Every finding on record at Mesquite 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 2 of 14 (14%) records reviewed the agency did not ensure that the drug profile contained all of the patient's current prescription and over the counter (OTC) drugs. Policy TX.17 Medication List and Monitoring read in part, '1. Agency will maintain a current, accurate list of all prescription and over the counter (OTC) medications taken by the patient.' Clinical Record 9: The hospice election of benefit was dated 06/30/2021. During review of the 02/15/2024 episode of care, the 03/20/2024 registered nurse visit note, the 03/21/2024 updated comprehensive assessment and the 03/21/2024 updated hospice plan of care included documentation of patient utilization of Oxygen at 3 liters per minute vis nasal cannula. At the time of the review on 03/28/2024, Oxygen was not included on the medication profile. Clinical Record 11: The hospice election of benefit was dated 01/11/2024. During review of the 01/11/2024 episode of care, the 01/18/2024 updated comprehensive assessment and the 01/25/2024 updated hospice plan of care included documentation of patient utilization of Oxygen at 3 liters per minute vis nasal cannula. At the time of the review on 03/28/2024, Oxygen was not included on the medication profile. During interview 03/29/2024, the Administrator reviewed the associated records and stated that the Oxygen had been inadvertently omitted from the medication profile and had since been corrected.

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. This standard was not met as evidenced by clinical record review, document review and interview. In 8 of 14 (57%) records reviewed the agency did not ensure that the individualized written plan of care reflected the patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Policy.6 Care Planning Process read in part, “The plan of care must reflect client and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. 2.3 Content of the IDT care plan will include medications and treatments to meet the needs of the patient.” Clinical Record 1: The hospice election of benefit was dated 12/05/2022. The 02/28/2024 hospice plan of care for the 02/28/2024 hospice benefit of care aide frequency read 5xweek. The 02/23/2024 recertification assessment completed by the registered nurse read in part, “unable to make needs known, conversation is nonsensical, requires assistance with 5/6 ADLs minus feeding,” At the time of the review on 03/27/2024 the 02/28/2024 recertification and the 03/08/2024 and 03/21/2024 updated hospice plans of care did not include aide interventions and goals related to the provision of ordered service. Clinical Record 2: The hospice election of benefit was dated 08/04/2023. The 01/31/2024 hospice plan of care for the 01/31/2024 hospice benefit of care aide frequency read 5xweek. The 01/22/2024 and the 03/21/2024 recertification assessments completed by the registered nurse read in part, “requires assistance with 5/6 ADLs minus feeding,” At the time of the review on 03/27/2024 the 01/31/2024 recertification and the 02/08/2024, 02/22/2024. 03/08/2024 and 03/21/2024 updated hospice plans of care did not include aide interventions and goals related to the provision of ordered service. Clinical Record 3: The hospice election of benefit was dated 05/02/2023. The 01/27/2024 hospice plan of care for the 01/27/2024 hospice benefit of care aide frequency read 5xweek. The 01/22/2024 and the 03/21/2024 recertification assessments completed by the registered nurse read in part, “requires assistance with 5/6 ADLs minus feeding,” At the time of the review on 03/27/2024 the 01/27/2024 recertification and the 02/08/2024, 02/22/2024. 03/08/2024 and 03/21/2024 updated hospice plans of care did not include aide interventions and goals related to the provision of ordered service. Clinical Record 4: The hospice election of benefit was dated 02/27/2024. The 02/27/2024 hospice plan of care aide frequency read 5xweek. The 02/27/2024 initial and the 03/06/2024 and 03/19/2024 updated assessments completed by the registered nurse read in part, “requires assistance with 5/6 ADLs minus feeding,” At the time of the review on 03/28/2024 the 02/27/2024 initial and the 03/08/2024 and 03/21/2024 updated hospice plans of care did not include aide interventions and goals related to the provision of ordered service. Clinical Record 8: The hospice election of benefit was dated 08/13/2023. The 02/09/2024 hospice plan of care for the 02/09/2024 hospice benefit of care aide frequency read 3xweek. The 02/02/2024 recertification and the 02/09/2024, 03/08/2024 and the 03/21/2024 updated assessments completed by the registered nurse read in part, “requires assistance with 5/6 ADLs minus feeding,” At the time of the review on 03/28/2024 the 02/09/2024 recertification and the 02/22/2024. 03/08/2024 and 03/21/2024 updated hospice plans of care did not include aide interventions and goals related to the provision of ordered service. Clinical Record 9: The hospice election of benefit was dated 06/30/2021. The 02/15/2024 hospice plan of care for the 02/15/2024 hospice benefit of care aide frequency read 5xweek. The 02/01/2024 recertification and the 02/15/2024, 03/08/2024 and the 03/21/2024 updated assessments completed by the registered nurse read in part, “requires assistance with 5/6 ADLs minus feeding,” At the time of the review on 03/28/2024 the 02/09/2024 recertification and the 02/22/2024. 03/08/2024 and 03/21/2024 updated hospice plans of care did not include aide interventions and goals related to the provision of ordered service. Clinical Record 12: The hospice election of benefit was dated 10/26/2023. The 10/26/2023 hospice plan of care aide frequency read 3xweek. The 10/26/2023 initial assessment completed by the registered nurse read in part, “requires assistance with 5/6 ADLs minus feeding,” At the time of the review on 03/28/2024 the 10/26/2023 initial and the11/05/2023 and 11/27/2023 updated hospice plans of care did not include aide interventions and goals related to the provision of ordered service. Clinical Record 14: The hospice election of benefit was dated 01/26/2024. The 01/26/2024 hospice plan of care aide frequency read 5xweek. The 01/26/2024 initial and the 02/08/2024 and 02/22/2024 updated assessments completed by the registered nurse read in part, “requires assistance with 5/6 ADLs minus feeding,” At the time of the review on 03/28/2024 the 01/26/2024 initial and the 02/08/2024 and 02/22/2024 updated hospice plans of care did not include aide interventions and goals related to the provision of ordered service. During interview 03/29/2024, the Administrator reviewed the associated records and stated that the plans of care had since been corrected with the addition of aide interventions and goals.

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 6 of 14 (43%) records reviewed the agency did not ensure that care and services were provided in accordance with the plan of care. Policy.8 Coordination of Carae and Services read in part, '3. 3.2 Ensure that the care and services are provided in accordance with the POC.' Clinical Record 2: The hospice election of benefit was dated 08/04/2023. The 01/31/2024 hospice plan of care for the 01/31/2024 hospice benefit of care read 'SN 1xweek.' At the time of the review on 03/27/2024, there was no documented skilled nursing visit for the week of 01/31/2024 and no documented explanation of why services were not provided at the frequency ordered. Clinical Record 3: The hospice election of benefit was dated 05/02/2023. The 01/27/2024 hospice plan of care for the 01/27/2024 hospice benefit of care read 'SN 1xweek.' At the time of the review on 03/27/2024, there was no documented skilled nursing visit for the week of 01/27/2024 and no documented explanation of why services were not provided at the frequency ordered. Clinical Record 4: The hospice election of benefit was dated 02/27/2024. The 02/27/2024 hospice plan of care read 'SN 2xweek.' At the time of the review on 03/28/2024, there was one documented skilled nursing visit dated 02/27/2024 for the week of 02/27/2024 and no documented explanation of why services were not provided at the frequency ordered. Clinical Record 5: The hospice election of benefit was dated 11/07/2022. The 03/01/2024 hospice plan of care for the 03/01/2024 hospice benefit of care read 'SN 2xweek.' At the time of the review on 03/28/2024, there was one documented skilled nursing visit dated 03/01/2024 for the week of 03/01/2024 and no documented explanation of why services were not provided at the frequency ordered. Clinical Record 6: The hospice election of benefit was dated 10/06/2023. The 01/04/2024 hospice plan of care for the 01/03/2024 hospice benefit of care read 'SN 1xweek.' At the time of the review on 03/28/2024, there was no documented skilled nursing visit for the week of 02/05/2024 and no documented explanation of why services were not provided at the frequency ordered. Clinical Record 8: The hospice election of benefit was dated 08/13/2023. The 02/09/2024 hospice plan of care for the 02/09/2024 hospice benefit of care read 'SN 2xweek.' At the time of the review on 03/28/2024, there was only one documented skilled nursing visit dated 02/09/2024 for the week of 02/09/2024 and no documented explanation of why services were not provided at the frequency ordered. During interview 03/29/2024, the Administrator reviewed the associated records and stated the incorrect frequencies had been addressed and that remedial education would need to be provided in relation to missed visit documentation and recertification frequencies.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by document review, clinical record review, interviews, and review of findings with the Administrator which revealed the following issues regarding Hospice Aide services: Failure to ensure the Hospice Aide provided services as ordered in the plan of care [HCDT.16. I/L626]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.76: Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving home health care service from the agency.

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 11 of 13 (85%) records reviewed with the provision of aide services, the agency did not ensure that the aide provided the services per the plan of care. Clinical Record 1: The hospice election of benefit was dated 12/05/2022. The 02/28/2024 hospice plan of care for the 02/28/2024 hospice benefit of care aide frequency read '5xweek.' At the time of the review on 03/27/2024, there were only 3 documented aide visits dated 02/28/2024, 02/29/2024 and 03/01/2024 and no documented explanation of why services were not provided at the frequency ordered. The 02/28/2024 hospice aide plan of care created by the registered nurse contained a task frequency of every Monday for linen change. At the time of the review on 03/27/2024, the task was documented as completed on the following aide visit note dates 02/29/2024 (Thursday), 03/05/2025 (Tuesday, 03/07/2024(Thursday), 03/08/2024 (Friday), 03/13/2024 (Wednesday) and on 03/15/2024 (Friday). Clinical Record 2: The hospice election of benefit was dated 08/04/2023. The 01/31/2024 hospice plan of care for the 01/31/2024 hospice benefit of care aide frequency read '5xweek.' At the time of the review on 03/27/2024, there were only 3 documented aide visits dated 1/31/2024, 02/01/2024 and 02/02/2024 and no documented explanation of why services were not provided at the frequency ordered. Clinical Record 3: The hospice election of benefit was dated 05/02/2023. The 01/27/2024 hospice plan of care for the 01/27/2024 hospice benefit of care aide frequency read '5xweek.' At the time of the review on 03/27/2024, there were only 3 documented aide visits dated 02/28/2024, 02/29/2024 and 03/01/2024 and no documented explanation of why services were not provided at the frequency ordered. The 01/27/2024 hospice aide plan of care created by the registered nurse contained a task frequency of weekly for shampoo and shave. At the time of the review on 03/27/2024, the task of shave was documented as completed on the following aide visit note dates 02/12/2024, 02/13/2024 and 02/16/2024 for the week of 02/12/2024; 02/19/2024 and 02/21/2024 for the week of 02/19/2024; 03/11/2024 and 03/15/2024 for the week of 03/11/2024. The task of shampoo was documented as completed on the following aide visit note dates 03/04/2024, 03/05/2024 and 03/06/204 for the week of 03/04/2024. Clinical Record 4: The hospice election of benefit was dated 02/27/2024. The 02/27/2024 hospice plan of care aide frequency read '5xweek.' At the time of the review on 03/28/2024, there were only 3 documented aide visits dated 02/28/2024, 02/29/2024 and 03/01/2024 and no documented explanation of why services werenot provided at the frequency ordered. The 02/27/2024 hospice aide plan of care created by the registered nurse contained a task frequency of weekly for shampoo, foot care and nail care. At the time of the review on 03/28/2024, the tasks of foot care and nail care was documented as completed on all visits dated 03/04/2024 through 03/22/2024 with a noted aide visit frequency of 5xweek. Clinical Record 5: The hospice election of benefit was dated 11/07/2022. The 03/01/2024 hospice plan of care for the 03/01/2024 hospice benefit of care read '5xweek.' At the time of the review on 03/28/2024, there were only 1 documented aide visit dated 03/01/2024 and no documented explanation of why services were not provided at the frequency ordered. The 03/01/2024 hospice aide plan of care created by the registered nurse contained a task frequency of weekly for shampoo, shave, and linen change. At the time of the review on 03/28/2024, the tasks of shampoo, shave and linen change were documented as completed on all visits dated 03/18/2024 through 03/22/2024 with a noted aide visit frequency of 5xweek. Clinical Record 6: The hospice election of benefit was dated 10/06/2023. The 01/04/2024 hospice plan of care for the 01/04/2024 hospice benefit of care aide frequency read '2xweek.' At the time of the review on 03/28/2024, there was only 1 documented aide visit dated 01/05/2024 and no documented explanation of why services were not provided at the frequency ordered. Clinical Record 8: The hospice election of benefit was dated 08/13/2023. The 02/09/2024 hospice plan of care for the 02/09/2024 hospice benefit of care aide frequency read '3xweek.' At the time of the review on 03/28/2024, there was only 1 documented aide visit dated 02/09/2024 and no documented explanation of why services were not provided at the frequency ordered. Clinical Record 9: The hospice election of benefit was dated 06/30/2021. The 02/15/2024 hospice plan of care for the 02/15/2024 hospice benefit of care aide frequency read '5xweek.' At the time of the review on 03/28/2024, there were only 2 documented aide visits dated 02/15/2024 and 02/16/2024 with no documented explanation of why services were not provided at the frequency ordered. Clinical Record 12: The hospice election of benefit was dated 10/26/2023. The 10/26/2023 hospice plan of care aide frequency read '3xweek.' At the time of the review on 03/28/2024, there was only 1 documented aide visit dated 10/28/2023 with no documented explanation of why services were not provided at the frequency ordered. Clinical Record 13: The hospice election of benefit was dated 07/17/2023. The 01/13/2024 hospice plan of care for the 01/13/2024 hospice benefit of care aide frequency read '5xweek.' At the time of the review on 03/28/2024, there were no documented aide visits dated for the week for 01/13/2024 with no documented explanation of why services were not provided at the frequency ordered. Clinical Record 14: The hospice election of benefit was dated 01/26/2024. The 01/26/2024 hospice plan of care aide frequency read '5xweek.' At the time of the review on 03/28/2024, there were no documented aide visits for the week of 01/26/2024 with no documented explanation of why services were not provided at the frequency ordered. During interview on 03/29/2024, the Administrator reviewed the associated records and stated measures to ensure recertification frequency orders align with plan of care would be implemented as well as the provision of remedial education to staff regarding aide care planning and aide provision of care.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following; A summary of the patient’s hospice stay, including treatments, symptoms, and pain management; 2. The patient’s current plan of care; 3. The patient’s latest physician orders; 4. Any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 5 (40%) discharged records reviewed in which a discharge summary was required, the agency did not ensure the summary included the required components. Policy PE.6 Patient Discharge Notice read in part, '11 The Discharge Summary includes at least the following: a summary of the patient's stay including treatments, symptoms and pain management. The patient's current POC, The patient's latest physician orders. Any other documentation that will assist in post- discharge continuity of care or that is requested by the attending physician or receiving facility.' Clinical Record 13: The patient live discharge date was 02/03/2024. At the time of the review on 03/28/2024, a discharge summary had not been completed. Clinical Record 14: The patient live discharge date was 02/25/2024. At the time of the review on 03/28/2024, a discharge summary had not been completed. During interview 03/29/2024, the Administrator reviewed the associated records and stated while the HIS and the physician had been notified, and that the staff would need further education on completing the discharge summary.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by document review, clinical record review, and interview. 1 of 5 (20%) clinical records reviewed revealed the agency failed to perform a comprehensive assessment with the 5-calendar day requirement. Hospice policy PE.3 states in part: "The initial comprehensive health assessment, with input from appropriate IDT member and the attending physician, will be completed within 5 calendar days." This was a previous required action during the agency survey completed in August 2021. Record 3: This patient was admitted on 12/19/2022 with Senile Degeneration of the Brain. The initial comprehensive visit by social work was not completed until 12/29/2022. There was no documented evidence that the social worker made any contact with the patient or family prior to this date. During an interview and joint review of record with the Clinical Director she confirmed that the documentation was missing and timeline was not met. This was a previous required action during the agency survey completed in August 2021. Hospice policy PE.3 states in part: "The initial comprehensive health assessment, with input from appropriate IDT member and the attending physician, will be completed within 5 calendar days."

It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes history of pain and its treatment, both pharmacological and non-pharmacological, use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status. Characteristics of the pain, including location, frequency, and intensity, how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping), and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by document review, clinical record review, and interview. 2 of 5 (40%) clinical records reviewed failed to provide evidence that a comprehensive pain assessment was completed. This was a required action during the agencies previous survey completed in August 2021. Hospice Policy TX.30 "Pain Management" states, in part: "All patients will be assessed for pain or risk for pain in the initial patient assessment to include pain character, severity/intensity, frequency, location, duration. 2. Pain intensity ratings will be recorded utilizing a pain scale as determined by the Agency. Vital signs may be recorded. 3. Patient's pain goal will also be assessed utilizing a pain scare as determined by the Agency." Record 3: This patient was admitted to hospice on 12/19/2022 with a diagnosis of Senile degeneration of the brain. Review of the initial RN assessment done 12/19/2022 revealed no evidence that a comprehensive pain assessment was completed. There was a care plan for pain documented under the plan of care problems tab. It was documented under the pain tab that pain was not active problem for this patient. Listed on the active medication list was Voltaren gel, apply to bilateral knees as needed for pain and Naproxen 250mg twice a day by mouth for pain. Record 2: This patient was admitted to hospice on 11/07/2022 with a diagnosis of Multiple Sclerosis. RN initial assessment on 11/7/2022 contained no evidence that a comprehensive pain assessment was done for the patient. The nurse rated the pain portion of the Edmonton scale a 2. There was also documentation that the patient displayed facial grimacing when adjusted in bed. The patient had Fentanyl 50mcg for pain listed on the active medication list. In an interview with the Clinical Director, it was confirmed that this patient was currently on Fentanyl and the agency failed to document an initial pain assessment. During an interview and joint review of record with the Clinical Director, it was confirmed that this patient does take pain medication and that the agency failed to document an initial pain assessment. This was a required action during the agencies previous survey completed in August 2021. Hospice Policy TX.30 "Pain Management" states, in part: "All patients will be assessed for pain or risk for pain in the initial patient assessment to include pain character, severity/intensity, frequency, location, duration. 2. Pain intensity ratings will be recorded utilizing a pain scale as determined by the Agency. Vital signs may be recorded. 3. Patient's pain goal will also be assessed utilizing a pain scare as determined by the Agency."

It is required that the 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. 1 of 5 (20%) clinical records reviewed failed to show evidence that the medication profile was updated properly after new medications were written by the physician. Record 1:This patient was admitted to hospice services 2/5/2021 with a diagnosis of Parkinson's disease. During benefit period 12/27/2022 - 2/25/2022 the patient was diagnosed with a urinary tract infection. Cefurozime 500mg tablets by mouth for 5 days was ordered by the doctor. There was no documented evidence that the medication was added to the medication list. During an interview with the Clinical Director, it was verified that the policy for the agency is if the doctor writes a new order, it should be added to the medication profile and then reviewed in the interdisciplinary group meetings, and that this requirement was not met. In an interview with the Clinical Director, it was verified that the policy for the agency is if the doctor writes a new order, it should be added to the medication profile and then reviewed in the interdisciplinary group meetings.

It is required that hospice aides are supervised by a Registered Nurse (RN) who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide, ensure that services ordered by the hospice interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by document review, clinical record review, and interview. 1 of 5 (20%) clinical records reviewed revealed that not aide supervisory visit was made by RN with the 14-day requirement. Hospice Policy states in part: "Agency will provide timely supervision of the following employees by qualified individuals: Home health aides by a registered nurse no less frequently than 14 days and annually to the location where patient is receiving care." Record 1: This patient was admitted to hospice on 2/5/2021 with a diagnosis of Parkinson's disease. The plan of care states that she receives aide services 5 times a week. The RN completed a supervisory visit on 1/30/2023 another supervisory visit was due on 2/13/2023, there was no evidence in the record that this visit had been done. During an interview and joint review of record with Clinical Director it was confirmed that the agency failed to provide the supervisory visit per policy. Hospice Policy states in part: "Agency will provide timely supervision of the following employees by qualified individuals: Home health aides by a registered nurse no less frequently than 14 days and annually to the location where patient is receiving care."