Every finding on record at Merit Hospice LLC

It is required that each patient’s individualized written plan of care reflect patient and family goals and identify planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 11 of 14 (79%) Clinical records revealed that the hospice agency did not ensure that each patient's individualized written plan of care included interventions based on problems identified in the initial and updated comprehensive assessments. Agency Policy, titled ‘Interdisciplinary Group Plan of Care’ (undated), stated in part. “The Plan of Care will include an assessment of the individual's needs and identification of services, including the management of discomfort and symptom relief. The Plan of Care will contain interventions to manage pain and symptoms.” Clinical Record 1: The patient elected their hospice benefit on 08/29/2024 with a diagnosis of Unspecified Severe Protein-Calorie Malnutrition with secondary Adult Failure to Thrive. On the initial comprehensive assessment, dated 08/29/2024, the Registered Nurse (RN) documented the patient had weight loss. The plan of care, dated 08/29/2024 to 11/26/2024, did not include any problems, goals, or interventions related to weight loss. Clinical Record 2: The patient elected their hospice benefit on 10/01/2024 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction with secondary Dysphagia and Aphasia. On the initial comprehensive assessment, dated 10/01/2024, the Registered Nurse (RN) documented the patient had symptoms of dysphagia, constipation, bowel and bladder incontinence, and shortness of breath. The plan of care, dated 10/01/2024 to 12/29/2024, did not include any problems, goals, or interventions related to these symptoms. Clinical Record 3: The patient elected their hospice benefit on 10/16/2023 with a diagnosis of Senile Degeneration of the Brain. On the initial comprehensive assessment, dated 10/16/2023, the Registered Nurse (RN) documented the patient had symptoms of bowel and bladder incontinence, and agitation. The plan of care, dated 10/16/2023 to 01/13/2024, did not include any problems, goals, or interventions related to these symptoms. Clinical Record 4: The patient elected their hospice benefit on 08/22/2024 with a diagnosis of Congestive Heart Failure. On the initial comprehensive assessment, dated 08/22/2024, the Registered Nurse (RN) documented the patient had symptoms of decreased appetite, bowel and bladder incontinence, and fall risk. The plan of care, dated 08/22/2024 to 11/19/2024, did not include any problems, goals, or interventions related to these symptoms. Clinical Record 5: The patient elected their hospice benefit on 09/21/2024 with a diagnosis of Malignant Neoplasm of Unspecified Renal Pelvis. On the initial comprehensive assessment, dated 09/21/2024, the Registered Nurse (RN) documented the patient had symptoms of expressive aphasia, bowel and bladder incontinence, shortness of breath with moderate exertion, edema, and constipation. The plan of care, dated 09/21/2024 to 12/19/2024, did not include any problems, goals, or interventions related to these symptoms. Clinical Record 6: The patient elected their hospice benefit on 09/19/2024 with a diagnosis of Malignant Neoplasm of Colon with secondary Malignant Neoplasm of Lung. On the initial comprehensive assessment, dated 09/19/2024, the Registered Nurse (RN) documented the patient had symptoms of bowel and bladder incontinence. The plan of care, dated 09/19/2024 to 12/17/2024, did not include any problems, goals, or interventions related to these symptoms. Clinical Record 7: The patient elected their hospice benefit on 06/13/2024 with a diagnosis of End Stage Renal Disease. On the initial comprehensive assessment, dated 06/13/2024, the Registered Nurse (RN) documented the patient had symptoms of dysphagia, fall risk, bowel and bladder incontinence, and weight loss. The plan of care, dated 06/13/2024 to 09/10/2024, did not include any problems, goals, or interventions related to these symptoms. Clinical Record 8: The patient elected their hospice benefit on 03/21/2024 with a diagnosis of Alzheimer's Disease. On the initial comprehensive assessment, dated 03/21/2024, the Registered Nurse (RN) documented the patient had symptoms of dysphagia, fall risk, bowel and bladder incontinence, and weight loss. The plan of care, dated 03/21/2024 to 06/18/2024, did not include any problems, goals, or interventions related to these symptoms. Clinical Record 9: The patient elected their hospice benefit on 10/24/2024 with a diagnosis of Malignant Neoplasm of Stomach. On the initial comprehensive assessment, dated 10/24/2024, the Registered Nurse (RN) documented the patient had symptoms of edema, bowel and bladder incontinence, and shortness of breath. The plan of care, dated 10/24/2024 to 01/21/2025, did not include any problems, goals, or interventions related to these symptoms. Clinical Record 10: The patient elected their hospice benefit on 10/30/2024 with a diagnosis of Heart Failure. On the initial comprehensive assessment, dated 10/30/2024, the Registered Nurse (RN) documented the patient had symptoms of weakness, bowel and bladder incontinence, and shortness of breath. The plan of care, dated 10/30/2024 to 01/27/2025, did not include any problems, goals, or interventions related to these symptoms. Clinical Record 14: The patient elected their hospice benefit on 11/29/2023 with a diagnosis of Senile Degeneration of the Brain. On the initial comprehensive assessment, dated 11/29/2023, the Registered Nurse (RN) documented the patient had symptoms of fall risk, decreased oral intake, and bowel and bladder incontinence. The plan of care dated 11/29/2023 to 12/12/2023 did not include any problems, goals, or interventions related to these symptoms. During interviews on 11/05/2024 and 11/06/2024, the Director of Nursing stated that the agency was aware of the issues with the individualized patient's plan of care and that the hospice agency had a performance improvement project/plan currently open to correct the non-compliance.

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 medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 10 of 14 (71%) records reviewed it was revealed that the agency did not ensure the individualized written plan of care included the medical supplies necessary to meet the patient's needs Clinical Record 1: The patient elected their hospice benefit on 08/29/2024 with a diagnosis of Unspecified Severe Protein-Calorie Malnutrition with secondary Adult Failure to Thrive. On the initial comprehensive assessment, dated 08/29/2024, the Registered Nurse (RN) documented the patient had bowel and bladder incontinence and wounds. The Director of Nursing stated the hospice agency provided medical supplies to the patient, however the plan of care dated 08/29/2024-11/26/2024 did not include the list of medical supplies. Clinical Record 2: The patient elected their hospice benefit on 10/01/2024 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction with secondary Dysphagia and Aphasia. On the initial comprehensive assessment, dated 10/01/2024, the Registered Nurse (RN) documented the patient had bowel and bladder incontinence. The Director of Nursing stated the hospice agency provided medical supplies to the patient, however the plan of care dated 10/01/2024 to 12/29/2024did not include the list of medical supplies. Clinical Record 3: The patient elected their hospice benefit on 10/16/2023 with a diagnosis of Senile Degeneration of the Brain. On the initial comprehensive assessment, dated 10/16/2023, the Registered Nurse (RN) documented the patient had symptoms of bowel and bladder incontinence. The Director of Nursing stated the hospice agency provided medical supplies to the patient, however the plan of care dated 10/16/2023 to 01/13/2024 did not include the list of medical supplies. Clinical Record 4: The patient elected their hospice benefit on 08/22/2024 with a diagnosis of Congestive Heart Failure. On the initial comprehensive assessment, dated 08/22/2024, the Registered Nurse (RN) documented the patient had symptoms of bowel and bladder incontinence. The Director of Nursing stated the hospice agency provided medical supplies to the patient, however the plan of care dated 08/22/2024 to 11/19/2024 did not include the list of medical supplies. Clinical Record 5: The patient elected their hospice benefit on 09/21/2024 with a diagnosis of Malignant Neoplasm of Unspecified Renal Pelvis. On the initial comprehensive assessment, dated 09/21/2024, the Registered Nurse (RN) documented the patient had symptoms of bowel and bladder incontinence. The Director of Nursing stated the hospice agency provided medical supplies to the patient, however the plan of care dated 09/21/2024 to 12/19/2024 did not include the list of medical supplies. Clinical Record 6: The patient elected their hospice benefit on 09/19/2024 with a diagnosis of Malignant Neoplasm of Colon with secondary Malignant Neoplasm of Lung. On the initial comprehensive assessment, dated 09/19/2024, the Registered Nurse (RN) documented the patient had symptoms of bowel and bladder incontinence. The Director of Nursing stated the hospice agency provided medical supplies to the patient, however the plan of care dated 09/19/2024 to 12/17/2024 did not include the list of medical supplies. Clinical Record 7: The patient elected their hospice benefit on 06/13/2024 with a diagnosis of End Stage Renal Disease. On the initial comprehensive assessment, dated 06/13/2024, the Registered Nurse (RN) documented the patient had symptoms of bowel and bladder incontinence. The Director of Nursing stated the hospice agency provided medical supplies to the patient, however the plan of care dated 06/13/2024 to 09/10/2024 did not include the list of medical supplies. Clinical Record 8: The patient elected their hospice benefit on 03/21/2024 with a diagnosis of Alzheimer's Disease. On the initial comprehensive assessment, dated 03/21/2024, the Registered Nurse (RN) documented the patient had symptoms of bowel and bladder incontinence. The Director of Nursing stated the hospice agency provided medical supplies to the patient, however the plan of care dated 03/21/2024 to 06/18/2024 did not include the list of medical supplies. Clinical Record 9: The patient elected their hospice benefit on 10/24/2024 with a diagnosis of Malignant Neoplasm of Stomach. On the initial comprehensive assessment, dated 10/24/2024, the Registered Nurse (RN) documented the patient had symptoms of bowel and bladder incontinence. The Director of Nursing stated the hospice agency provided medical supplies to the patient, however the plan of care dated 10/24/2024 to 01/21/2025 did not include the list of medical supplies. Clinical Record 10: The patient elected their hospice benefit on 10/30/2024 with a diagnosis of Heart Failure. On the initial comprehensive assessment, dated 10/30/2024, the Registered Nurse (RN) documented the patient had symptoms of bowel and bladder incontinence. The Director of Nursing stated the hospice agency provided medical supplies to the patient, however the plan of care dated 10/30/2024 to 01/27/2025 did not include the list of medical supplies. Clinical Record 14: The patient elected their hospice benefit on 11/29/2023 with a diagnosis of Senile Degeneration of the Brain. On the initial comprehensive assessment, dated 11/29/2023, the Registered Nurse (RN) documented the patient had symptoms of bowel and bladder incontinence. The Director of Nursing stated the hospice agency provided medical supplies to the patient, however the plan of care dated 11/29/2023 to 12/12/2023 did not include the list of medical supplies. During interviews on 11/05/2024 and 11/06/2024, the Director of Nursing stated that medical supplies were listed on the aide care plans, but those did not populate to the plan of care. The Director of Nursing stated the agency was aware of the issues with the individualized patient's plans of care and that the hospice agency had a performance improvement project/plan currently open to correct the non-compliance.

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 5 of 14 (36%) clinical records reviewed in which an aide was accepted revealed that the agency did not ensure that the aide care plan provided clear and specific instructions for the aide. Clinical Record 2: The patient elected their hospice benefit on 10/01/2024 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction with secondary Dysphagia and Aphasia. The aide care plan dated 10/01/2024 included the following relevant tasks: assist in the transfer “as needed,” and assist in ambulation “as needed.” The RN did not include specific indications for the “as needed” tasks. Clinical Record 5: The patient elected their hospice benefit on 09/21/2024 with a diagnosis of Malignant Neoplasm of Unspecified Renal Pelvis. The aide care plan dated 09/21/2024 included the following relevant tasks: assist in the transfer “as needed,” and assist in ambulation “as needed,” range of motion “as needed”, and incontinence care “as needed.” The RN did not include specific indications for the “as needed” tasks. Clinical Record 7: The patient elected their hospice benefit on 06/13/2024 with a diagnosis of End Stage Renal Disease. The aide care plan dated 06/13/2024 included the following relevant tasks: clean under the nails and file once a week and “as needed.” The RN did not include specific indications for the “as needed” tasks. Clinical Record 9: The patient elected their hospice benefit on 10/24/2024 with a diagnosis of Malignant Neoplasm of Stomach. The aide care plan dated 10/24/2024 included the following relevant tasks: clean under the nails and file once a week and “as needed.” The RN did not include specific indications for the “as needed” tasks. Clinical Record 12: The patient elected their hospice benefit on 10/03/2023 with a diagnosis of Parkinson's Disease. The aide care plan dated 10/03/2023 included the following relevant tasks: nail care and cleaning once a week and “as needed.” The RN did not include specific indications for the “as needed” tasks. During an interview on 11/07/2024, the Director of Nursing was asked about the aide care plans have tasks assigned as needed. The Director of Nursing stated that she did not like the way the aide care plans were being completed and was working with the hospice agency nurses to improved them.

Observed in Record Review. In 7 of 11 patient records reviewed, the surveyor found that the organization had not consistently identified measurable goals for the patient. For example, in review of the medical record for HV1, the following was noted: Nutrition goal-Patient on pureed diet; Skin goal-turn patient every 2 hours; Respiratory goal-check oxygen level each visit; Pain goal-assess pain level. In HV2, the following was noted: Edema goal-Patient will have edema effectively managed; Respiratory goal-bilateral wheezing in lower lobes; Fear/Grief goal-Patient will receive visits and spiritual and emotional support. In HV3, the goal for Grief and Anxiety was Chaplain to provide visits and spiritual support. In RR4, the goal for potential for dyspnea was dyspnea will be managed throughout the certification period. In RR6, the goal for high fall risk was that the facility will report all falls to Merit Hospice within 24 hours. In RR7, the fall risk goal was that the patient will work toward using her walker. The Guilt and Anger goal was written as Chaplain goal is to provide spiritual and emotional support, bible reading, hymns, prayer, ministry of presence and human touch. In RR8, the spiritual goal was that the family and patient will receive spiritual support from the Chaplain. The risk for constipation goal was that staff will report s/sx constipation to RN. These observations were discussed with the Administrator and the Director of Clinical Services.

Observed in Record Review. In 1 of 11 patient records reviewed, the surveyor found that the plan of care did not include all information on medications and treatments needed to meet the needs of the patient. For example, in review of the medical record for RR7, the surveyor found that the patient had hydrocodone, meloxicam, and Tylenol ordered prn for pain without further defining when to give each medication. This was discussed with the Administrator and the Director of Clinical Services.

Observed in Record Review. In 1 of 11 patient records reviewed, the surveyor noted that the organization had not provided care according to the patient's plan of care. For example, in review of the medical record for RR6, the plan of care required that the patient's wound be covered with a foam or nonadherent dressing. On multiple visits, the nurse documented gauze was used to cover the wound and not the ordered foam or nonadherent dressing. This observation was discussed with the Administrator and Director of Clinical Services.

Observed in Patient Home. In 3 of 3 home visits conducted, the surveyor noted that the staff member did not complete hand hygiene as required by organization policy. For example, during the home visit for HV1, the staff member was observed using soap and paper towels present in the home, not what was supplied by the organization. During this same visit, the staff member was observed changing either one or both gloves without performing hand hygiene between changes. During the home visit for HV2, the staff member was observed removing gloves on multiple occasions but did not consistently perform hand hygiene prior to performing another task. During the home visit for HV3, the staff member was observed changing gloves on multiple occasions without performing hand hygiene between doffing and donning. These observations were discussed with the Administrator and Director of Clinical Services.

Observed in Record Review. In 2 of 9 patient records reviewed, where the patient had hospice aide services ordered, the surveyor found that the registered nurse had not consistently provided the aide with information on safety precautions to implement or when to notify the nurse. For example, in review of the medical record for HV2 and RR4, the patient was on an anticoagulant. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this. This observation was discussed with the Administrator and the Director of Clinical Services.

Observed in Patient Home. In 2 of 2 home visits conducted, where medication reconciliation was observed, the surveyor noted that the organization medication profile was not consistent with what was found in the home. For example, during the home visit for HV2, the organization medication profile listed a chewable aspirin. In the home was EC aspirin that had been supplied by the hospice contracted pharmacy. During the home visit for HV3, the patient stated she was taking robitussin as needed for her cough and this was verified by her caregiver. This was not listed to her medication profile. In addition, the dosage for Diazepam was listed on the medication profile was 1/2 tablet (0.5) and on the bottle in the home, the dosage was one tablet. The caregiver verified the patient had been taking one tablet for some time. Zofran was listed on the medication profile as an oral tablet but the form found in the home was an orally disintegrating tablet (ODT). These observations were verified by the staff member present during the visit.