Every finding on record at Rhi Magnolia of North Texas

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; 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. CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that the drug profile contained the patient's current prescription and over the counter supplements. Clinical Record 1: The patient elected the hospice benefit on 06/14/2024, with a terminal diagnosis of hypertensive chronic kidney disease stage 5. The Registered Nurse assessment dated 06/14/2024 documented pain as an active problem, and Tylenol for pain relief. During the home visit with the Registered Nurse (RN) (Personnel Record 3) and Director of Clinical Services(Personnel Record 1) on 10/21/2024, the family provided a bag of the patient’s medications. The bag included Morphine 100mg/5ml, 0.25-1ml by mouth every 2 hours as needed for pain or shortness of breath dated 06/15/2024. The medication bag also included Tylenol tablets. The hospice medication profile did not include the Morphine or Tylenol. The Registered Nurse (Personnel Record 3) was interviewed and stated, "Things get missed between admissions and I just need to remember to look at them during my visit."

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. CONTINUED REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure the patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 06/14/2024, with a terminal diagnosis of hypertensive chronic kidney disease stage 5. The Registered Nurse (RN) assessment dated 06/14/2024 documented pain as an active problem, Tylenol for pain relief, and bilateral 3+ edema. The plan of care reviewed 06/14/2024-10/21/2024 did not include interventions related to the patient’s pain and edema. Clinical Record 2: The patient elected the hospice benefit on 04/05/2023, with a terminal diagnosis of senile degeneration of brain. The plan of care dated 07/28/2024 ordered chaplain visits 1wk1, 1every4wk. The Chaplain visit dated 07/30/2024 and 08/13/2024 documented provided prayer and companionship. The plan of care dated 07/28/2024 did not include interventions for the Chaplain. During a joint record review and interview on 10/21/2024, the Director of Clinical Services agreed the interventions were not identified in the plan of care. The Director of Clinical Services also stated, " We have some new staff that need more education on documenting the plan of care properly in the EMR.

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; 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 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the drug profile contained the patient's current prescription and over the counter supplements. Agency policy PC.17 Medication List and Monitoring stated in part, “Agency will maintain a current, accurate list of all prescription and over the counter (OTC) medications taken by the patient. The medication profile will also include dosage, frequency and route.” Clinical Record 2/Home Visit 2: During the home visit observation with the Registered Nurse (RN), the patient discussed the continuation of self-administration of Garlic, Krill, and Dinger oral supplements with the RN. These supplements were not listed on the patient’s medication profile. During interview 10/12/2023, Director of Clinical Implementation/Education reviewed the associated record and stated that the medication profile was incomplete and had since been corrected.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 15 of 19 (79%) clinical records reviewed, the agency did not ensure the comprehensive assessment included an initial bereavement assessment of the needs of the patient's family and other individuals. Agency policy PC.26 stated in part, The initial bereavement risk assessment will be completed as part of the comprehensive health assessment. The bereavement risk assessment will be performed on admission and after death and will reflect an assessment of survivor risk factors associated with patient's death and family needs. Clinical Record 2: The patient elected the hospice benefit on 02/07/2023. The clinical record contained no documented evidence that the initial bereavement risk assessment had been completed. Clinical Record 4: The patient elected the hospice benefit on 02/09/2023. The initial bereavement risk assessment was dated 02/15/2023, 6 days after the patient’s election of hospice benefit. The initial bereavement risk assessment was not completed as part of the comprehensive assessment no later than 5 calendar days after the election of benefit. Clinical Record 5: The patient elected the hospice benefit on 09/09/2023. The initial bereavement risk assessment was dated 10/09/2023, 51 days after the patient’s election of hospice benefit. The initial bereavement risk assessment was not completed as part of the comprehensive assessment no later than 5 calendar days after the election of benefit. Clinical Record 6: The patient elected the hospice benefit on 08/28/2023. The initial bereavement risk assessment was dated 09/18/2023, 21 days after the patient’s election of hospice benefit. The initial bereavement risk assessment was not completed as part of the comprehensive assessment no later than 5 calendar days after the election of benefit. Clinical Record 7: The patient elected the hospice benefit on 08/21/2023. The initial bereavement risk assessment was dated 10/11/2023, 51 days after the patient’s election of hospice benefit. The initial bereavement risk assessment was not completed as part of the comprehensive assessment no later than 5 calendar days after the election of benefit. Clinical Record 8: The patient elected the hospice benefit on 01/23/2023. The initial bereavement risk assessment was dated 09/18/2023, 238 days after the patient’s election of hospice benefit. The initial bereavement risk assessment was not completed as part of the comprehensive assessment no later than 5 calendar days after the election of benefit. Clinical Record 9: The patient elected the hospice benefit on 01/19/2023. The initial bereavement risk assessment was dated 09/25/2023, 249 days after the patient’s election of hospice benefit. The initial bereavement risk assessment was not completed as part of the comprehensive assessment no later than 5 calendar days after the election of benefit. Clinical Record 10: The patient elected the hospice benefit on 05/09/2023. The initial bereavement risk assessment was dated 05/16/2023, 7 days after the patient’s election of hospice benefit. The initial bereavement risk assessment was not completed as part of the comprehensive assessment no later than 5 calendar days after the election of benefit. Clinical Record 11: The patient elected the hospice benefit on 08/16/2023. The clinical record contained no documented evidence that the initial bereavement risk assessment had been completed. Clinical Record 12: The patient elected the hospice benefit on 02/11/2023. The initial bereavement risk assessment was dated 02/18/2023, 7 days after the patient’s election of hospice benefit. The initial bereavement risk assessment was not completed as part of the comprehensive assessment no later than 5 calendar days after the election of benefit. Clinical Record 13: The patient elected the hospice benefit on 04/18/2023. The initial bereavement risk assessment was dated 04/24/2023, 6 days after the patient’s election of hospice benefit. The initial bereavement risk assessment was not completed as part of the comprehensive assessment no later than 5 calendar days after the election of benefit. Clinical Record 15: The patient elected the hospice benefit on 01/18/2023. The initial bereavement risk assessment was dated 04/11/2023, 83 days after the patient’s election of hospice benefit. The initial bereavement risk assessment was not completed as part of the comprehensive assessment no later than 5 calendar days after the election of benefit. Clinical Record 16: The patient elected the hospice benefit on 05/23/2023. The clinical record contained no documented evidence that the initial bereavement risk assessment had been completed. Clinical Record 17: The patient elected the hospice benefit on 07/23/2023. The initial bereavement risk assessment was dated 08/25/2023, 33 days after the patient’s election of hospice benefit. The initial bereavement risk assessment was not completed as part of the comprehensive assessment no later than 5 calendar days after the election of benefit. Clinical Record 19: The patient elected the hospice benefit on 07/05/2023. The initial bereavement risk assessment was dated 07/13/2023, 8 days after the patient’s election of hospice benefit. The initial bereavement risk assessment was not completed as part of the comprehensive assessment no later than 5 calendar days after the election of benefit. During an interview on 10/12/2023, the Director of Clinical Implementation/Education reviewed the associated records and stated that risk assessments were completed outside the 5-day window and missing assessments had since been completed and entered.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure the patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Agency policy PC.6 Plan of Care Process stated in part, “The Plan of Care (POC) includes but is not limited to: Interventions to manage pain and symptoms and identified issues/problems; Measurable outcomes anticipated from implementing and coordinating the POC; Drugs and treatments necessary to meet the needs of the patient.” Clinical Record 7: The patient elected the hospice benefit on 08/21/2023, with a terminal diagnosis of senile degeneration of the brain. The plan of care dated 08/21/2023 also included a diagnosis of Type 2 Diabetes with hyperglycemia exacerbation and included medication orders for Glargine Insulin 15 Units subcutaneous twice daily and Insulin Aspart 100units/milliliter per sliding scale before meals as needed. The start of care comprehensive assessment dated 08/21/2023 completed by the Registered Nurse included documentation that stated, “blood sugar checks completed daily.” The hospice plan of care did not include interventions related to the patient’s diabetic diagnosis or diabetic status. Clinical Record 11: The patient elected the hospice benefit on 08/16/2023 with a terminal diagnosis of breast cancer. The POC dated 08/16/2023 included an order for the skilled nurse frequency twice a week for one week, then once a week for twelve weeks, but did not include interventions for the skilled nurse. The plan of care reviews and updates completed by the interdisciplinary team dated 08/23/2023, 09/06/2023, 09/20/3023, and 10/04/2023 did not include interventions for the nurse. Clinical Record 13: The POC dated 08/12/2023 included orders for skilled nurse frequency once a week for twelve weeks, social worker frequency once a month, and chaplain frequency once a month. The POC did not include interventions for the skilled nurse, social worker, or chaplain. The plan of care reviews and updates completed by the interdisciplinary team dated 08/23/2023, 09/06/2023, 09/20/3023, and 09/28/2023 did not include interventions for the nurse, social worker, or chaplain. During an interview on 10/12/2023, the Director of Clinical Implementation/Education reviewed the findings and stated the interventions had inadvertently been omitted 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 document review, clinical record review, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient's written plan of care included drugs and treatment necessary to meet the needs of the patient. Agency policy PC.6 Plan of Care Process [no date] stated in part, “The Plan of Care (POC) includes but is not limited to: Interventions to manage pain and symptoms and identified issues/problems, Measurable outcomes anticipated from implementing and coordinating the POC, and Drugs and treatments necessary to meet the needs of the patient.” Clinical Record 7: The patient elected the hospice benefit on 08/21/2023, with a terminal diagnosis of senile degeneration of the brain. The plan of care dated 08/21/2023 also included a diagnosis of Type 2 Diabetes with hyperglycemia exacerbation and included medication orders for Glargine Insulin 15 Units subcutaneous twice daily and Insulin Aspart 100units/milliliter per sliding scale before meals as needed. The Insulin Aspart order did not include sliding scale parameters. During an interview on 10/12/2023, the Director of Clinical Implementation/Education reviewed the findings and stated the plan of care order related to monitoring of blood sugars was incomplete.

It is required that 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 3 of 19 (16%) clinical records reviewed, the agency did not ensure care and services were provided in accordance with the plan of care. Agency policy PC.22 Coordination of Care [no date] stated in part, “The IDG [interdisciplinary group] will ensure that the care and services provided are based on all assessments of the patient and family's needs and are provided in accordance with the plan of care. All communications and coordination of care is documented in the clinical record.” Clinical Record 1: The patient elected the hospice benefit on 09/15/2023. The hospice plan of care included an order for Chaplain frequency of visits three times a week for one week, effective 09/17/2023. Clinical record review revealed the Chaplain provided a visit on 09/22/2023 but no other Chaplain visits were provided the week of 09/17/2023. The clinical record contained no documented evidence to explain why the visits were not completed as ordered. Clinical Record 3: The patient elected the hospice benefit on 04/19/2022, with a terminal diagnosis of bone cancer. The hospice plan of care dated 08/12/2023 included an order for skilled nurse frequency once a week. Clinical record review revealed no documented evidence that a nursing visit was provided for the week of 08/12/2023 and no documented evidence to explain why the visit was not made as ordered. Clinical Record 15: The patient elected the hospice benefit on 01/18/2023, with a terminal diagnosis of senile degeneration of the brain. The hospice plan of care dated 08/12/2023 included an order for skilled nurse frequency once a week. Clinical record review revealed no documented evidence that a nursing visit was provided for the week of 08/12/2023 and no documented evidence to explain why the visit was not made as ordered. During an interview on 10/12/2023, the Director of Clinical Implementation/Education reviewed the associated records and stated missed visit entries had since been completed.

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 7 of 16 (44%) clinical records reviewed with aide services provided, the agency did not ensure that the aide provided services as ordered on the plan of care. Clinical Record 1: The patient elected the hospice benefit on 09/15/2023. The aide care plan created by the Registered Nurse (RN) dated 09/15/2023 included a visit frequency of five times a week and assigned the task of shampoo once a week. Review of aide visit notes dated 09/19/2023 through 10/04/2023 revealed the aide documented shampoo at each aide visit. The aide did not follow the aide care plan assignment when the aide performed shampoo at each visit. Clinical Record 3: The patient elected the hospice benefit on 04/19/2022. The aide care plan created by the RN dated 09/24/2023 assigned the task of shampoo three times a week. Clinical record review revealed the aide provided shampoo once a week for the weeks of 09/25/2023 and 10/02/2023 and did not provide shampoo three times a week as assigned. Clinical Record 5: The patient elected the hospice benefit on 09/09/2023. The aide care plan created by the RN dated 09/19/2023 assigned the tasks of shampoo once a week and alternating bed bath and shower. Clinical record review revealed the aide provided shampoo at each aide visit instead of once a week for aide visits dated 09/20/2023, 09/21/2023, 09/23/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/05/2023, and 10/06/2023. The aide documented completion of shower at each visit instead of alternating with a bed bath for visits dated 09/20/2023, 09/21/2023, 09/23/2023, 10/02/2023, 10/03/2023, 10/04/2023, 10/05/2023, and 10/06/2023. Clinical Record 6: The patient elected the hospice benefit on 08/28/2023. The aide care plan created by the RN dated 09/18/2023 assigned the task of shampoo once a week. Clinical record review revealed the aide provided shampoo twice a week for the week of 09/11/2023. The aide documented shampoo on visits dated 09/13/2023 and 09/15/2023. Clinical Record 7: The patient elected the hospice benefit on 08/22/2023. The aide care plan created by the RN dated 09/18/2023 assigned the frequency of aide visits five times a week. Clinical record review revealed the aide provided four visits the week of 10/01/2023. The aide documented visits on 10/03/2023, 10/04/2023, 10/05/2023, and 10/06/2023. The clinical record contained no documented evidence of missed visits. Clinical Record 8: The patient elected the hospice benefit on 01/23/2023. The aide care plan created by the RN dated 01/23/2023 assigned the task of linen change once a week. Clinical record review revealed the aide provided linen change twice a week for the week of 09/25/2023. The aide documented linen change on visits dated 09/25/2023 and 09/29/2023. Clinical Record 10: The patient elected the hospice benefit on 05/09/2023. The aide care plan created by the RN dated 08/07/2023 assigned the frequency of aide visits five times a week. Clinical record review revealed the aide provided four visits the week of 08/15/2023. The aide documented visits on 08/15/2023, 08/16/2023, 08/17/2023, and 08/18/2023. The clinical record contained no documented evidence of missed visits. During an interview on 10/12/2023, the Director of Clinical Implementation/Education reviewed the associated records and stated the aide care plans had not been followed and education would be provided.

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 and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that entries in the patients’ records were appropriately authenticated and dated by the person performing the care/service. Clinical Record 6: The patient elected the hospice benefit on 08/28/2023 with a terminal diagnosis of cerebrovascular disease. Review of the hospice aide visit notes dated 09/25/2023, 09/26/2023 and 09/29/2023 revealed the aide signatures did not include credentials with the associated aide signature and date. Clinical Record 10: Clinical record review of the hospice aide visit notes dated 09/25/2023, 09/26/2023, 09/27/2023, 09/28/2023, 10/02/2023, and 10/03/2023 revealed the aide signatures did not include credentials with the associated aide signature and date. During an interview on 10/12/2023, the Director of Clinical Implementation/Education reviewed the associated records and stated signatures were incomplete and had since been corrected.