Every finding on record at Life Hospice 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. 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 and interview. In 5 of 14 (36%) records reviewed the agency did not ensure that the medication profiles included the patient’s current prescription drugs. Agency Policy: PC.M55 Medication-Profile read in part “2. The medication profile must include: a. All current medications. 3. The patient's medication profile is reviewed by the IDG whenever there is a significant change and, at a minimum, every fifteen days. 5. The patient's medication profile review includes but is not limited to: a. Determining accuracy and completeness of the profile.” Clinical Record 1: The hospice election of benefit was dated 12/01/2023. A physician ordered dated 12/01/2023 read in part “O2 @2-4L per NC prn dyspnea/respiratory distress” was not included on the medication profile at the time of the record review on 12/11/2023. The interdisciplinary team meeting documentation dated 12/06/2023 included completion pf medication profile review. Clinical Record 2: The hospice election of benefit was dated 08/31/2023. A physician ordered dated 08/31/2023 read in part “O2 @2-4L per NC prn dyspnea/respiratory distress” was not included on the medication profile at the time of the record review on 11/29/2023 for the hospice episode of care on 12/11/2023. The interdisciplinary team meetings documentation dated 11/22/2023 and 12/06/2023 included completion pf medication profile review. Clinical Record 4: The hospice election of benefit was dated 11/21/2023. A physician ordered dated 11/21/2023 read in part “O2 @2-4L per NC prn dyspnea/respiratory distress” was not included on the medication profile at the time of the record review on 12/12/2023. The interdisciplinary team meetings documentation dated 11/22/2023 and 12/06/2023 included completion pf medication profile review. Clinical Record 5: The hospice election of benefit was dated 11/30/2023. A physician’s order dated 11/30/2023 read in part “O2 @2-4L per NC prn dyspnea/respiratory distress” was not included on the medication profile at the time of the record review on 12/12/2023. The interdisciplinary team meeting documentation dated 12/06/2023 included completion pf medication profile review. Clinical Record 13: The hospice election of benefit was dated 07/28/2023. A physician’s order dated 07/28/2023 read in part “O2 @2-4L per NC prn dyspnea/respiratory distress” was not included on the medication profile at the time of the record review on 12/13/2023. The interdisciplinary team meetings documentation dated 07/28/2023, 08/02/2023, 08/16/2023, 08/30/2023, 09/13/2023, 09/27/2023 and 10/11/2023 included completion pf medication profile review. During interview on 12/14/2023, the Director of Patient Care Services (DPCS) reviewed the records and stated, “Oxygen standing orders had inadvertently been omitted from the medication profiles and had since been corrected.”

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 drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) records reviewed revealed that the agency did not ensure that each patient’s individualized written plan of care included all the treatments necessary to meet the needs of the patient. Agency Policy: PC. P50 Plan of Care read in part 'The hospice must develop an individualized written plan of care for each patient. 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. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: h. Drugs and treatments necessary to meet the needs of the patient:' Clinical Record 5: A physician's order dated 11/30/2023 on the hospice plan of care (POC) stated, “sacral wound -cleanse skin integrity wound spray, pat dry, apply thin layer of hydrogel and skin prep, cover with foam bordered gauze every 3 days and prn.” There was no documented evidence of a reason for the as needed (prn). Clinical Record 10: A review of the initial registered nurse (RN) comprehensive assessment completed by the RN dated 09/23/2023 and the hospice POC dated 09/23/2023 identified that the patient was utilizing sliding scale insulin before meals and had a gallbladder drain in place. There was no documented evidence of orders for the frequency of blood sugar monitoring and no orders for gallbladder drain site care on the hospice plan of care at the time of the record review on 12/12/2023. During interview on 12/13/2023, the DPCS reviewed the records and stated the prn order for wound care, the frequency for accuchecks and drain site care had been obtained but had inadvertently been omitted from the plan of care and had since been corrected.

It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that care and services provided are in accordance with the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) records reviewed revealed that the agency did not ensure that care and services were provided are in accordance with the plan of care. Agency Policy: PC.C90 Coordination of Services read in part '1. The hospice will maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to: b. Ensure that the care and services are provided in accordance with the plan of care;' Clinical Record 3: The hospice election of benefit was dated 09/05/2023. The plan of care (POC) dated 09/05/2023 and the updated POC dated 09/13/2023 included a physician order for skilled nurse (SN) frequency that read two times a week. For the week of 09/25/023 there was only one documented nursing visit note. There was no documented evidence of any additional nursing visits that week or a note as to why visits were not provided as ordered. During interview on 12/13/2023, the DPCS reviewed the associated record and stated that the missed visit entry for the week of 09/25/2023 had not been completed and had since been corrected.

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 3 of 11 (27%) records reviewed, which included the provision of aide services, the agency did not ensure services were provided as per the hospice plan of care. Clinical Record 1: The election of the hospice benefit was dated 12/1/2023. The hospice plan of care (POC) dated 12/01/2023 included a physician order for hospice aide for five times a week. A review of the clinical record on 12/11/2023 revealed there were no documented hospice aide visits for the week of 12/01/2023 and no documentation as to why the aide services were not provided as ordered. Clinical Record 2: The election of the hospice benefit was dated 08/31/2023. The hospice POC dated 11/29/2023 included a physician order for hospice aide for five times a week. A review of the clinical record on 12/11/2023 revealed for the week of 11/29/2023 there were only three hospice aide visit notes for the week and no documentation as to why the aide services were not provided as ordered. Clinical Record 3: The election of the hospice benefit was dated 09/05/2023. A physician's order dated 11/20/2023 and the updated hospice POC dated 11/22/2023 included an order for hospice aide five times a week. A review of the clinical record on 12/11/2023 revealed that there were only two documented aide visits for the week of 11/22/2023 and no documentation as to why the aide services were not provided as ordered. During interview 12/13/2023, the DPCS reviewed the associated records and stated that services were not provided at the frequency ordered and stated that the incorrect frequency was inadvertently placed on the hospice plan of care and had since been corrected.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review and interview. In 10 of 14 (71%) records reviewed the agency did not ensure that all entries in the patient record were appropriately authenticated per agency policy. Agency Policy: PC. D25 Documentation Requirements read in part “12. All documentation is signed using complete first and last name, credentials, and title.” Clinical Record 1: The 12/04/2023 chaplain visit note did not include credentials with chaplain signature and date. Clinical Record 2: The 11/30/2023 and the 12/05/2023 volunteer notes did not include credentials with the volunteer and volunteer coordinator signatures and dates. Clinical Record 3: The 10/09/2023 chaplain progress note did not include credentials with the chaplain signature and date. Clinical Record 4: The aide visit notes dated 11/24/2023-12/08/2023 did not include credentials with the aide signatures and dates. Clinical Record 6: The 11/27/2023 chaplain progress notes and the 11/30/2023 chaplain bereavement progress note did not include credentials with the signatures and dates. Clinical Record 8: The 11/20/2023 chaplain progress note did not include credentials with the chaplain signature and date. Clinical Record 9: The 11/06/2023 chaplain progress note did not include credentials with the chaplain signature and date. Clinical Record 10: The 10/17/2023chaplain progress note did not include credentials with the chaplain signature and date. Clinical Record 12: The 09/21/2023 volunteer note did not include credentials with the volunteer and volunteer coordinator signatures and dates. Clinical Record 13: The 07/31/2023 chaplain progress note did not include credentials with the chaplain signature and date. During the interview with the DPCS on 12/13/2023, the DPCS reviewed the associated records and stated that the missing credentials have since been corrected.