Every finding on record at Hospice of Stars Inc

It is required that testing: The hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years, if the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to: A second full-scale exercise that is community-based or a facility-based functional exercise; or a mock disaster drill; or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. The agency did not ensure the hospice conducted exercises to test the emergency preparedness plan annually. A review of the agency's Emergency Preparedness Plan (EP) on 01/15/2025 revealed the agency did not ensure participation in a full-scale exercise that was community-based at least every 2 years, or a mock disaster drill or a tabletop exercise for the years of 2023 and 2024. During the EP program review and interview, the Quality Coordinator and the Administrator stated the "office staff had participated in the fire drill the building had performed." They both agreed there was no documentation that other members of the Interdisciplinary Group had participated in this drill and that the building fire drill was not a clinically relevant emergency scenario as described per the regulation. A review of the Agency's Emergency Preparedness Plan (EP) on 01/15/2025 revealed the agency did not ensure participation in a full-scale exercise that was community-based at least every 2 years, or a mock disaster drill or a tabletop exercise for the years of 2023 and 2024. During an interview on the same date, the Quality Coordinator and Administrator advised the "office staff had participated in the fire drill the building had performed." There was no documentation other members of the Interdisciplinary Group had participated in this drill. The interview also confirmed the fire drill was not a clinically relevant emergency scenario as described per the regulation.

It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient discharge for extended prognosis, the agency did not ensure the patient was involved in the development of his or her plan of care when there were changes in the plan of care. Clinical Record 7: The clinical record review revealed the patient was discharged for extended prognosis on 08/12/2024. The Notice of Medicare Non-Coverage (NOMNC) form was dated the same day as the discharge date of 08/12/2024. There was no documentation in the clinical record that the patient had participated in the change in the plan of care related to discharge from hospice care. Clinical Record 8: The clinical record review revealed the patient was discharged for extended prognosis on 02/16/2024. The Notice of Medicare Non-Coverage (NOMNC) form was dated the same day as the discharge date of 02/16/2024. There was no documentation in the clinical record that the patient had participated in the change in the plan of care related to discharge from hospice care. During an interview and joint clinical record review on 01/16/2025, the Administrator/Director of Nursing confirmed the NOMNC should have been "given at least 72 to 48 hours before the discharge."

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; 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 and interview. In 2 of 3 (67%) home visit observations, the agency did not ensure the drug profile contained the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. Home Visit 2: The patient elected the hospice benefit on 12/23/2024 for a diagnosis of sequelae of cerebral infarction. The patient resided in a group home. During the home visit observation with the Spiritual Counselor (Personnel Record 5) on 01/15/2025, the hospice medication profile (printed on 01/14/2025) was compared to the Group Home medication profile (printed on 01/15/2025). The hospice list documented the following medications that were not documented on the Group Home medication profile: An order dated 12/23/2024 for Combivent 20 mcg 1 puff in the AM and an order dated 12/23/2024 for Haldol 0.5 mg by mouth twice daily as needed for agitation/restlessness. Home Visit 3: The patient elected the hospice benefit on 01/02/2025 for a diagnosis of gastrointestinal stromal tumor. The patient resided in a group home. During the home visit observation with the Nurse Practitioner (Personnel Record 2) on 01/15/2025, the hospice medication profile (printed on 01/14/2025) was compared to the Group Home medication profile (printed on 01/15/2025). Both lists contained an order dated 01/02/2025 for "Loperamide 2 mg every bowel movement, maximum of four capsules per day." The caregiver at the facility had marked the medication as "R" for refusal by the patient. The Hospice Medical Director was interviewed and advised the medication should have been reconciled to read "as needed for loose bowel movement." There was also a Nicotine patch listed on the hospice and group home medication lists to be applied daily. During the home visit, the caregiver stated the patient had not received the nicotine patch as the "family had never provided it." During a joint clinical record review and interview on 01/15/2025, the Administrator/Director of Nursing confirmed the medication list(s) had discrepancies and had not been reconciled.

It is required that the hospice designates a Registered Nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 14 of 14 (100%) clinical records reviewed, the agency did not ensure a Registered Nurse (RN), as a member of the Interdisciplinary Group (IDG), developed and implemented the interdisciplinary plan of care. Clinical Record 1: The patient elected the hospice benefit on 12/19/2024 with a terminal diagnosis of Parkinson’s disease. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the Licensed Practical Nurse (LPN). The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. Clinical Record 2: The patient elected the hospice benefit on 12/23/2024 with a terminal diagnosis of sequelae of cerebral infarction. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the LPN. The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. Clinical Record 3: The patient elected the hospice benefit on 01/02/2025 with a terminal diagnosis of gastrointestinal stromal tumor. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the LPN. The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. Clinical Record 4: The patient elected the hospice benefit on 12/23/2024 with a terminal diagnosis of Alzheimer’s disease. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the LPN. The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. Clinical Record 5: The patient elected the hospice benefit on 10/25/2024 with a terminal diagnosis of hypertensive heart disease. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the LPN. The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. Clinical Record 6: The patient elected the hospice benefit on 07/11/2024 with a terminal diagnosis of hypertensive heart disease. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the LPN. The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. Clinical Record 7: The patient elected the hospice benefit on 04/24/2024 with a terminal diagnosis of nontraumatic intracranial hemorrhage in brain stem. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the LPN. The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. Clinical Record 8: The patient elected the hospice benefit on 07/18/2024 with a terminal diagnosis of atherosclerotic cardiovascular disease. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the LPN. The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. Clinical Record 9: The patient elected the hospice benefit on 05/25/2024 with a terminal diagnosis of chronic obstructive heart disease. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the LPN. The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. Clinical Record 10: The patient elected the hospice benefit on 02/26/2024 with a terminal diagnosis of hemiplegia following cerebral infarction. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the LPN. The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. Clinical Record 11: The patient elected the hospice benefit on 09/05/2024 with a terminal diagnosis of malignant neoplasm of the brain. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the LPN. The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. Clinical Record 12: The patient elected the hospice benefit on 04/26/2024 with a terminal diagnosis of chronic obstructive pulmonary disease. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the LPN. The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. Clinical Record 13: The patient elected the hospice benefit on 07/07/2024 with a terminal diagnosis of Alzheimer’s disease. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the LPN. The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. Clinical Record 14: The patient elected the hospice benefit on 03/20/2024 with a terminal diagnosis of hypertensive heart disease. Review of the patient’s plan of care revealed the problems, goals, and interventions were developed by the LPN. The plan of care did not include evidence that the RN developed and implemented the patient’s interdisciplinary plan of care. During a joint clinical record review and interview on 01/15/2025, the Administrator/Director of Nursing confirmed the plans of care had been developed by a Licensed Practical Nurse (LPN). The Administrator stated she did not "realize a RN had to create them."

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 interview and clinical record review. 1 of 5 (20%) clinical records reviewed revealed the hospice did not ensure the hospice aide was compliant with the ordered visit frequency. Record #81025: Review of the record revealed the hospice aide visit frequency of "one time a week", was documented on the Plan of Care orders dated 3/24/22, and the "IDG Meeting" forms dated 3/25/22 and 4/8/22. Review of the clinical record revealed two extra Hospice Aide visits were documented as completed during the weeks of 3/27/22 and 4/3/22. During interview on 4/12/22, the Hospice RN and Intake Coordinator confirmed the ordered hospice aide visit frequency was documented as "one time a week", however the correct hospice aide visit frequency of "three times a week" was inadvertently added to the "Volunteer" visit frequency section. Review of the clinical record revealed that volunteer services were declined. After review of the clinical record, the Hospice RN presented for review an order that was obtained from the physician on 4/12/22 which stated: "clarification of frequency order due to plan of care error, Hospice Aide frequency effective 3/24/22, 1 week 1, 3 week 12, volunteer services declined, current hospice aide frequency 3 week 13 effective 4/11/22".