Every finding on record at Interim Health Care Hospice of Western PA, Inc

It is required that during the initial assessment visit and in advance of providing care, the hospice provides the patient—or his or her representative—with verbal and written notice of the patient’s rights and responsibilities. This information is provided in a language and manner that the patient understands. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Communication with the Patient/Family" (revised 12/29/2019) stated in part, "Information is provided to patients/clients in plain language and in a manner that is accessible to (b) persons with limited English proficiency (LEP) through the provision of language services at no cost to the individual, including oral interpretation and written translations...Language and communication assistance is provided to patients through bi-lingual employees, employee interpreters or through an arrangement with an organization to provide interpretation or translation services in person, via technology or telephone as well as any other auxiliary aids." 1 of 15 (7%) clinical records reviewed, the agency did not ensure the patient or representative was provided with verbal and written notice of the patient’s rights and responsibilities in a language and manner that the patient understands. Clinical Record 13: The patient elected hospice care on 2/13/2022 with the diagnosis of atherosclerotic heart disease. The hospice benefit of election statement documented in English was signed by the son on 2/13/2022. The initial assessment completed by the Registered Nurse (RN) on 2/13/2022 documented in part, "son stated he is the medical power of attorney (POA) but could not give papers and wants patient to be a full code. Son says patient does not understand and speaks Italian and some English....client speaks Italian and broken English...The nurse stressed that the agency needed a copy of the POA; otherwise the patient's wife and the son's mother would be the legal persons to make decisions. Son said she does not understand English." The assessment documented, "I asked the client what the year is, client answered appropriately. Did not know the month, but when asked time of year answered with the appropriate season." A review of the clinical record revealed no evidence the nurse and the agency attempted to provide the patient and the patient’s wife with verbal and written notice of the patient’s rights and responsibilities in a language and manner that the patient and wife could understand, Italian. Additionally, there was no documented evidence the son was the patient’s POA. The record contained a discharge summary due to revocation signed by the son one week later, on 12/20/2022. During a joint record review and interview on 9/7/2023, the Director of Clinical Services confirmed the hospice agency did not obtain documentation of the Power of Attorney from the son or family. The Director of Clinical Services confirmed the patient did not speak and understand English. The agency did not provide the patient with a Bill of Rights in their primary language (Italian).

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 "Drugs and Biologics Use and Disposal" (revised 6/8/2023) stated in part, "Each patient's drugs, biologics, over-the-counter drugs, herbal remedies, and alternative treatments are identified on the medication profile as part of the Interdisciplinary Group (IDG) plan of care." In 2 of 2 (100%) home visits observed, the agency did not ensure the drug profile was updated to reflect the patient's current drug regimen. Home Visit 1/Clinical Record 2: During the home visit on 9/6/2023 with the Registered Nurse (RN) [Personnel 2] and the Director of Clinical Services [Personnel 1], the agency's medication profile was compared to the patient's medication regimen. The agency's medication profile dated 8/29/2023 through 9/6/2023 documented, "Aldactone one-hundred (100) milligrams (mg). Take one (1) tablet two (2) times daily." The medication bottle documented "Aldactone fifty (50) milligrams (mg). Take one (1) tablet two (2) times daily." The patient and caregiver confirmed the patient takes Aldactone 50 mg, one (1) tablet two (2) times daily. The agency's medication profile documented, "Allopurinol two-hundred (200) milligrams (mg). Take one (1) tablet two (2) times daily." The medication bottle documented Allopurinol one-hundred (100) milligrams (mg). Take one (1) tablet two (2) times daily. The patient and caregiver reported the patient takes "Allopurinol 100 mg one (1) tablet two (2) times daily." The patient and caregiver both reported the patient also takes one (1) multivitamin a day and Compazine 10 mg, one (1) tablet every six (6) hours as needed for nausea and vomiting. The agency's medication profile did not include documentation of the multivitamin or Compazine. There was no evidence the multivitamin and Compazine were included in the patient's medication regimen review. Home Visit 2/Clinical Record 1: During the home visit on 9/6/2023 with the Director of Clinical Services [Personnel 1], the agency's medication profile was compared to the patient's medication profile provided by the Assisted Living Facility (ALF). The ALF medication profile documented, "Olanzapine two and a half (2.5) milligrams. Take one (1) tablet every bedtime (QHS)… Nyamyc powder one hundred thousand (100,000) units per gram (u/G). Apply topically to the groin two (2) times a day until healed." The agency's medication profile did not include documentation of the Nyamyc powder and Olanzapine. There was no evidence that Nyamyc powder and Olanzapine were included in the review of the patient's medication regimen. During a joint record review and interview on 9/6/2023, the Director of Clinical Services confirmed the agency's medication profile did not match the patients' medication regimen.

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. In 2 of 15 (13%) clinical records reviewed, the agency did ensure the plan of care reflected patient and family goals and included planned interventions based on problems identified in the comprehensive assessments. Clinical Record 5: The patient elected hospice care on 3/29/2022. The initial comprehensive assessment completed by the Registered Nurse on 3/29/2022 (RN) documented two (2) wounds: "Left arterial ulcer fully granulated and scabbed wound...left lower leg arterial ulcer fully granulating without drainage." The plan of care dated 3/29/2022 through 6/26/2022 ordered, "Wound care left leg and foot. Cleanse with (blank), pack with/apply (blank). Cover with (blank). Secure with (blank). Change dressing every (blank) day/week and PRN." The plan of care wound care orders were incomplete. Additionally, the plan of care did not include documentation of the wound as a problem with interventions and goals. Clinical Record 8: The patient elected hospice care on 12/8/2022. The initial assessment completed by the Registered Nurse (RN) on 12/8/2022 documented a wound and ordered " foam dressing on coccyx that was wrinkled and soiled. Removed, and the area newly epithelialized. Encouraged to use a barrier to buttocks every eight hours." A review of the interdisciplinary team meetings revealed no information or discussion of wounds. The plan of care dated 12/8/2022 through 3/7/2023 did not include documentation of the wound as a problem with interventions and goals. During a joint record review and an interview on 9/6/2023, the Director of Clinical Services confirmed the care plan did not contain any information, interventions, or goals related to wound 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: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, observation, document review, and interview. Agency policy "Drugs and Biologics Use and Disposal" (revised 6/8/2023) stated in part, "Hospice ensures prior to administering any medication that is the right patient, right drug, right dose, right route, and right time...The designated RN is responsible for maintaining a current medication profile that includes prescription drugs and biologics, over-the-counter drugs, herbal remedies, and alternative treatments, as well as the current dosage, frequency, and route of administration." In 2 of 15 (13%) clinical records reviewed, the agency did ensure the plan of care included drugs and treatments necessary to meet the patient's needs. Clinical Record 1/Home Visit 2: The patient elected hospice care on 8/28/2023. During the home visit on 9/6/2023, the agency's medication profile was compared to the patient's medication profile provided by the Assisted Living Facility (ALF). The ALF medication profile documented, "Olanzapine two and a half (2.5) milligrams. Take one (1) tablet every bedtime (QHS)… Nyamyc powder one hundred thousand (100,000) units per gram (u/G). Apply topically to the groin two (2) times a day until healed." A review of the clinical record revealed the plan of care did not include documentation of the Olanzapine and Nyamyc powder. Clinical Record 2/Home Visit 1: The patient elected hospice care on 8/29/2023. During the home visit on 9/6/2023, the agency's medication profile was compared to the patient's medication regimen. The patient and caregiver reported the patient takes one (1) multivitamin a day and Compazine 10 mg, one (1) tablet every six (6) hours as needed for nausea and vomiting. A review of the clinical record revealed the plan of care did not include documentation of the multivitamin or Compazine.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, and information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Certification of Terminal Illness" (revised 8/3/2018) stated in part, "The Hospice Medical Director/Hospice Physician ensures that processes are in place to (b) document a clinical narrative confirming the findings of the review or examination...The Hospice Medical Director/Hospice Physician considers the following information in certifying an individual's terminal illness, (a) the primary condition, (b) related diagnosis, (c) current subjective and objective medical findings, (d) current medications, (e) information about the medical management of any conditions unrelated to the terminal illness...The hospice Medical Director/Hospice Physician or the patient's attending physician documents a brief narrative explanation of the clinical findings." In 1 of 15 (7%) clinical records reviewed, the agency did not ensure the Certification of Terminal Illness contained the elements required by the agency's policy. Clinical Record 3: The patient elected hospice care on 11/24/2022 with the terminal diagnosis of acute respiratory failure with hypoxia. The Certification of Terminal Illness (CTI) signed by the attending physician, who was not the medical director, on 11/30/2022 documented, "Based on the patient's diagnosis and current condition, I expect this patient has a life expectancy of six months or less if the terminal disease continues to take its normal course, and I hereby certify this patient as eligible for hospice care." The primary physician obtained Verbal Certification of Terminal Illness on 11/25/2022, and the hospice Medical Director on 11/24/2022. There was no additional CTI obtained from the Medical Director. A clinical record review revealed no evidence of a narrative explanation of the clinical findings per the agency's policy. During a joint record review and interview on 9/5/2023, the Director of Clinical Services [Personnel Record 1] confirmed the hospice did not ensure a narrative statement was obtained for the patient's Certificate of Terminal Illness from either the attending physician or the Medical Director.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Certification of Terminal Illness" (revised 8/3/2018) stated in part, "The Hospice Medical Director/Hospice Physician considers the following information in certifying an individual's terminal illness, (a) the primary condition, (b) related diagnosis, (c) current subjective and objective medical findings, (d) current medications, (e) information about the medical management of any conditions unrelated to the terminal illness. In 1 of 15 (7%) clinical records reviewed, the agency did not ensure correct clinical information was used for recertification of the terminal illness. Clinical Record 10: The patient elected hospice care on 5/31/2022 with a primary hospice diagnosis of vascular dementia. The primary diagnosis was changed to Unspecified Severe protein-calorie malnutrition with a physician's order on 6/3/2022. The order documented, "Primary diagnosis clarified and discussed with attending and Medical Director and due to extensive weight loss primary diagnosis changed to severe protein-calorie malnutrition." The Certificate of Terminal Illness for benefit period one (1) 5/31/2022 through 8/28/2022, stated in part, "84-year-old female with malnutrition." The Certificate of Terminal Illness for benefit period two (2) 8/29/2022 through 11/26/2022, signed and dated 9/14/2022 by the Medical Director, stated in part, "84-year-old female with vascular dementia." During a joint record review and interview on 9/6/2023, the Director of Clinical Services [Personnel Record 1] confirmed the Certificate for Terminal Illness for benefit period two (2) contained an incorrect primary diagnosis, vascular dementia. The Director of Clinical Services confirmed the record did not contain any updated physician orders after 6/3/2022 to change the primary terminal diagnosis from protein-calorie malnutrition.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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. In 2 of 15 (13%) clinical records reviewed, the agency did not ensure the patient's clinical record contained physician orders. Clinical Record 8: The patient elected hospice care on 12/8/2022. The initial assessment completed by the Registered Nurse (RN) on 12/8/2022 documented a wound and ordered " foam dressing on coccyx that was wrinkled and soiled. Removed, and the area newly epithelialized. Encouraged to use a barrier to buttocks every eight hours." On 12/9/2022, the RN documented, "Aquaphor to buttocks. No open area was noted. Calmoseptine was ordered from the pharmacy." A clinical record review revealed no evidence of a physician's order for the Calmoseptine. During a joint record review and interview on 9/6/2023, the Director of Clinical Services confirmed the RN documented they obtained an order for the Calmoseptine, but the record did not contain a physician order, either verbal or signed, for Calmoseptine. The Director of Clinical Services stated, "There should have been a physician order documented under the physician's order tab for the Calmoseptine, and I don't see one." Clinical Record 5: The patient elected hospice care on 3/29/2022. A review of the clinical record revealed the physician ordered "Keflex one (1) dose three (3 ) times daily" on 3/31/2022. The physician's order did not include documentation of the dosage and the route of administration of the Keflex.