Every finding on record at Open Arms 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; 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 document review, clinical record review, and interview. In 6 of 19 (32%) clinical records reviewed, the agency did not ensure the medication profile included the patient’s current medications. Agency policy PC.M55 Medication-Profile, dated 05/19/2024, required in part, "When a patient is admitted to hospice, a medication profile is initiated to document all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. The patient's medication profile is reviewed by the IDG [interdisciplinary group] whenever there is a significant change and, at a minimum, every fifteen days." CLINICAL RECORD 5: The patient elected the hospice benefit on 01/08/2025. The clinical record included a physician order dated 01/08/2025 for "Oxygen as needed to maintain comfort at 2 liters via nasal cannula." The medication profile dated 01/08/2025 did not include oxygen. CLINICAL RECORD 7: The patient elected the hospice benefit on 03/24/2025. The clinical record included a physician order dated 03/24/2025 for "Oxygen as needed to maintain comfort at 2 liters via nasal cannula." The medication profile dated 03/24/2025 did not include oxygen. CLINICAL RECORD 8: The patient elected the hospice benefit on 12/18/2024. The clinical record included a physician order dated 12/18/2024 for "Oxygen as needed to maintain comfort at 2 liters via nasal cannula." The medication profile dated 12/18/2024 did not include oxygen. CLINICAL RECORD 10: The patient elected the hospice benefit on 01/29/2025. The clinical record included a physician order dated 01/29/2025 for "Oxygen as needed to maintain comfort at 2 liters via nasal cannula." The medication profile dated 01/29/2025 did not include oxygen. CLINICAL RECORD 12: The patient elected the hospice benefit on 11/15/2024. The clinical record included a physician order dated 11/15/2024 for " Oxygen continuous at 4 liters via nasal cannula." The medication profile dated 11/15/2024 did not include oxygen. CLINICAL RECORD 18: The patient elected the hospice benefit on 07/31/2024. The clinical record included a physician order dated 08/15/2024 for "Oxygen as needed to maintain comfort at 2 liters via nasal cannula." The medication profile dated 08/15/2024 did not include oxygen. During an interview on 04/17/2025, the Director of Nursing reviewed the records, confirmed the findings, and stated, "Oxygen is not listed on these medication profiles."

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, 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 2 of the 19 (11%) clinical records reviewed, the agency did not ensure the individualized written plan of care included orders for medical supplies and appliances necessary to meet the patient’s needs. CLINICAL RECORD 2: The patient elected the hospice benefit on 09/04/2024. The plan of care dated 12/03/2024 to 03/02/2025 included an order to "Change suprapubic catheter monthly." The order on the plan of care did not include the size of the suprapubic catheter. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/06/2025. The plan of care dated 03/06/2025 to 06/04/2025 an order for "Urinary catheter as per orders to maintain ability to eliminate urine." The order on the plan of care did not include the size of the catheter. During a joint record review and interview on 04/17/2025, the Director of Nursing confirmed the orders on the plans of care did not include the size of the catheters.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) 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 2 of the 17 (12%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse (RN) provided written patient care instructions for the hospice aide. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/05/2024. The plan of care dated 02/06/2025 to 04/06/2025 included an order for "Hospice Aide 2 times per week." Clinical record review revealed a physician order dated 03/27/2025 for wound care with a wound dressing to a wound on the patient's coccyx. The aide care plan assignment dated 03/24/2025 assigned the aide the task of "bed bath at every visit." The aide care plan did not include updated instructions to the aide related to caring for the wound dressing should the wound dressing on the patient's coccyx become dislodged or wet during the bed bath. CLINICAL RECORD 11: The patient elected the hospice benefit on 02/19/2025. The plan of care dated 02/19/2025 to 05/19/2025 included an order for "Hospice Aide 2 times per week." Clinical record review revealed a physician order dated 02/25/2025 for a Foley catheter. The aide care plan assignment was not updated to include foley catheter care instructions until 04/03/2025. During an interview on 04/17/2025, the Director of Nursing reviewed the records, confirmed the findings, and stated, "There are no wound dressing instructions and the foley catheter care should have been added when the foley catheter was inserted on 02/25/2025."

It is required that hospice aides are supervised by a Registered Nurse 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; and 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 clinical record review and interview. In 10 of 17 (59%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse (RN) made an on-site supervisory visit to the patient's home no less frequently than every 14 days. CLINICAL RECORD 2: The patient elected the hospice benefit on 09/04/2024. The plans of care dated 09/04/2024 to 12/02/2024, 12/03/2024 to 03/02/2025, and 03/03/2025 to 05/01/2025 included an order for "Hospice Aide 2 times per week." Review of the clinical record revealed a hospice aide supervisory visit dated 10/02/2024. The next hospice aide supervisory visit was dated 03/05/2025, a total of 161 days and 147 days outstanding. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/05/2024. The plans of care dated 10/09/2024 to 12/07/2024, 12/08/2024 to 02/05/2025, 02/06/2025 to 04/06/2025 and 04/07/2025 to 06/05/2025 included an order for "Hospice Aide 2 times per week." The first hospice aide visit was dated 09/12/2024. The first hospice aide supervisory visit was dated 03/23/2025, 192 days after the first hospice aide visit and 178 days outstanding. CLINICAL RECORD 7: The patient elected the hospice benefit on 03/24/2025. The plan of care dated 03/24/2025 to 06/21/2025 included an order for "Hospice Aide 1 time per week." There was no documented evidence in the clinical record of hospice aide supervisory visits. CLINICAL RECORD 8: The patient elected the hospice benefit on 12/18/2024. The plans of care dated 12/18/2024 to 03/17/2025 and 03/18/2025 to 06/15/2025 included an order for "Hospice Aide 1 time per week." Review of the clinical record revealed a hospice aide supervisory visit dated 03/05/2025. However, there was no documented evidence of a hospice aide supervisory visit after 03/05/2025, as of the date of record review on 04/17/2025, a total of 43 days and 29 days outstanding. CLINICAL RECORD 9: The patient elected the hospice benefit on 01/23/2025. The plan of care dated 01/23/2025 to 04/22/2025 included an order for "Hospice Aide 2 times per week." Review of the clinical record revealed a hospice aide supervisory visit dated 03/06/2025. However, there was no documented evidence of a hospice aide supervisory visit after 03/06/2025, as of the date of record review on 04/17/2025, a total of 42 days and 28 days outstanding. CLINICAL RECORD 10: The patient elected the hospice benefit on 01/29/2025. The plan of care dated 01/29/2025 to 04/28/2025 included an order for "Hospice Aide 2 times per week." Review of the clinical record revealed a hospice aide supervisory visit dated 03/04/2025. However, there was no documented evidence of a hospice aide supervisory visit after 03/04/2025, as of the date of record review on 04/17/2025, a total of 44 days and 30 days outstanding. CLINICAL RECORD 11: The patient elected the hospice benefit on 02/19/2025. The plan of care dated 02/19/2025 to 05/19/2025 included an order for "Hospice Aide 2 times per week." There was no documented evidence in the clinical record of hospice aide supervisory visits, as of the date of record review on 04/17/2025. CLINICAL RECORD 12: The patient elected the hospice benefit on 11/15/2024. The plans of care dated 11/15/2024 to 02/12/2025 and 02/13/2025 to 05/13/2025 included an order for "Hospice Aide 2 times per week." There was no documented evidence in the clinical record of hospice aide supervisory visits, as of the date of record review on 04/17/2025. CLINICAL RECORD 14: The patient elected the hospice benefit on 11/29/2024. Review of the clinical record revealed a hospice aide supervisory visit dated 03/04/2025. However, there was no documented evidence of a hospice aide supervisory visit after 03/04/2025, as of the date of record review on 04/17/2025, a total of 44 days and 30 days outstanding. CLINICAL RECORD 15: The patient elected the hospice benefit on 10/02/2024. The plans of care dated 10/02/2024 to 12/30/2024 and 12/31/2024 to 01/11/2025 included an order for "Hospice Aide 2 times per week." There was no documented evidence in the clinical record of hospice aide supervisory visits, as of the date of record review on 04/17/2025. During an interview and review of records on 04/17/2025, the Director of Nursing confirmed that hospice aide supervisory visits were not documented by a Registered Nurse (RN) every 14 days. The Director of Nursing explained during the interview that the RN Case Manager completed the supervisory visits but was not documenting them in the EMR [electronic medical record] system and that training was needed.

HCPC.19.I - The hospice designates a registered nurse member of the IDG to: Provide coordination of care; Ensure continuous assessment of each patient’s and family’s needs; Ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. It is required that the hospice designates a Registered Nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by a review of clinical records and interview. In 2 of 9 (22%) clinical records reviewed, the agency failed to ensure that care was provided with respect to following the ordered visit frequencies. Record #65635: Start of care on 12/29/2021 included an order for home health aide (HHA) services 2 times a week. During the week of 2/21/2022, one HHA visit was performed on 2/24/2022 with no documentation of a missed visit for the second HHA visit ordered that week. During the week of 2/28/2022, one HHA visit was performed on 3/3/2022 with no documentation of a missed visit for the second HHA visit ordered that week. Record #54097: Start of care on 4/26/2022 included an order for HHA services one time a week to begin on 5/1/2022. During the week of 5/1/2022, a HHA visit was completed on 5/3/2022. During the week of 5/8/2022, a HHA visit was completed on 5/10/2022. During the week of 5/15/2022, no HHA visits were performed with no documentation of a missed visit. During the week of 5/22/2022, no HHA visits were performed with no documentation of a missed visit. During the week of 5/29/2022, no HHA visits were performed with no documentation of a missed visit. In an interview with the Director of Clinical Services on 6/29/2022, it was confirmed that the care was not provided following the ordered frequencies.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of: the hospice discharge summary described in HCDT 40.I; and the patients record, if requested. This standard was not met as evidenced by review of clinical record, interview and document review. In 1 of 1 (100%) of applicable charts, incomplete information was provided to the receiving Medicare certified facility. Agency policy PC.D20 Discharge from Hospice, reviewed 6/27/2022, stated in part: “When the patient is discharged from hospice (by discharge, transfer or revocation), the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patient's attending physician and any new agency providing care (home care agency, skilled nursing facility, assisted living facility), if applicable. This discharge summary is filed in the clinical record and includes: Discharge orders, instructions, medication profile and allergies, if discharge is other than patient death; Status of patient at time of discharge; Brief description of services provided and ongoing needs that cannot be met; A copy of the patient's current plan of care, including the current drug profile; Any other documentation that will assist in post-discharge continuity of care or is requested by the attending physician or receiving facility”. Record #56859: Clinical record reveals patient was transferred to another hospice on 10/12/2021. The discharge summary information was provided to receiving hospice that did not include required elements as described in HCDT40.I: summary of the patient’s hospice stay, including treatments, symptoms, and pain management; The patient’s current plan of care; The patient’s latest physician orders. Interview with the Director of Clinical Services on 6/27/2022 who stated current EMR discharge summary and agency process does not contain required elements or procedure of providing additional required documents to receiving facility.

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; the patient’s current plan of care; the patient’s latest physician orders; 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 review of clinical record, interview and document review. In 1 of 1 (100%) of applicable charts, incomplete information was provided to the receiving Medicare certified facility. Agency policy PC.D20 Discharge from Hospice, reviewed 6/27/2022, stated in part: “When the patient is discharged from hospice (by discharge, transfer or revocation), the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patient's attending physician and any new agency providing care (home care agency, skilled nursing facility, assisted living facility), if applicable. This discharge summary is filed in the clinical record and includes: Discharge orders, instructions, medication profile and allergies, if discharge is other than patient death; Status of patient at time of discharge; Brief description of services provided and ongoing needs that cannot be met; A copy of the patient's current plan of care, including the current drug profile; Any other documentation that will assist in post-discharge continuity of care or is requested by the attending physician or receiving facility”. Record #56859: Clinical record reveals patient was transferred to another hospice on 10/12/2021. The discharge summary information was provided to receiving hospice that did not include required elements: summary of the patient’s hospice stay, including treatments, symptoms, and pain management; The patient’s current plan of care; The patient’s latest physician orders. Interview with the Director of Clinical Services on 6/27/2022 who stated current EMR discharge summary and agency process does not contain required elements or procedure of providing additional required documents to receiving facility.