Every finding on record at M & L Medical Services Hospice Inc

Based on record review and interview, the agency failed to include measurable goals and outcomes in the plan of care of 2 (#6 & #9) of 3 active patients. This failure could result in patient needs and goals not being adequately addressed. --- Findings: Record review of patient #6s record revealed a written certification dated 12/24/2021 with a terminal diagnosis of COPD (inability to breathe). The plans of care dated 1/12/2022, 1/26/2022, 2/9/2022, 2/23/2022, and 3/23/2022 did not contain goals or outcomes for the goals. Record review of patient #9s record revealed a plan of care order dated 4/19/2023 with a terminal diagnosis of Alzheimers disease (forgetfulness). The plans of care dated 5/3/2023, 5/17/2023, 5/31/2023, and 6/14/2023 did not contain goals or outcomes for the goals. Per interview 7/17/2023 about 2:30 pm, the Director of Nurses stated, ";collaboration of the plan of care [at IDT] has been done by the nurse on the laptop. From now on each discipline will document their own." The agency had a policy (PC.6) titled, ";Plan of Care Process" dated 5/1/2020. The policy read in parts: ";...Purpose: To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient and familys specific needs. ...Policy: I. All hospice care and services furnished to patients and their families will follow an individualized written POC established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patients needs. II. The hospice will develop an individualized written POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions. ...Procedure: ...C. The update of the comprehensive assessment will be accompanied by the hospice IDG (in collaboration with the individuals attending physician, if any) and will evaluate changes that have taken place since the initial assessment. 1. Updates will include information on the patients progress toward desired outcomes, as well as a reassessment of the patients response to care. 2. The comprehensive assessment will be updated by the IDG as frequently as the patients condition requires but no less frequently than every fifteen (15) days....VI. The POC includes, but is not limited to: ...B. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, including level of care; C. Measurable outcomes anticipated from implementing and coordinating the POC D. Drugs and treatments necessary to meet the needs of the patient ...F. Designation of discipline(s) responsible for providing specific services ...VII. ...Documentation will support that the patient receives the appropriate level of care and services as indicated by the interdisciplinary assessments...."

Based on record review and interview, the agency failed to include physician orders for wound care in the plan of care for 3 (#5, #7, #11) of 3 patients with wounds. This failure could result in improper or inadequate care of the wounds. --- Findings: Record review of patient #5s record revealed a written certification by the hospice medical director dated 9/21/2022. The initial nursing admission assessment did not document any wounds or skin breakdown. On 9/29/2022 the nurse documented a stage 1 pressure sore on the left buttocks which was treated with a duoderm (aides wound healing) dressing. On 10/11/2022 the nurse documented the stage 1 pressure sore on the buttocks with a duoderm (aides wound healing) dressing. This nurse also mentioned a blister on the right foot that would be treated with betadine (antiseptic medicine) twice a day. A physician order regarding the treatment of the blister with betadine was received 10/12/2022. This order does not mention the stage 1 pressure sore treatment. The plans of care dated 9/21/2022 and 10/11/2022 do not mention the stage 1 pressure sore or the blister. There are no plans of care after 10/11/2022. Record review of patient #7s record revealed a written certification by the hospice medical director dated 11/19/2022. The certification mentions, ";decubitus ulcer requiring hospice agency to perform wound care." The initial nursing assessment dated 11/19/2022 a stage 3 pressure ulcer on the buttocks and states, ";to cleanse the wound with normal saline and wound cleanser, pat dry, apply betadine-soaked gauze to the wound base and cover with ABD and secure with tape three times a week." The plan of care dated 11/19/2022 mentioned the wound but did not specify the treatment to be done. The nurse visit dated 11/20/2022 did not mention the wound. The plan of care dated 11/30/2022 mentioned the wound but did not specify the treatment to be done. On 12/5/2022 a physician order was received that specified the treatment for the wound. There are no plans of care after 11/30/2022 in the medical record. Record Review of patient #11s record revealed a written certification by the hospice medical director dated 12/2/2022. The certification mentions ";multiple pressure ulcers requiring wound care." On 12/2/2022 at 11:00 am a licensed practical nurse made a visit and documented multiple wounds. The nurse stated, ";use aseptic technique to clean all area with normal saline, pat dry, apply betadine wet to dry to heel, great toe, 5th phalanges wrapped with kerlix taped in place, ace wrap in place. Applied betadine allow to dry leave open to air on buttock and scrotum." On 12/2/2022 at 5:00 pm the registered nurse made the initial assessment. The nurse documented multiple wounds but did not mention the treatments in the initial assessment. Plans of care dated 12/2/2022, 12/14/2022, 12/28/2022, 1/9/2023, 1/11/2023, 1/20/2023, 1/25/2023, 2/1/2023, 2/8/2023, and 2/24/2023 documented ";multiple open areas" but did not specify the treatment for the wounds. On 12/28/2022 a physician order was received regarding wound care to the left below the knee stump twice a week. No other orders for wound treatment were in the medical record. Per interview 7/18/2023 about 1:35 pm with the administrator present; the Director of Nurses stated, ";normally a verbal order is put in the electronic medical record then sent to the doctor to sign. The nurse has to add [the order] to the plan of care and then it would stay on the plan of care until it is discontinued." The agency had a policy (PC.6) titled, ";Plan of Care Process" dated 5/1/2020. The policy read in parts: ";...Purpose: To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient and familys specific needs. ...Policy: I. All hospice care and services furnished to patients and their families will follow an individualized written POC established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patients needs. II. The hospice will develop an individualized written POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions. ...Procedure: ...C. The update of the comprehensive assessment will be accompanied by the hospice IDG (in collaboration with the individuals attending physician, if any) and will evaluate changes that have taken place since the initial assessment. 1. Updates will include information on the patients progress toward desired outcomes, as well as a reassessment of the patients response to care. 2. The comprehensive assessment will be updated by the IDG as frequently as the patients condition requires but no less frequently than every fifteen (15) days....VI. The POC includes, but is not limited to: ...B. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, including level of care; C. Measurable outcomes anticipated from implementing and coordinating the POC D. Drugs and treatments necessary to meet the needs of the patient ...F. Designation of discipline(s) responsible for providing specific services ...VII. ...Documentation will support that the patient receives the appropriate level of care and services as indicated by the interdisciplinary assessments...."

Based on record review and interview, the agency failed to include the participation of psychological and counseling services in the ongoing interdisciplinary comprehensive assessments, developing, and evaluating the plan of care in 2 (#6, & #9) of 3 active clients plans of care. This failure could result in the psychological and spiritual needs of the client and family member not being met. --- Findings: Record review of patient #6s record revealed a written certification by the hospice medical director dated 12/24/2021 with a terminal diagnosis of COPD (inability to breathe). The plans of care dated 1/12/2022, 1/26/2022, 2/9/2022, 2/23/2022, and 3/23/2022 did not contain the participation of the social worker and chaplain in the ongoing comprehensive assessment, development, and evaluation of the plan of care. Record review of patient #9s record revealed a plan of care order dated 4/19/2023 with a terminal diagnosis of Alzheimers disease (forgetfulness). The plans of care dated 5/3/2023, 5/17/2023, 5/31/2023, and 6/14/2023 did not contain the participation of the social worker and chaplain in the ongoing comprehensive assessment, development, and evaluation of the plan of care. Per interview 7/17/2023 about 2:30 pm, the Director of Nurses stated, ";collaboration of the plan of care [at IDT] has been done by the nurse on the laptop. From now on each discipline will document their own." The agency had a policy (PC.6) titled, ";Plan of Care Process" dated 5/1/2020. The policy read in parts: ";...Purpose: To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient and familys specific needs. ...Policy: I. All hospice care and services furnished to patients and their families will follow an individualized written POC established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patients needs. II. The hospice will develop an individualized written POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions. ...Procedure: ...C. The update of the comprehensive assessment will be accompanied by the hospice IDG (in collaboration with the individuals attending physician, if any) and will evaluate changes that have taken place since the initial assessment. 1. Updates will include information on the patients progress toward desired outcomes, as well as a reassessment of the patients response to care. 2. The comprehensive assessment will be updated by the IDG as frequently as the patients condition requires but no less frequently than every fifteen (15) days....VI. The POC includes, but is not limited to: ...B. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, including level of care; C. Measurable outcomes anticipated from implementing and coordinating the POC D. Drugs and treatments necessary to meet the needs of the patient ...F. Designation of discipline(s) responsible for providing specific services ...VII. ...Documentation will support that the patient receives the appropriate level of care and services as indicated by the interdisciplinary assessments...." The agency had a policy (PC.8) titled, ";Interdisciplinary Group Roles and Responsibilities" dated 12/1/2019. The policy read in parts: ";...Purpose: To identify the roles and responsibilities of the Interdisciplinary Group (IDG). Policy: The agency will designate an IDG, who, in collaboration with the patients attending physician, will work together to provide for the physical, medical, psychosocial, emotional, and spiritual needs of the terminally ill patient and/ or family members as delineated in a patient specific plan of care. ...Procedure: I. The IDG, in collaboration with the attending physician (if any), will prepare a written plan of care for each patient/ family, which specifies the care and services necessary to meet the patient/ family-specific needs identified in the comprehensive assessment, as those needs relate to the terminal illness and related conditions. ...VII. The IDG will review and discuss circumstances surrounding deaths since the last patient care conference. Develop bereavement plans of care, coordinating bereavement services and monitoring changes that may contribute to risk for pathological grief. VIII. Formal communication regarding the patients plan of care is documented at the IDG meeting ensuring care and services are provided in accordance with the POC. Informal verbal and written communication demonstrating coordination f care among all staff members and others providing care is also documented in the medical record...."

Based on record review and interview, the agency failed to include an effective date on the election of benefits as outlined in CFR 418.24(b)(4) in 3 (#3, #6, #9) of 3 active patients. This failure could result in patients not receiving care and services in a timely manner. --- Findings: Per the Code of Federal Regulations (CFR) 418.24(b)(4), ";the election statement must include the effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement." Record review of patient #3s record revealed a plan of care order dated 2/8/2023 with a terminal diagnosis of COPD (inability to breathe). The record included the hospice informed consent and election of hospice benefit signed by the patient on 10/29/2021. The consent did not include the start of care election date. Record review of patient #6s record revealed a written certification dated 12/24/2021 with a terminal diagnosis of COPD (inability to breathe). The record included the hospice informed consent and election of hospice benefit signed by the patient on 12/24/2021. The consent did not include the start of care election date. Record review of patient #9s record revealed a plan of care order dated 4/19/2023 with a terminal diagnosis of Alzheimers disease (forgetfulness). The record included the hospice informed consent and election of hospice benefit signed by the patients power of attorney on 4/18/2023. The consent did not include the start of care election date. Per phone interview 7/18/2023 about 11:20 am, employee #3 stated the ";election date comes from the order. [The] actual date of service is the day I visit them. The patient doesnt tell me when they want to start hospice." Per phone interview 7/18/2023 about 11:40 am, employee #4 stated, ";we are informed by the office that we have a patient requesting services. We dont ask when a patient wants to start hospice its just when the paperwork is done, and the patient is admitted." Per interview 7/18/2023 about 1:35 pm with the Administrator present; the Director of Nurses stated, ";I understand what youre saying regarding the importance of the date. We get the referral and coordinate with the patient/ family. We send someone to admit when the patient requests. We just dont enter the actual date in the election statement." The agency had a policy (PE.5) titled, ";Eligibility and Election of the Medicare Hospice Benefit" dated 10/01/2021. The policy read in parts: ";...Purpose: To provide guidelines and processes for eligibility and election of the Medicare Hospice Benefit. ...Definition: ";Representative" means an individual who has the authority under state law (whether by statute or pursuant to an appointment by the courts of the state) to authorize or terminate medical care or to elect or revoke the election of hospice care on behalf of a terminally ill patient who is mentally or physically incapacitated. This may include a legal guardian. ...Policy: ...II. A signed copy of the election statement will be retained in the clinical record. ...Procedure: ...VIII. A. Content of the election statement will include: ...3. The date of ";election of hospice care" which is the effective date of the election statement. The patient may sign the hospice election statement with a later (not earlier) effective date. The effective date may not be retroactive; ..."

Based on record review and interview, the agency failed to include in the medical record physician orders for wound care for 2 (#5, & #11) of 3 patients with wounds. This failure could result in improper or inadequate care of the wounds. --- Findings: Record review of patient #5s record revealed a written certification by the hospice medical director dated 9/21/2022. The initial nursing admission assessment did not document any wounds or skin breakdown. On 9/29/2022 the nurse documented a stage 1 pressure sore on the left buttocks which was treated with a duoderm (aides wound healing) dressing. On 10/11/2022 the nurse documented the stage 1 pressure sore on the buttocks with a duoderm (aides wound healing) dressing. This nurse also mentioned a blister on the right foot that would be treated with betadine (antiseptic medicine) twice a day. A physician order regarding the treatment of the blister with betadine was received 10/12/2022. This order does not mention the stage 1 pressure sore treatment. Record Review of patient #11s record revealed a written certification by the hospice medical director dated 12/2/2022. The certification mentions ";multiple pressure ulcers requiring wound care." On 12/2/2022 at 11:00 am a licensed practical nurse made a visit and documented multiple wounds. The nurse stated, ";use aseptic technique to clean all area with normal saline, pat dry, apply betadine wet to dry to heel, great toe, 5th phalanges wrapped with kerlix taped in place, ace wrap in place. Applied betadine allow to dry leave open to air on buttock and scrotum." On 12/2/2022 at 5:00 pm the registered nurse made the initial assessment. The nurse documented multiple wounds but did not mention the treatments in the initial assessment. On 12/28/2022 a physician order was received regarding wound care to the left below the knee stump twice a week. No other orders for wound treatment are in the medical record. Per interview 7/18/2023 about 1:35 pm with the Administrator present; the Director of Nurses stated, ";normally a verbal order is put in the electronic medical record then sent to the doctor to sign. The nurse has to add [the order] to the plan of care and then it would stay on the plan of care until it is discontinued."

Based on record review and interview, the agency failed to include in the medical record a discharge summary of the patients stay including treatments, symptoms and pain management, current plan of care, and latest physician orders in 3 (#2, #4, & #8) of 3 live discharged patients. This failure could result in improper or inadequate care after discharge. --- Findings: Record review of patient #2s record revealed a written certification by the hospice medical director dated 11/8/2022 with a terminal diagnosis of Alzheimers disease (forgetfulness). The caregiver signed the revocation statement 4/10/2023. The medical record did not include a discharge summary. Record review of patient #4s record revealed a written certification by the hospice medical director dated 11/10/2022 with a terminal diagnosis of Alzheimers disease (forgetfulness). The caregiver signed the revocation statement 2/10/2023. The medical record did not include a discharge summary. Record review of patient #8s record revealed a written certification by the hospice medical director dated 2/6/2023 with a terminal diagnosis of CHF (heart failure). The caregiver signed the revocation statement 5/20/2023. The medical record did not include a discharge summary. Per phone interview 7/18/2023 about 11:20 am, employee #3 stated, ";DC (discharge) summary is generally done at the visit on the same day." Per phone interview 7/18/2023 about 11:40 am, employee #4 stated, ";DC (discharge) summary should be done immediately. It is the responsibility of the nurse who pronounced or discharged the patient." Per interview 7/18/2023 about 1:35 pm, the Director of Nurses stated, ";who receives the revocation/ death (whoever is there) puts it [discharge summary] in then." The agency had a policy (PE.4) titled, ";Patient Discharge" dated 10/01/2021. The policy read in parts: ";Purpose: To establish guidelines and processes by which patients are discharged or recommended for discharge from the hospice program. ...Policy: I. The hospice will follow accrediting standards (if applicable), federal, state, and local regulations related to patient discharge. ...Procedure: ...IX. The hospice will forward copies of the following to the patients attending physician upon discharge from hospice services: A. The hospice discharge summary which includes but is not limited to: ..."