Every finding on record at Riverside Hospital 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 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 clinical record review, interview and observation. 6 of 19 (32%) clinical records reviewed where medication reconciliations were performed revealed the agency did not ensure the medication profile contained the patient's current medications. Clinical Record 16: During the home visit (Home Visit 1) on 6/14/2023 with the registered nurse and the patient (Clinical Record 16) with an election of hospice benefit dated 9/20/2021, a medication profile reconciliation was performed by comparing the agency's medication profile to the patient's medicine bottles. The reconciliation revealed several medications on the medication profile that the patient verbalized he was not taking anymore, which included Colace 100mg by mouth daily as needed for constipation, ketorolac (Toradol) 10 mg by mouth every six hours as needed for moderate pain, senna-docusate 8.6-50mg, one tablet by mouth twice daily as needed for constipation, and melatonin 5mg by mouth daily as needed for insomnia. The patient verbalized taking Mucinex DM daily as needed for congestion however this medication was not listed on the medication profile. Additionally, the medication review revealed the hospice emergency (E-Kit) medications were all expired on 9/21/2022: Tylenol suppositories, Haldol 2mg tablets, Levsin 0.125mg/mL, morphine 20mg/mL concentrated solution, and promethazine 25mg tablets. In an interview on 6/14/2023, the RN Case Manager confirmed the medication profile was inaccurate and that the emergency meds were expired. Clinical Record 9: During the home visit (Home Visit 3) on 6/15/2023 with the registered nurse (RN) and the patient (Clinical Record 9) who resided in a nursing facility, a medication reconciliation was performed by comparing the agency's and the facility's medication profiles. The facility's medication profile documented the bowel medication of polyethylene glycol (MiraLAX) powder packet 17 grams: "give 17 grams orally every 12 hours as needed for constipation; one packet 17 grams by mouth twice a day as needed (PRN) for constipation," with an order date of 4/13/2022 and state date of 7/27/2022. The agency medication profile was missing the polyethylene glycol (MiraLAX) medication. Additionally, the facility profile listed Morphine Sulfate (Concentrate) Solution 20mg/mL, "give 0.5mL by mouth every hour as needed for severe pain, dyspnea---hospice patient," with an order and start date of 4/25/2023. However, the agency profile listed a dosage range of 0.25mL to 0.5mL for the morphine sulfate 20mg/mL concentrate with a start date of 1/27/2023. The findings were reviewed during an interview with the RN Case Manager and the Clinical Manager, and they confirmed the agency medication profile was not correct. Clinical Record 19: During Home Visit (Home Visit 4) on 6/15/2023 with the medical social worker and the patient (Clinical Record 19), a medication reconciliation was performed by comparing the agency's medication profile dated 6/15/2023 and the medicine bottles provided by the daughter. The daughter participated in the review. The reconciliation revealed the blood pressure medication hydralazine 25mg by mouth every eight hours was missing from the medication profile. The daughter verbalized the patient was on the hydralazine medicine and showed the pills in the medication planner. During the record review, a physician order dated 5/14/2023 documented the discontinuation of the hydralazine 25mg because the "patient was not taking" it. The Clinical Manager called the patient's RN Case Manager. The RN Case Manager stated and confirmed that the patient was still taking the medication and needed to take the medicine. Clinical Record 2: Patient with election of the hospice benefit dated 1/6/2022 had a primary diagnosis of squamous cell carcinoma of the left leg and received hospice services at a nursing facility. Wound care medications documented on the medication profile were listed as daily or twice a day as needed (PRN): Dakins with a start date of 2/2/2022 topically daily, sodium hypochlorite topically twice daily as needed with a start date of 1/6/2022, wound cleanser solution (VASHE Cleansing) topically two times a day as needed with the start date of 1/6/2022; wound dressing (TRIAD HYDROPHILIC WOUND EX) topically once daily with a start date of 1/6/2022, but the metronidazole was not found on the medication profile and therefore not included in the medication review. Clinical Record 12: Patient with election of the hospice benefit dated 4/24/2023 had a primary diagnosis of cerebral accident and was NPO due to dysphagia related to the late effects of stroke. The patient received hospice services at a nursing facility. The medication profile listed the medication’s route incorrectly since the patient could not swallow by mouth: Phenergan 25mg by mouth every 4 hours as needed for nausea and vomiting started 4/24/2023. There was no documentation of updated orders for the route of administration for the Phenergan on the patient’s POC. Clinical Record 8: Patient with election of hospice benefit dated 1/5/2023 had a primary diagnosis of rectal cancer with liver metastasis. The patient had an implanted intravenous port documented on the SN Recertification Assessment visit note dated 3/28/2023, which included an "unsuccessful port flush attempted access (x3) three times with (second RN name). Will re-attempt 3/30." The SN Visit dated 3/30/2023 documented the successful flush of the implanted port. There were no physician orders for saline or heparin flushes on the medication profile. During joint record review and interview on 6/16/2023, the Agency Auditor confirmed the physician order and medications for the implanted port maintenance were not included on the POC.

It is required that the hospice designates an Interdisciplinary Group or groups who, inonsultation with the patient's attending physician, prepare a written plan of care (POC) for specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. each patient. The plan of care specifies the hospice care and services necessary to meet the issues with individualization and specificity of patients' plans of care as follows: Failed to develop individualized written plans of care for each patient that included interventions THIS IS A CONDITION LEVEL DEFICIENCY. This Condition of participation was not met as evidenced by review of clinical records,and interview which revealed based on problems identified in the initial and updated comprehensive assessments (53%) [HCPC.21.I/L545]. The cumulative effect of these findings could negatively impact the organization's ability to develop, update, and implement plans of care to ensure services are provided that will meet the care needs of patients.

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, and interview revealed 10 of 19 (53%) clinical records reviewed did not ensure that individualized plans of care included orders and interventions identified in patient assessments. Clinical Record 16: Patient with election of the hospice benefit dated 9/20/2021 had a primary diagnosis of lung mesothelioma. The patient was admitted to the agency with "nonhealing surgical incisions to right posterior flank, with tunneling being treated with ABX at this, Doxycycline 100mg BID," documented on the SN Admission note dated 9/20/2021. Additionally, the SN Hospice Visit note dated 9/24/2021 documented, "patient is up in chair denies pain or dyspnea, wound care performed two surgical wounds. They were cleaned with normal saline and are being packed with sterile gauze, which I added honey to and covered with an ABD..." The LPN Visit note dated 10/4/2021 documented, "patient seen for SN visit this morning for wound dressing change...wound care performed to the left mid-back, drain sites look good, minimal redness noted, very little drainage noted on the bandage that was removed. Repacked with iodoform, covered with ABD pad and tape." The IDT Meeting 10/5/2021 documented the "patient antibiotic finished. The patient continues to get wound care three times a week, patient is taking medications and has relief." The SN Visit note dated 11/17/2021 documented the surgical wound healed. The written plan of care (POC) effective from 9/20/2021 through 12/18/2021 did not include documentation of orders for the wound care that was provided. An interview with the Agency Manager on 6/15/2023 confirmed wound care orders and treatments were missing from the plan of care, as she was the RN Case Manager for the patient during that time. A discharge summary from the hospital was requested by the site visitor to determine the ordered wound care treatment. However, orders were not located by the agency. Clinical Record 2: Patient with election of the hospice benefit dated 1/6/2022 had a primary diagnosis of squamous cell carcinoma of the left leg and received hospice services at a nursing facility. Registered Nurse (RN) Hospice Admission assessment dated 1/6/2022 documented "Patient's skin is pink, has 26cm x11cm x 0.5cm wound to the left lower leg, wound care was provided as ordered, cleaned wound with Dakin’s, applied metronidazole cream, and covered with adaptic AD wrap with Kerlex from the ankle to knee." The POC effective 1/6/2022 did not include documentation of orders for the wound care that was provided. The RN Visit dated 6/29/2022 documented under the integumentary section: "Left leg wound due to squamous cell cancer has copious amounts of drainage; Nurse Mentor and this nurse consulted on wound care and a new wound treatment plan was documented: "Cleanse wound with Dakin’s, apply alginate dressing, apply charcoal dressing, cover with ABD, secure with Kling and stockinette." There was no documentation of an order written and sent to the physician for this wound care treatment. The IDT note by RN dated 7/5/2022 documented in the section for "skin integrity" has a "purulent wound with a large amount of green drainage from the left wound from cancer. It encompasses 80% of the leg." An order dated 5/14/2022 signed by the facility physician documented "clean lesion to left lower leg with Dakin's-soaked gauze. Apply calcium alginate to wound bed. Cover the wound with charcoal dressing. Apply ABD to the wound. Wrap the leg from the toes to the knee with Kerlex. Cover the entire dressing with stocking net, daily and as needed (PRN)" This facility wound treatment order was not documented on the hospice plan of care. The record review revealed no evidence of wound care orders on the hospice plan of care for wound care treatments that were provided. Clinical Record 4: Patient with election of the hospice benefit dated 3/22/2022 had a primary diagnosis of ovarian cancer and required paracentesis for fluid management of ascites and comfort. The patient had an Aspira drain inserted at the hospital on 4/4/2022. The written POC was not updated with orders for using and maintaining the Aspira catheter to drain to treat ascites. RN Visit on 4/5/2022 documented the status post drain insertion and the LPN visit dated 4/8/2022 documented the drain site dressing was changed. The SN Visit dated 4/11/2022 by LPN documented, “drained the PleurX this morning, got 500ML of dark rust colored fluid. There was a notable decrease in her abdomen, and the patient stated that she can feel the difference." Additionally, during the following skilled nursing visits, the nurses documented the dates and amounts of drainage on: 4/25/2022, 1000ml was drained; 5/5/2022, 2000ml was drained; 5/12/2022, 2000 ml was drained; 5/18/2022, 1000 ml was drained; 5/20/2022, 2000ml was drained; 5/26/2022, 2500ml was drained. After 5/26/2022, the patient was actively dying and there was no further draining of the catheter. There was no evidence in the clinical record that the agency contacted the physician regarding the amount of drainage or the color of the drainage. The patient expired on the agency's service on 6/12/2022. The POC effective 3/22/2022 did not include documentation of physician orders related the amount to drain using aseptic technique, the dressing change and site cleaning and maintenance, and the frequency of draining/dressing even if PRN. The interview with the agency clinical managers during the joint record review on 6/15/2023 confirmed there were no physician orders on the POC for the using the Aspira drain and draining the patient. Clinical Record 6: Patient with an election of hospice benefit dated 12/7/2022 had a primary diagnosis of Alzheimer's and a decubitus wound to the right hip. The SN Hospice Admission note dated 12/7/2022 documented a stage 3 right hip decubitus. The RN documented, "Wound care provided to right hip; barrier cream applied covered with Allevyn, surrounding area is red, small 3cm x 3cm, open area noted." The LPN visit note dated 12/29/2022 documented "patient was changed and cleaned up, bandage on the right hip was changed as well; area is healed just with minimal redness, zinc cream applied, and foam dressing applied for protection; barrier cream applied to the patient's bottom." The RN visit note dated 1/3/2023 documented "stage 3 to right hip healed." The zinc oxide barrier cream was also not listed on the medication profile. The POC effective 12/7/2022 did not include documentation of wound care orders for the wound care that was provided. During the joint record review with the agency Clinical Manager on 6/15/2023, it was confirmed there were no plan of care orders for the wound care provided to the right hip wound. Clinical Record 15: Patient with election of the hospice benefit dated 5/20/2023 had a primary diagnosis of Alzheimer's and a history of frequent falls. The SN admission note dated 5/20/2023 documented the patient had fallen greater than five times in the last six months and had an emergency room visit on 5/11/2023 for an unwitnessed fall. The POC dated 5/20/2023 did not include documentation of fall prevention and home safety interventions in the Safety Measures field. The Agency Auditor confirmed on 6/16/2023 that fall prevention and home safety interventions were not included on the POC. . Clinical Record 11: Patient with election of the hospice benefit dated 3/22/2023 had a primary diagnosis of pulmonary fibrosis. The RN Admission note dated 3/22/2023 documented the patient wore CPAP 24/7 with 6L of oxygen attached to the CPAP machine. The medication profile recorded oxygen therapy with a start date of 5/28/2018; however, there were no details of the oxygen flow amount on the POC. Additionally, the DME section of the POC listed the "CPAP" without any other information and two 10L concentrators (one for bedroom, one for living room) with backup tanks. The POC did not include documentation of oxygen flow rate and frequency, and CPAP order settings. Clinical Record 9: Home Visit 3 on 6/16/2023 with the registered nurse (RN) and patient that resided in a nursing facility. The patient had a primary diagnosis of penile cancer and severe lymphedema to the lower extremities. The agency wound care treatment order included documentation of the incorrect location and missing the zinc barrier cream compared to the facility order. The agency wound care order with a start date of 1/26/2023 stated "wound care location right outer shin/ankle - Cleanse site with Vashe wound cleanser. Leave Vashe moistened gauze in place for five (5) minutes. Pat dry. Apply oil emulsion gauze to open/weeping lesions. Cover with Exu-Dry (if Exu-Dry not available, use ABD pads). Wrap leg with "stretch bandage" every other day and as needed until healed." The facility wound treatment order with a start date of 4/28/2023 stated "left and right medial lower extremities: cleanse open area with NS (normal saline) and pat dry. Apply zinc cream to surrounding skin to protect from moisture. Apply oil emulsion dressing to wound bed. Cover wound with Exu-Dry and wrap LLE with gauze and Coban. Change every two (2) days and as needed. If Exu-Dry is not available, ok to use ABD pad." The hospice POC did not include current wound care orders for treatment of the patient’s lower extremity wounds. The findings were reviewed and confirmed with the RN Case Manager and Clinical Manager after the home visit visit on 6/15/2023. Clinical Record 12: Patient with election of the hospice benefit dated 4/24/2023 had a primary diagnosis of cerebral accident and was NPO due to dysphagia related to the late effects of stroke. The patient received hospice services at a nursing facility. The SN Admission note dated 4/24/2023 documented the patient had dysphagia, and NPO diet, and PEG tube feeding: Nutren 2.0 bolus 250mL every 4 hours. There were no physician orders for the tube feedings including the frequency of the tube feedings on the POC. The last RN visit note dated 6/13/2023 documented that the patient received tube feeding four times daily and tolerated it well. The last IDT Meeting dated 6/14/2023 documented tube feeding every 6 hours instead of every 4 hours. Additionally, the agency's medication profile listed the medication’s route incorrectly since the patient could not swallow by mouth: Phenergan 25mg by mouth every 4 hours as needed for nausea and vomiting started 4/24/2023. There was no documentation of updated orders for the frequency of tube feedings and the route of administration for the Phenergan was not correct on the patient’s POC. During the joint record review with the agency clinical managers on 6/16/2023, it was confirmed the tube feedings were missing from the POC. Clinical Record 14: Patient with election of the hospice benefit dated 5/7/2023 had a primary diagnosis of prostate cancer. The SN Admission note dated 5/7/2023 documented the patient had a "dry, stage II to left inner buttock uses Medi honey, and supplies needed 3x3 foam dressings sacral dressing, supplied patient with zinc barrier cream." There was no evidence or documentation of physician orders entered for wound care treatment or for the use of Medi honey or zinc oxide for wound care on the POC. In an interview during joint record review on 6/16/2023, the Agency Auditor confirmed there was no wound care order. Clinical Record 8: Patient with an election of hospice benefit dated 1/5/2023 had a primary diagnosis of rectal cancer with liver metastasis. The patient had an implanted intravenous port documented on the SN Recertification Assessment visit note dated 3/28/2023, which included an "unsuccessful port flush attempted access (x3) three times with (second RN name). Will re-attempt 3/30." The SN Visit dated 3/30/2023 documented the successful flush of the implanted port. There were no physician orders for the maintenance of the implanted port on the POC and no documentation of saline or heparin flushes on the medication profile. During joint record review and interview on 6/16/2023, the Agency Auditor confirmed there were no flush orders on the POC.

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, document review, interview and observation. 3 of 15 (20%) clinical records reviewed where hospice aide services were accepted revealed a lack of clear and specific written instruction for the aide assignment, thus leaving the aide to make decisions outside the aides' scope of practice. Clinical Record 5: The patient with an election of hospice benefits dated 9/23/2022 had a primary diagnosis of Alzheimer's disease and received hospice aide services three times weekly (3xweekly.). The patient was not able to make decisions about their care. The hospice aide care plan dated 9/23/2022 had two types of baths assigned to the hospice aide: "aide assist with bath every visit: assistance with shower or bed bath." In the following hospice aide visit notes dates, the hospice aide documented completing the assigned task that included both bath types and did not specify which bath type was completed: 9/27/2022, 9/30/2022, 10/3/2022, 10/5/2022, 10/12/2022, 10/14/2022, 10/25/2022, 10/27/2022. The hospice aide did not receive specific instructions regarding the type of bath to provide. Clinical Record 9: During Home Visit 3 on 6/15/2023 with the registered nurse (RN) and the patient who resided in a long-term care nursing facility, the patient was chairbound and unable to stand for any extended period. The hospice aide care plan dated 1/26/2023 documented a shower was to be provided every visit. The patient was interviewed and stated he refused to take a shower in the facility's shower room because he gets too cold, and he only allowed a seated sponge bath in his chair. The aide plan of care did not get updated to reflect the change in the type of bath the patient was to receive. On 6/16/2023, the Clinical Manager called the routine hospice aide, who confirmed the patient received a basin sponge bath in his recliner. Clinical Record 18: During Home Visit 2 on 6/15/2023 with a hospice aide and a patient who resided in an assisted living facility, the hospice aide provided a seated sponge bath in the patient's bathroom. The hospice aide care plan dated 11/14/2022 documented "assistance with a shower" and "assist patient with shampooing hair" at each visit. During the interview with the hospice aide, she stated the patient got claustrophobic in the shower and refused to get into the shower. The hospice aide stated the patient's daughter and registered nurse were aware of the refusal, however, the hospice aide care plan was not updated. The patient had only received one failed attempt of a shower and the rest have been seated sponge baths since November 2022. Additionally, the patient was receiving a hair shampoo weekly, not every visit. The aide POC did not get updated to reflect the change in the type of bath and shampoo frequency.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. 4 of 15 (27%) records reviewed where the patients received hospice aide services revealed the registered nurse (RN) was not notified of assigned tasks that were not completed by the hospice aide. Clinical Record 18: The patient with an election of hospice benefits dated 11/14/2022 received hospice aide services twice weekly at an assisted living facility. The hospice aide care plan dated 11/14/2022 documented the assigned task of shampooing to be completed every visit. The hospice aide visit notes dated 6/7/2023; 6/5/2023; 6/1/2023; 5/25/2023 documented that the patient refused to shampoo, but there was no documented evidence in the clinical record that the aide reported to the RN that the shampoo was not provided as assigned. Clinical Record 2: The patient with an election of hospice benefits dated 1/6/2022 received hospice aide services at a nursing facility twice weekly. The hospice aide care plan dated 1/6/2022 included the assigned task of shampoo to be completed every visit. The following hospice aide visit notes documented the patient refused to be shampooed, but there was no documentation in the clinical record or evidence that the RN was notified: 1/24/2022, 1/27/2022, 1/31/2022, 2/2/2022, and 2/7/2022. Clinical Record 3: The patient with an election of hospice benefits dated 8/15/2022 received hospice aide services three times weekly. The hospice aide care plan dated 8/15/2022 documented all assigned tasks to be completed every visit. In the hospice aide visit notes dated 9/30/2022 and 9/23/2022, the hospice aide recorded the patient refused to have the bed linens changed and shaved, but there was no documented evidence that the RN was notified. The hospice aide visit notes dated 9/26/2022, 9/19/2022, 9/16/2022, 9/14/2022, 9/12/2022, 9/9/2022, 9/6/2022, included documentation that the patient refused bed linens changed, however there was no documented evidence that the hospice aide reported the refusals to the RN. Clinical Record 19: The patient, with an election of hospice benefits dated 4/28/2023, received hospice aide services twice weekly, effective 5/15/2023, for ten weeks. The hospice aide care plan dated 5/15/2023 documented all assigned tasks to be completed every visit: Making the bed, cleaning patient area, changing bed linens, shampooing hair, nail care, skin care, oral care, hair care, assisting with dressing, assistance with shower, and assist the patient to the bathroom. The hospice aide notes dated 6/1/2023, 5/30/2023, and 5/22/2023 documented that the patient refused all assigned tasks except shampooing hair, making the bed, and cleaning the patient area. There was no documentation or evidence that the RN was notified of the incomplete assigned tasks. In an interview during the record reviews on 6/16/2023, it was confirmed by the Agency Auditor and Clinical Manager that the hospice aides did not notify the RN when assigned tasks were not completed.

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. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by document review and interview. Website reference of the State's Durable Do Not Resuscitate Program stated, “Durable Do Not Resuscitate Order” means a written physician’s order issued pursuant to §54.1-2987.1 to withhold cardiopulmonary resuscitation from a particular patient in the event of cardiac or respiratory arrest. For purposes of this program, cardiopulmonary resuscitation shall include cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, and related procedures. Review of the agency's sample admission packet revealed a blank State form with the medical director's signature pre-signed on the "Durable Do Not Resuscitate Order" State form. Five additional admission packets were reviewed, all having the same pre-signed physician order State form. An interview with the clinical manager on 6/15/2023 confirmed the State form was photocopied with the physician's signature and inserted into the admission packets. During record review and interview on 6/15/2023 with the Clinical Manager, the pre-signed paper was found in the clinical records. The Clinical Manager immediately removed the pre-signed form and began getting an original document signed by the patients/caregivers and attending physicians. Reviewing the agency's sample admission packet revealed a blank State form with the medical director's signature pre-signed on the "Durable Do Not Resuscitate Order" State form. Five additional admission packets were reviewed, all having the same pre-signed physician order State form. An interview with the clinical manager on 6/15/2023 confirmed the State form was photocopied with the physician's signature and inserted into the admission packets. During the record review, the paper was found in the clinical records. The clinical manager immediately removed the pre-signed form and began getting an original document signed by the patients/caregivers and attending physicians. Website reference of the State's Durable Do Not Resuscitate Program: “Durable Do Not Resuscitate Order” means a written physician’s order issued pursuant to §54.1-2987.1 to withhold cardiopulmonary resuscitation from a particular patient in the event of cardiac or respiratory arrest. For purposes of this program, cardiopulmonary resuscitation shall include cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, and related procedures.