tablets in half and takes 5 mg two times a day instead of 10 mg once a day. Blood pressure during the site visit was 130/60. The RN (Personnel Record 1) confirmed that medications have not been reconciled to match what is prescribed per the medication labels and patient reports. Home Visit 2: The patient was admitted on 10/11/2024 with a diagnosis of malignant neoplasm of the prostate. During the home visit (Home Visit 2) with the Chaplain (Personnel Record 2) on 12/10/2024 a review of the patient’s medications includes Systane eyedrops. The patient reported that he has dry eyes and has used Systane daily for "half a dozen months." Systane eye drops were not included on the patient medication profile. The COO (Personnel Record 8) stated in an interview on 12/10/2024, that she would expect medication reconciliation to occur every visit and voiced understanding that the nurse confirmed that a reconciliation had not been completed for some time since the prescription was over 30 days old.

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 and interview. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that the plan of care identified all of the planned interventions based on the assessment. Clinical Record 8: The patient’s election of benefits was 11/23/2024 with a diagnosis of metastatic prostate cancer. The initial SN assessment on 11/23/2024, described the patient having frequent UTIs and requiring a Foley catheter, 16 FR with a leg bag last inserted 11/04/2024. The SN assessment did not include a balloon size. The plan of care dated 11/23/2024 - 02/20/2024 did not include goals or interventions for the care and management of the Foley catheter. Orders were added on 12/03/2024 that read, "May have foley catheter." Goals and interventions were added on 12/03/2024 to teach assess for UTI symptoms, for the family to voice understanding related to the catheter, and for the catheter to remain patent. The clinical record did not contain any orders for the size of the catheter, balloon size, or management of catheter changes. After a joint review of the clinical record on 12/11/2024, the COO (Personnel Record 8) confirmed that the plan of care did not include sufficient orders for the care of the patient's foley catheter.

It is required that all hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed the hospice: Failed to ensure that the Registered Nurse prepared the written home health aide care plan with clear and patient-specific directions {HCDT.15. I/L625}; Failed to ensure that aides followed the aide plan of care {HCDT.16. I/L626}; and Failed to ensure that all aides reported changes in the patient’s nursing needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities {HCDT.18. I/L628}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.76, Hospice Aide and Homemaker Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 11 (18%) clinical records reviewed with a home health aide involved in the care revealed that the agency did not ensure that that a home health aide care plan was written with clear and patient-specific directions. Clinical Record 14: The patient’s election of benefit was 10/28/2024 with a diagnosis of malignant neoplasm of the colon. The plan of care dated 11/11/2024 included orders for an HHA 1 wk1, 2 wk. 12 beginning 10/29/2024. The clinical record contained no evidence of an aide care plan 10/28/2024- 11/14/2024. On 11/15/2024 there was an aide care plan initiated that stated, "Problem ADL's/IADL's=HHA". There was no documented evidence that the RN developed a specific care plan. Clinical Record 18: The patient’s election of benefit was 10/06/2024 with a diagnosis of malignant neoplasm of the liver. The skilled nurse assessment and plan of care dated 10/06/2024 revealed that the patient had a peritoneal drain in place. The care plan included orders for an HHA 3 times per week. The aide plan of care did not include the peritoneal drain or provide the aide any direction related to the site of the drain or dressing. There was no documented evidence that the RN developed a specific care plan In an interview on 12/11/2024, the COO (Personnel Record 8) reviewed the clinical record and confirmed the finding and lack of clarity in the aide care plan.

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 and interview. In 1 of 11 (9%) clinical records reviewed with a home health aide revealed that the agency did not ensure that aides followed the aide plan of care. Clinical Record 14: The patient’s election of benefit was 10/28/2024 with a diagnosis of malignant neoplasm of the colon. Aide services were ordered one time a week for 1 week, two times a week for 12 weeks (1 w 1, 2 wk 12). There was no aide care plan created to define tasks for the aide. The aide visited the patient on 11/02/2024 and documented "Upon arrival patient was lying in bed with her daughter by her side but couldn't get a shower today because hot water is out. The patient was left comfortably lying in bed. The patient was visited by the aide on 11/08/2024. The aide noted in the clinical record, "Upon arrival, the patient was lying in the bed sleeping. The patient got a warm bath, a clean diaper, a hair wash, clean clothes, and bed change. The patient was left comfortably sitting at the dining room table. There was no aide care plan assigning the tasks completed on 11/08/2024. On 11/12/2024, the aide visited the patient and documented in part, "Patient got a warm bed bath, a clean diaper, a hair wash, clean clothes, and a bed change. The patient was left comfortably lying in her bed. On 11/19/2024 the aide documented a visit that read in part, "Patient got a warm bath, a clean diaper, a hair wash, clean clothes and bed changed. On 11/23/2024, the aide documented a visit that read, "Upon arrival, the patient was complaining about pain. The patient received total personal care, and lotion to all extremities. The patient was left down in bed with caregiver at side. Aide visited patient on 11/26/2024 and documented "Patient got a warm shower, a clean diaper, a hair wash, clean clothes and a bed changed. Patient was left lying comfortably on her bed." On 12/03/2024 aide visit note read, "Patient got a warm shower, a clean diaper, a hair wash, clean clothes and a bed changed. Patient was left lying comfortably on her bed." on 12/06/2024 the aide visited the patient and documented, "Note: Pt. still in get up shower pt. after shower caregiver she was going to eat breakfast took precautions safety." After dual chart review, COO (Personnel Record 8) confirmed on 12/09/2024 that the home health aide did not have a plan of care and provided services without a plan of care.

It is required that the hospice aides must report changes in the patient’s nursing needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed revealed that the agency did not ensure that all aides reported changes in the patient’s nursing needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. Clinical Record 14: The patient’s election of benefit was 10/28/2024 with a diagnosis of malignant neoplasm of the colon. The SN assessment revealed that the patient required assistance with ADL's and a home health aide was ordered as aide one time a week for 1 week, two times a week for 12 weeks (1 w 1, 2 wk 12) on the plan of care. There was no documented evidence of an aide plan of care with assigned tasks. The aide visited the patient on 11/01/2024, 11/05/2024, 11/08/2024, 11/12/2024, 11/19/2024, 11/23/2024, 11/26/2024, 12/03/2024, and 12/06/2024. There was no aide care plan, task list, or direction for any aide visits. There was no documentation that an RN was notified to request specific patient information and task list. On 11/23/2024, the aide documented that the patient was complaining about pain. There was no documentation to indicate that the RN was notified of patient complaints of pain. In an interview and joint chart review with COO (Personnel Record 8) on 12/10/2024, the COO confirmed there was not a completed aide care plan in the clinical record and no aide documentation that a nurse was notified.

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, policy, and an interview. 2 of 13 (15%) records reviewed, the agency failed to ensure that the Spiritual Assessment component of the Initial Comprehensive Assessment was completed within five days of admission to the hospice as required. Agency policy “Admission Criteria and Process," Policy No. 1-009, (Revised July 2021), read in part, ”If a patient is accepted for hospice care, a comprehensive assessment of the patient will be performed no later than five calendar after the election of hospice care. A plan of care will be developed by the attending physician, the Medical Director of physician designee, and the hospice team." Record #86148: The patient was admitted to hospice on 11/26/2021. The Initial Spiritual Assessment was documented on 12/04/2021, eight calendar days after admission. There was no documentation that the Chaplain contacted the family/patient within five days of admission to hospice. Record #56428: The patient was admitted to hospice on 12/21/2021. The Initial Spiritual Assessment was documented on 12/28/2021, seven calendar days after admission. There was no documentation that the Chaplain contacted the family/patient within five days of admission to hospice. An interview was conducted on 12/29/21 and 12/30/21 with the Director of Nursing (DON) (Staff ID: #58809) and the CEO/Administrator/ (Staff ID: #72670), who stated after review that there was no documentation explaining the reason the chaplain assessment was delayed.

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; The medication review process includes the identification of the following: The effectiveness of drug therapy, drug side effects, actual or potential drug interactions and duplicate drug therapy. 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. This standard was not met as evidenced by a document review, clinical record review, and an interview. Agency policy "Medication Profile," Policy No. 2-004, (Revised July 2021) read in part, "... A drug regimen review will be performed at the time of initial and comprehensive assessment, and when updates to the comprehensive assessments are performed. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy." 1 of 13 (7%) records reviewed revealed the agency had failed to update the medication profile with allergies, as ordered per policy. Record #24780: The History and Physical, dated 6/11/2021, listed Allergies as Augmentin, Codeine, and Macrodantin. The Medication Profile, dated 11/30/2021, for the third certification 11/30/2021 through 1/28/2022, under the "Client Allergies" section listed "NKA." An interview was conducted on 12/29/21 and 12/30/21 with the Director of Nursing (DON) (Staff ID: #68809) and the CEO/Administrator/ (Staff ID: #72670), who stated that the patient History and Physical had been faxed after the admission, and the allergies had not been added to the medication profile.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by a review of clinical records and interviews which revealed a significant issue in which the RN had failed to coordinate care and update the interdisciplinary plan of care for continuous assessment of patient needs following an occurrence so that all members of the IDG ensure the safety and needs of patient and others were met [HCPC.19.I/L540] and the Administrator failed to ensure leadership, oversite, and implementation of the ongoing assessments of the patient care/family needs, clinical staff providing care as ordered, and supervision of staff related to the patient safety [HSLG.2.I/L574]. The effect of this systemic practice could negatively impact the on going care, safety of all patients, caregivers and agency staff.

It is required that the hospice designates a Registered Nurse member of the IDG to: provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by document review, clinical record review, and an interview. Agency policy "Interdisciplinary Group Meeting (IDG)," Policy No.1036 (Revised July 2021), read in part, "Problem-solving for optimal care of the patient and family/caregiver will occur, and changes will be documented on the interdisciplinary group meeting form." 1 of 6 (17%) patients with Oxygen therapy, the RN had failed to coordinate care, update the interdisciplinary plan of care for continuous assessment of patient needs following an occurrence so that all members of the IDG to ensure the safety needs of patient and others are met. Record #24780: For the 3rd benefit period beginning 11/30/2021, through 1/28/2022, 65 y/o home patient, a diagnosis that included Pulmonary Emboli, Heart Disease, and COPD, a physician order was noted, dated on 6/3/2021. The order stated, "may have O2 at 2-6 liters per nasal cannula may titrate for comfort." The RN visit, dated 12/11/2021, documented, "the patient on Wednesday [stated] she had diarrhea and was outside smoking, and when she ran into the house with a lit cigarette, she states the ashes fell and burnt the oxygen tubing and started a small fire in her house.” The IDG/IDT, dated 12/22/2021, did not include documented evidence of the occurrence of a fire. There was no documented evidence that the physician had been notified of the fire. There was no documented evidence of follow-up actions to ensure patient safety on the updated interdisciplinary plan of care. An interview was conducted on 12/29/21 and 12/30/21 with the Director of Nursing (DON) (Staff ID: #58809) and the CEO/Administrator/ (Staff ID:#72670), who stated that they were unaware that this had not been documented during the interdisciplinary group meeting.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s: ongoing performance improvement and patient safety program that is defined, implemented, and maintained. This requirement was not met as evidenced by a review of clinical records and interviews. 1 of 6 (17%)records reviewed for patients with Oxygen therapy, the Administrator failed to ensure leadership, oversite, and implementation following an occurrence of the ongoing assessments of the patient care/family needs, clinical staff providing care as ordered, and supervision of staff related to the patient safety. There is no documented evidence of coordination of care for the well-being and safety of the agency’s patients. There is a lack of documented evidence of managerial oversight of implementing the patient safety program. Record #24780: For the 3rd benefit period beginning 11/30/2021, through 1/28/2022, 65 y/o home patient with a diagnosis that included Pulmonary emboli, heart disease, and COPD. A physician order was noted, dated 6/3/2021, that the patient "may have O2 at 2-6 liters per nasal cannula, may titrate for comfort." The RN visit, dated 12/11/2021, documented, "the patient on Wednesday [stated] she had diarrhea and was outside smoking, and when she ran into the house with a lighted cigarette'’, She states the “ashes fell and burnt the oxygen tubing, and started a small fire in her house.” The IDG/IDT, dated 12/22/2021, did not address the fire. There is no documented evidence of coordination of care for the follow-up actions to ensure patient safety on the updated interdisciplinary plan of care. An interview was conducted on 12/29/21 and 12/30/21 with the Director of Nursing (DON) (Staff ID: #58809) and the CEO/Administrator/ (Staff ID: #72670), stating that the agency had spoken with the nurse to ensure that the exchange of information should have been documented in the clinical record.

It is required that the Interdisciplinary Group (IDG) determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. The plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. If the patient and/or family cannot administer drugs or biologicals, it is noted in the plan of care, as well as how it is addressed by the IDG. This standard was not met as evidenced by a review of clinical records and interview. 7 of 7 (100%) records reviewed of home patients who self-administered their medications revealed that the agency had failed to ensure documented evidence validating that the patient and/or family had been assessed for their ability to administer drugs or biologicals to the patient in the home. Record #39091: For the 2nd benefit period beginning 12/20/2021 through 3/19/2021, 92 y/o home patient diagnosis, which included COPD and Heart Disease, there was no documented evidence on the plan of care, during IDG meetings, or on the medication profile regarding safe self-administration and/or family capacity for the administration of drugs and biologicals. Record #24780: For the 3rd benefit period beginning 11/30/2021, through 1/28/2022, 65 y/o home patient with a diagnosis that included Pulmonary Emboli, Heart Disease, and COPD, there was no documented evidence on the plan of care, during IDG meetings, or on the medication profile, regarding safe self-administration and/or family capacity for the administration of drugs and biologicals. Record #38037: For the Start of Care (SOC) benefit period beginning 11/30/2021, 95 y/o home patient, diagnosis included Alzheimer's and Anxiety disorder, unspecified, there was no documented evidence that the plan of care, during IDG meetings, or on the medication profile regarding safe self-administration and/or family capacity for the administration of drugs and biologicals. Record #86148: For the Start of Care (SOC) benefit period beginning 11/26/2021, 58 y/o home patient, a diagnosis that included Malignant Neoplasm and Secondary Malignant Neoplasm of liver and bile duct, there was no documented evidence that the plan of care, during IDG meetings, or on the medication profile regarding self-administration and/or family capacity for the administration of drugs and biologicals. Record #56428: For the Start of Care (SOC) benefit period beginning 12/21/2021, 86 y/o home patient, diagnosis included Alzheimer's and Heart disease. There was no documented evidence that the plan of care, during IDG meetings, or on the medication profile regarding safe self-administration and/or family capacity for the administration of drugs and biologicals. Record #61671: For the Start of Care (SOC) benefit period beginning 11/06/2021, 99 y/o home patient, a diagnosis that included Atherosclerotic heart disease and repeated falls. There was no documented evidence that the plan of care, during IDG meetings, or on the medication profile regarding safe self-administration and/or family capacity for the administration of drugs and biologicals. Record #59051: For the 6th benefit period beginning 10/30/2021 to 12/28/2021, 80 y/o home patient, a diagnosis that included COPD and Asthma. There was no documented evidence that the plan of care, during IDG meetings, or the medication profile regarding safe self-administration and/or family capacity for the administration of drugs and biologicals. An interview was conducted on 12/29/21 and 12/30 /21 with the Director of Nursing (DON) (Staff ID: #58809) and the CEO/Administrator/ (Staff ID: #72670), who stated that they were unaware of the need for the Interdisciplinary Team to review the care plan for the administration of home medications by family/patients. They noted that the RN provides the assessments for the home administration of medications.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: Physician certification and recertification of the terminal illness. This standard was not met as evidenced by the review of clinical records, a review of organizational policy, and an in-person tour of a long-term care facility, which included an interview with the LMSW. This revealed that in 1 of 1 (100%) patient records present at the facility, the agency had failed to provide the Physician Certification of Terminal Illness and subsequent Recertification documentation. Agency policy, “Provision of Care to residents of SNF/NF or ICF/IID)," (Revised July 2021), Policy No.1-030, read in part, "The organization will provide the SNF/NF or ICD/IID the following information specific to each patient: Physician certification and recertification of the terminal illness." Record #94227: For the recertification from 12/1/2021 through 1/29/2022, the client had been transferred to an LTCF on 12/13/2021. The client's diagnosis included Parkinson's Disease, CHF, history of falling, and a status of being wheelchair-bound. The hospice patient records located at the long-term skilled facility did not provide the Physician Certification of the Terminal Illness or any Recertification of the Terminal Illness. An interview was conducted on 12/29/21 and 12/30/21 with the Director of Nursing (DON) (Staff ID: #58809) and the CEO/Administrator/ (Staff ID: #72670), who stated that they were unaware that the agency had not faxed over the certification of a terminal illness.

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. This standard was not met as evidenced by a review of contracts and an interview. A review of the contracts revealed that the Pharmacy and Therapy (PT/OT/ST) contracts failed to include the clause, in writing, between the contractor/contractee for the provision that requires criminal background checks. An interview was conducted on 12/29/21 and 12/30/21 with the Director of Nursing (DON) (Staff ID: #58809) and the CEO/Administrator/ (Staff ID: #72670), who stated that would provide an addendum to ensure compliance.