Every finding on record at Sangre De Cristo Hospice & Palliative Care

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 clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, it was revealed that the agency did not ensure the interdisciplinary group (IDG) completed an initial assessment no later than 5-calandar days after election of hospice. Clinical Record 15: The patient elected the hospice benefit on 01/18/2024, with a diagnosis of Alzheimer's disease. The plan of care (POC) dated 01/18/2024 - 04/16/2024, ordered a medical social worker (MSW) to assess and evaluate. The MSW documented a phone call to the caregiver on 01/22/2024, that stated, "Left a message for the family, will attempt again on another date." On 01/24/2024 (one day after the 5-calendar day requirement), the social worker documented, "Spoke with patients' spouse on the phone for a very short conversation and spouse declined having regular SW visits." During an interview on 04/04/2024, the Director of Compliance confirmed the finding and stated in part, "The MSW reported that the family had called the office sometime between 01/22/2024 and 01/24/2024, and asked the MSW to call back on 01/24/2024. However, the conversation was not documented."

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 clinical record review, observation and interview. In 2 of 26 (8%) clinical records reviewed, it was revealed that the agency did not ensure that each patient's individualized plan of care identified planned interventions. Clinical Record 1: The initial comprehensive assessment dated 02/06/2024, documented the patient had a terminal diagnosis of Alzheimer's disease, and stated in part, "Chronic aspiration due to esophageal stricture. Suction machine available for PRN (as needed) secretions." The assessment also documented the patient was NPO (nothing by mouth), had a diagnosis of esophageal dyskinesia, and received bolus tube feedings via a percutaneous endoscopic gastrostomy (PEG) tube. The plan of care (POC) effective 02/06/2024, documented the following: a goal that stated, "Patient can describe techniques to prevent aspiration;" and an intervention that stated, "Teach techniques to prevent aspiration." There were no specific interventions related to suctioning, tube feedings, care of the PEG tube, or NPO status. During a joint record review and interview on 04/02/2024, the Director of Compliance confirmed the finding and stated in part, "The interventions were not modified to meet the specific needs of the patient." Clinical Record 9: The patient elected the hospice benefit on 07/27/2023, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD), and a comorbidity of chronic aspiration. The initial comprehensive assessment dated 07/27/2023, documented the patient had chronic aspiration due to an anatomical deformity. The nursing assessment dated 07/28/2023, documented in part, "Patient just had something to drink and is having trouble swallowing." The POC dated 07/27/2024 - 10/24/2024, did not include specific interventions for aspiration precautions. During a joint record review and interview on 04/03/2024, the Director of Compliance confirmed the finding and stated that the POC should have included aspiration precautions.

It is required that each patient's individualized written plan of care: includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 26 (8%) clinical records reviewed, it was revealed that the agency did not ensure that each patient's individualized plan of care included measurable outcomes. Clinical Record 7: The patient elected the hospice benefit on 02/02/2024, with a primary diagnosis of hepatocellular carcinoma. The certification of terminal illness (CTI) and the initial comprehensive assessment dated 02/02/2024, stated in part, "Patient was also found to have C-diff and started on antibiotics." Multiple nursing assessments documented the RN and caregiver concerns of diarrhea, and patient being very sore due to the diarrhea. Communication dated 03/10/2024, documented the patient was transferred to the emergency department for evaluation of diarrhea and rectal tube placement. The plan of care (POC) effective 02/02/2024 - 05/01/2024, included the following intervention: "Assess gastrointestinal status including bowel sounds and bowel elimination; and assess bowel management regimen; modify as needed." There were no measurable outcomes or goals documented for these interventions. During a joint record review and interview on 04/02/2024, the Director of Compliance confirmed there were no goals documented for the patient interventions. Clinical Record 9: The patient elected the hospice benefit on 07/27/2023, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD), and a comorbidity of chronic aspiration. The initial comprehensive assessment dated 07/27/2023, documented the patient had chronic aspiration due to an anatomical deformity. The nursing assessment dated 07/28/2023, documented in part, "Patient just had something to drink and is having trouble swallowing." The POC dated 07/27/2024 - 10/24/2024, did not include measurable outcomes or goals for aspiration. During a joint record review and interview on 04/03/2024, the Director of Compliance confirmed there were no goals documented for aspiration.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 23 (17%) clinical records reviewed, of patients who received aide services, it was revealed that the agency did not ensure written patient care instructions for a hospice aide were prepared by a registered nurse (RN). Clinical Record 1: The initial comprehensive assessment dated 02/06/2024, documented in part, "Chronic aspiration due to esophageal stricture, the patient was NPO (nothing by mouth), had a diagnosis of esophageal dyskinesia, and receives bolus tube feedings via a percutaneous endoscopic gastrostomy (PEG) tube." The hospice aide care plan, effective 02/06/2024, included the following tasks: shower; bed bath; and oral hygiene. The care plan did not instruct the aide as follows: the patient had a PEG tube; what action(s) to take if the PEG tube site dressing became wet or soiled; the patient was NPO; and the patient was on aspiration precautions. Clinical Record 3: The initial comprehensive assessment dated 03/28/2024, documented that the patient had a gastrostomy tube (G-tube) in place. The aide care plan effective 03/28/2024, included the following tasks: shower; and bed bath. The care plan did not instruct the aide as follows: the patient had a G-tube; and what action to take if the G-tube site dressing became wet or soiled. Clinical Record 18: The initial comprehensive assessment dated 03/20/2024, documented that the patient was diagnosed with malignant neoplasm of the brain, and new onset of seizures. The aide care plan effective 03/22/2024, included the task of shower. The care plan instructed the aide that the patient was on fall precautions, standard precautions, and oxygen precautions. However, the care plan did not instruct the aide regarding seizure precautions. Clinical Record 22: The initial comprehensive assessment dated 01/22/2024, documented that the patient had an Aspire drain intact to the peritoneum. The interdisciplinary team (IDT) meeting dated 03/20/2024, documented in part, "Monitor abdominal distension and pain, drain with Aspire drainage system as necessary." The aide care plan effective 01/23/2024, included the task of shower. The care plan did not instruct the aide of the following: the patient had a drain in place to the abdomen; and precautions needed to be followed during the shower. During an interview on 04/04/2024, the Director of Compliance confirmed the findings, and stated that the aide care plans should include tubes, dressings, diet restrictions, and precautions that could impact how the aide performs the task(s).

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review, observation and interview. In 1 of 26 (4%) clinical records reviewed, it was revealed that the agency did not ensure the record contained physician orders specific for the nutritional needs and treatment of the patient. Clinical Record 1 / Home Visit 1: The initial comprehensive assessment dated 02/06/2024, documented that the patient had a terminal diagnosis of Alzheimer's disease, and stated in part, "Chronic aspiration due to esophageal stricture. Suction machine available for PRN (as needed) secretions." The assessment also documented that the patient was NPO (nothing by mouth), had a diagnosis of esophageal dyskinesia, and received bolus tube feedings via a percutaneous endoscopic gastrostomy (PEG) tube. During the observed home visit on 04/01/2024, the patient had a tube feeding pump and a suction machine at bedside. The registered nurse (RN) reported that the patient continues to receive the tube feedings and had to be suctioned "any time she sneaks in food or fluids." The clinical record did not contain orders for the tube feeding formula or amount, the NPO status, or an order for suctioning. During the interview with the Director of Compliance, on 04/04/2024, it was confirmed that the hospice record did not contain the physician orders for these items. It was reported that the medical director recalled giving a verbal order for the tube feedings, but it was not entered into the record.