Every finding on record at Sapphire Hospice and Palliative Care

It is required that the comprehensive assessment includes consideration of the following factors: bowel regimen when opioids are prescribed. This standard was not met as evidenced by clinical record review and interview. In 4 of 8 (50%) clinical records reviewed for patients with prescribed opioids, the hospice agency did not ensure the comprehensive assessment included consideration of a bowel regimen for the patient. Clinical Record 1: The patient elected the hospice benefit on 02/19/2024. Clinical record review revealed the admission orders included an order for Oxycodone [an opioid medication] 5mg by mouth every six hours as needed for pain. The comprehensive assessment did not include assessment or consideration of a bowel regimen for the opioid medication ordered for the patient and there was no documented evidence in the clinical record that a bowel regimen was ordered for the patient. Clinical Record 2: The patient elected the hospice benefit on 05/16/2024. Clinical record review revealed the admission orders included an order for Tramadol [an opioid medication] 50mg by mouth every six hours as needed for pain. The comprehensive assessment did not include assessment or consideration of a bowel regimen for the opioid medication ordered for the patient and there was no documented evidence in the clinical record that a bowel regimen was ordered for the patient. Clinical Record 3: The patient elected the hospice benefit on 03/28/2024. Clinical record review revealed the admission orders included an order for Oxycodone 5mg by mouth every four hours as needed for pain. The comprehensive assessment did not include assessment or consideration of a bowel regimen for the opioid medication ordered for the patient and there was no documented evidence in the clinical record that a bowel regimen was ordered for the patient. Clinical Record 6: The patient elected the hospice benefit on 10/09/2023. Clinical record review revealed the admission orders included an order for Oxycodone 5mg by mouth three times a day for pain. The comprehensive assessment did not include assessment or consideration of a bowel regimen for the opioid medication ordered for the patient and there was no documented evidence in the clinical record that a bowel regimen was ordered for the patient. During an interview on 06/13/2024, the Director of Nursing agreed that the patients had been prescribed opioids without a bowel regimen.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review, interview, and observation. Review of the agency’s volunteer program and volunteer binder revealed no documented evidence that volunteer services equaled five percent (5%) of the total patient care hours. Agency policy Number PC.V.10, stated in part, volunteers will provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 (five) percent of the total patient care hours of all paid hospice employees and contract staff. During an interview and review of the volunteer program on 06/14/2024, the Volunteer Coordinator confirmed the agency had not recorded the percentage of volunteer hours for day-to-day administrative or direct patient care services provided.

It is required that each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 7 (43%) clinical records reviewed, the hospice agency did not ensure the patient record included an initial plan of care as required by agency policy. Agency policy Number PC.35, Comprehensive Assessments-Updates, stated in part, the hospice shall ensure the development of an initial plan of care, within twenty-four (24) hours of admission to the hospice, based on the initial assessment. Clinical Record 1: The patient elected the hospice benefit on 02/19/2024. Clinical record review revealed no documented evidence that an initial plan of care was developed within 24 hours of hospice admission as required by agency policy. Clinical Record 2: The patient elected the hospice benefit on 05/16/2024. Clinical record review revealed no documented evidence that an initial plan of care was developed within 24 hours of hospice admission as required by agency policy. Clinical Record 5: The patient elected the hospice benefit on 10/09/2023. Clinical record review revealed no documented evidence that an initial plan of care was developed within 24 hours of hospice admission as required by agency policy. During an interview on 06/13/2024, the Director of Nursing stated she did not realize the initial comprehensive assessment form used did not include a plan of care development section.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 4 (50%) clinical records reviewed for patients with live discharge, the hospice did not ensure a copy of the hospice discharge summary was forwarded to the patient’s attending physician. Agency policy Number PC.D.20, Discharge from Hospice Care, stated in part, when the patient is discharged from hospice, the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patient's attending physician. The discharge summary is filed in the clinical record. Clinical Record 4: Clinical record review revealed the Registered Nurse completed the hospice discharge summary on 03/17/2024. There was no documented evidence in the clinical record that the discharge summary was forwarded to the patient's attending physician. Clinical Record 5: Clinical record review revealed the Registered Nurse completed the hospice discharge summary note on 10/19/2023. There was no documented evidence in the clinical record that the patient's attending physician was forwarded a copy of the hospice discharge summary. During an interview on 06/13/2024, the Director of Nursing agreed that there was no documented evidence of the discharge summaries being forwarded to the patients’ attending physicians.