Every finding on record at Suncrest Hospice Richmond, LLC

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 measures 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, document review, interview, and observation. Agency policy #2-004 "Medication Profile" (revised June 2022) stated in part, "Patients receiving medications administered by (agency name) Hospice will have a current, accurate medication profile in the clinical record." In 1 of 19 (5%) clinical records reviewed and home visits observed, the agency did not ensure that the drug profile included the patient's current medications. Clinical Record 1/Home Visit 1: The patient elected hospice care on 08/29/2024 with a diagnosis of senile degeneration of the brain. The patient resided in an assisted living facility (ALF). During the home visit with the Registered Nurse (RN) [Personnel Record 6] on 10/01/2024, the patient's hospice medication profile and ALF medication administration record were reviewed. The ALF medication administration record documented Lorazepam Intensol 2mg/ml, give 0.25ml under the tongue every four hours as needed for anxiety beginning 08/29/2024. The hospice medication profile documented Lorazepam 1 mg oral tablet; take one (1) tab orally every four (4) hours as needed for anxiety/shortness of breath beginning 08/29/2024. The interdisciplinary group meeting (care plan update) documentation dated 09/19/2024 documented, "Medical Director: medications reviewed, no changes made at this time. MD (Medical Director) agrees with current POC (plan of care)." A clinical record review revealed that the hospice medication profile did not reflect the current form and dose of Lorazepam the facility administered to the patient. During an interview and the joint home visit observation on 10/01/2024, the Director of Clinical Services confirmed that the hospice medication profile did not accurately reflect the medications the facility administered to the patient.

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, document review, and interview. Agency policy #9-017, “The Plan of Care” (revised June 2022), stated in part, “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. This plan will focus on identified problems, goals, and interventions.” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient’s individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and comprehensive assessments. Clinical Record 8: The patient elected hospice care on 01/24/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The Registered Nurse (RN) identified and documented a right posterior arm/elbow wound during the assessment dated 08/30/2024. In addition, the RN documented that wound care was provided “cleansed with normal saline, Medihoney applied and covered with an Optifoam.” The patient’s plan of care and interdisciplinary group meeting updates (the updated plan of care) effective 09/05/2024 and 09/18/2024 did not document goals or interventions related to the right posterior arm/elbow wound identified on 08/30/2024. During the joint record review and interview on 10/01/2024, the Director of Clinical Services confirmed the plans of care did not reflect patient and family goals and planned interventions for the right posterior arm/elbow wound.

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 and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient's clinical record contained physician orders for care and services. Clinical Record 8: The patient elected hospice care on 01/24/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). During the assessment on 08/30/2024, the Registered Nurse (RN) identified a right posterior arm/elbow wound. The RN documented "cleansed with normal saline, Medihoney applied and covered with an Optifoam." A review of the clinical record revealed no evidence of a documented physician's order for the wound care provided. During the joint record review and interview on 10/01/2024, the Director of Clinical Services confirmed the plans of care did not include orders for the wound care.

Based on staff interview and document review, it was determined the agency failed to promote and protect all patients' rights. --- The hospice failed to appropriately implement advance directives to include durable do not resuscitate orders (see L503). The hospice failed to provide adequate pain and symptom management to patients (see L512). The cumulative effect of this systemic problem resulted in the hospice programs inability to inform, promote, and protect patient rights.

Based on staff interview and document review, it was determined the hospice failed to ensure each patient's advance directive to include Do Not Resuscitate orders was documented and implemented appropriately in one (1) of five (5) medical records reviewed in the survey sample. Medical record #2. --- Findings: The agency's admission package was reviewed 11/06/23. The admission package contained a presigned, blank Virginia Department of Health Durable Do Not Resuscitate Order (DDNR) document. The document contained a photocopy of the physician's signature. The boxes indicating whether the person was capable of making an informed decision and information related to advance directives were blank/not filled out despite the form already containing a physician signature. The DDNR reads in part: Physicians Order I, the undersigned, state that I have a bona fide physician/patient relationship with the patient named above. I have certified in the patients medical record that he/she or a person authorized to consent on the patients behalf has directed that life-prolonging procedures be withheld or withdrawn in the event of cardiac or respiratory arrest. The instructions for completing the DDNR read in part: f. The physician name should be clearly printed and the form signed...(AuthorizedDurableDNRForm-2017.pdf (virginia.gov) Five (5) medical records were reviewed 11/06/23-11/08/23 with the Regional Director of Clinical Operations (staff member #3) assisting in the navigation of the electronic record. Upon review of medical records, it was determined the medical record for patient #2 contained a DDNR form that was completed to include the photocopied physician's signature. During record review, staff member #3 confirmed that blank DDNRs containing photocopied physician's signatures were present in the admission package and the patient record. The medical record for patient #2 contained no evidence that a physician ever discussed the patient's resuscitation preferences, the alternatives available for response in the event of cardiac or respiratory arrest, when the Durable DNR Order can be followed, or how to and who may revoke the Durable DNR to the patient. Staff member #7 (Senior Director of Clinical Quality) was asked on 11/08/23 if the agency had a policy related to physicians photocopying signatures on blank DDNRs. Staff member #7 confirmed the agency did not have a policy to support this practice.

Based on staff interview and document review, it was determined the agency failed to ensure each patient received effective pain and symptom management in two (2) of five (5) medical records reviewed in the survey sample. Medical record #'s 3 and 4. --- Findings: Five (5) medical records were reviewed with the Regional Director of Clinical Operations (staff member #3) assisting in the navigation of the electronic record. The medical record for patient #3 contained documentation that the patient was admitted to the hospice on 08/18/23 with a terminal diagnosis of TIA (transient ischemic attack). The patient was ordered a Fentanyl patch for pain on 08/18/23. Clinical documentation indicated the patches were ordered from the pharmacy after the "cut off time" and would not be sent to the patient's facility until 08/22/23. The clinical record indicated the patient had morphine available for pain control while waiting for the Fentanyl patch to be delivered. The clinical record did not contain documentation that the patient's physician was notified of the delay in obtaining the Fentanyl or whether administering Morphine in lieu of the Fentanyl provided adequate pain control for the patient. On 08/22/23 the patient's daughter called the hospice at 8:37 PM stating the facility did not have the patient's medications. The on call nurse documented that the hospice contacted the patient's hospice nurse who stated the facility did have the medication. On 08/23/23 the hospice received another call stating the patient did not have their Fentanyl patch. The on call nurse called the patient's facility. The facility stated the Fentanyl patches were available. The first time the clinical documentation indicated the patient had a Fentanyl patch for pain was on 08/28/23, ten days after the order was written. The documentation in the clinical record did not clearly indicate when the Fentanyl patches were received by the facility or when the patient first was administered the patch. An interview was conducted with patient #3's nurse (staff member #6) on 11/06/23. Staff member #6 stated that they only cared for patient #3 for a short time. Staff member #6 recalled ordering a Fentanyl patch for the patient but could not recall how long the patient went without the Fentanyl patch. The medical record for patient #4 contained documentation that the patient was admitted to hospice services on 05/02/23. The record contained nursing documentation of multiple instances of patient complaints of severe dyspnea. The patient rated their dyspnea a 7-8 on a 1-10 numeric scale on 10/18/23, 10/30/23, 11/02/23, and 11/06/23. The medical record contained no documented interventions for dyspnea management, no follow up for severe dyspnea, and no documentation of a patient stated goal for level of dyspnea. The patient did have orders for lorazepam and morphine as needed for shortness of breath, but there was no documentation that these medications were administered and/or that the patient refused to take them. The patient's current care plan and Interdisciplinary Team Meeting notes were reviewed and these documents failed to contain interventions directed toward the patient's dyspnea. An interview was conducted with patient #4's nurse (staff member #5) on 11/06/23. Staff member #5 stated that patient #4 experienced severe shortness of breath. The patient oftentimes could only speak one to two words and took over an hour to eat meals because of rest breaks needed due to breathing concerns. Staff member #5 stated that that the patient's dyspnea was "getting worse." The surveyor asked staff member #5 what interventions or medications were in place to relieve the patient's dyspnea. Staff member #5 initially answered Tylenol, (ordered for pain management and not dyspnea) and then stated that the patient refused to take anything for dyspnea. The patient did not want to feel tired from side effects from medication and was satisfied with the level of dyspnea the patient was currently experiencing. The surveyor asked if the hospice physician or the interdisciplinary team had discussed any other non-pharmacological interventions or treatments for the patient. Staff member #5 stated that the patient lives in a facility and the hospice physician was not permitted to write orders there. Staff member #5 stated all orders must come through the facility physician. No documentation in patient #4's medical record indicated hospice staff had informed the facility physician of the patient's continued dyspnea. No documentation reviewed indicated the interdisciplinary team discussed issues obtaining orders from the facility physician, A home visit was conducted to patient #4 on 11/08/23. On arrival, patient #4 was visibly short of breath and at times was unable to speak due to shortness of breath. Patient #4 indicated they had "bad," "terrible" pain in the arm and shoulder and "severe" shortness of breath, but that patient had difficulty with quantifying the symptoms on a numeric scale. The hospice nurse (staff member #5) briefly reviewed medications available to the patient for symptom management. The patient stated they did not want to feel sleepy and did not want anything stronger than Tylenol. The nurse offered no non-pharmacologic measures to the patient for shortness of breath or pain management. During record review, staff member #3 confirmed the hospice's expectation for symptom management included documenting the patient's goal, whether or not the goal was being met, introducing or modifying treatments if a patient was experiencing inadequate symptom relief, documenting the problem in the care plan and with the Interdisciplinary Group (IDG).

Based on staff interview and document review it was determined the agency's Interdisciplinary Group (IDG) responsible for the patient's plan of care and coordination of services failed to create individualized plans of care (refer to L545); failed to ensure care plans contained all interventions necessary to manage patient symptoms (refer to L546); failed to ensure the plans of care contained measurable goals and outcomes for problems (refer to L548); failed to document patient's progress toward goals (refer to L553); and failed to coordinate care within the hospice agency and with other care providers (refer to L558). --- The cumulative effect of the agency's Interdisciplinary Group's not performing and documenting the above noted IDG responsibilities for each patient and their plan of care according to the Conditions of Participation resulted in the overall failure of the agency to develop and implement a comprehensive, multidisciplinary plan of care that accurately reflected the current and ongoing needs of the patient and family related to their terminal diagnosis.

Based on staff interview and document review, it was determined the agency failed to individualize each patient's plan of care. Specifically, the care plans failed to include patient and family goals and interventions based on problems identified during comprehensive assessments in five (5) of five (5) clinical records reviewed in the survey sample. Clinical record #'s 1, 2, 3, 4, and 5. --- Five (5) clinical records were reviewed with the Regional Director of Clinical Operations (staff member #3) assisting in the navigation of the electronic record. The clinical record for patient #1 contained documentation that the patient was living in a skilled nursing facility and receiving hospice services for extreme protein calorie malnutrition, oral ulcers, and frequent UTIs (urinary tract infections). The patient's plan of care contained no patient or family stated goals. Included on the plan of care were nineteen (19) nursing interventions that the nurse was to perform every visit. One intervention reads, "Encourage patient to utilize morphine and lorazepam per MD order due to risk of over-use" despite the fact that patient resides in a skilled nursing facility and does not manage their own medications. The care plan contained an order to insert and maintain an indwelling urinary catheter every 30 days per policy. During record review, staff member #7 confirmed patient #1 did have an indwelling urinary catheter, but the agency had no policy related to the frequency of inserting indwelling urinary catheters. The patient's plan of care included an intervention to assess mouth pain and the as needed use of Lidocaine mouthwash. Each visit the nurse marked the intervention completed but never indicated if the mouthwash was needed or not. The clinical record for patient #2 contained documentation that the patient was receiving hospice services for chronic obstructive pulmonary disease. The patient's plan of care contained no patient or family stated goals. The plan of care contained twenty-two interventions for the nurse to complete at each visit. Three (3) interventions related to initiating a referral for a hospice aide. These interventions remained on the plan of care for the certification period 10/07/23-12/05/23. The referral for the hospice aide was completed 04/10/23, approximately seven months earlier. The current plan of care contained nineteen (19) goals for nursing. All nursing goals had the same target completion date of 12/05/23. The clinical record for patient #3 contained documentation that the patient was admitted to hospice services for a terminal diagnosis of transient ischemic attack. The plan of care contained twenty-one (21) interventions to be performed by the nurse each visit. The care plan contained no patient stated goals. The goals for the aide, chaplain, interdisciplinary team, medical social worker, and skilled nurse all had the same estimated completion date of 11/15/23. The plan of care contained an order for the following: Change Foley catheter as ordered: Insert Foley catheter as ordered:. The plan of care contained no further orders related to changing or inserting the catheter. The patient's plan of care for the time period of 09/29/23 to 11/27/23 was reviewed and contained orders for wound care for a pressure ulcer to the buttocks and an abrasion on the head. A home visit was conducted with patient #4 on 11/08/23 and no dressing or abrasion was noted to the patient's head. The surveyor asked the skilled nurse about the patient's wounds during the home visit. The patient's nurse confirmed the wounds had healed and no wound care was currently ordered. All skilled nursing goals on the care plan contained the same target completion date of 11/27/23. The plan of care contained thirty-two (32) nursing interventions to be performed each nursing visit. The surveyor was present during the entirety of the nurse visit on 11/08/23 and eleven (11) of the thirty-two (32) interventions were not performed. Four (4) of the interventions on the plan of care would have been impossible for the nurse to perform as they related to wound assessment of a wound no longer present. Per discussion with the patient during the home visit, the patient did not want to utilize lorazepam or morphine for shortness of breath. No indication of the patient's preference for non-pharmacologic treatment of dyspnea was documented on the plan of care. The patient's medical record contained multiple instances of documentation of the patient experiencing severe dyspnea. During an interview on 11/06/23 the patient's nurse stated the patient was satisfied with their current level of dyspnea (7-8 on a 1-10 numeric scale). The plan of care did not reflect the patient stated goal for dyspnea. The plan of care for patient #5 contained twenty-seven (27) nursing interventions to be completed by the nurse each visit. All nursing goals on the plan of care contained the same target completion date of 12/05/23. One goal was documented as, "Patient will be pain free or verbalize an acceptable pain level with current pain regimen." the care plan did not contain documentation of what an acceptable pain level for the patient was. An interview was conducted with staff member #4 (the Assistant Director of Nursing) on 11/08/23 who confirmed that the patient's plans of care were not individualized to the patient and also acknowledged that the number of nursing interventions was excessive, and it was likely not possible to accomplish all tasks on the plans of care. Staff member #4 stated that the agency had recently begun auditing charts and plans of care and conducting education sessions with staff to address concerns identified with patient specific care planning and documentation.

Based on clinical record reviews and information collected during interviews at home visits and with agency staff, it was determined that the hospice failed to develop an individualized written plan of care for each patient that included interventions to manage pain and symptoms in one (1) out of five (5) clinical records reviewed in the survey sample: clinical record #4. --- Findings: Five (5) medical records were reviewed with the Regional Director of Clinical Operations (staff member #3) assisting in the navigation of the electronic record. The medical record for patient #4 contained documentation that the patient was admitted to hospice services on 05/02/23. The record contained nursing documentation of multiple instances of patient complaints of severe dyspnea. The patient rated their dyspnea a 7-8 on a 1-10 numeric scale on 10/18/23, 10/30/23, 11/02/23, and 11/06/23. The medical record contained no documented interventions for dyspnea management, no follow up for severe dyspnea, and no documentation of a patient stated goal for level of dyspnea. The patient did have orders for lorazepam and morphine as needed for shortness of breath, but there was no documentation that these medications were administered and/or that the patient refused to take them. The patient's current care plan and Interdisciplinary Team Meeting notes were reviewed and these documents failed to contain interventions directed toward the patient's dyspnea. An interview was conducted with patient #4's nurse (staff member #5) on 11/06/23. Staff member #5 stated that patient #4 experienced severe shortness of breath. The patient oftentimes could only speak one to two words and took over an hour to eat meals because of rest breaks needed due to breathing concerns. Staff member #5 stated that that the patient's dyspnea was "getting worse." The surveyor asked staff member #5 what interventions or medications were in place to relieve the patient's dyspnea. Staff member #5 initially answered Tylenol, (ordered for pain management and not dyspnea) and then stated that the patient refused to take anything for dyspnea. The patient did not want to feel tired from side effects from medication and was satisfied with the level of dyspnea the patient was currently experiencing. The surveyor asked if the hospice physician or the interdisciplinary team had discussed any other non-pharmacological interventions or treatments for the patient. Staff member #5 stated that the patient lives in a facility and the hospice physician was not permitted to write orders there. Staff member #5 stated all orders must come through the facility physician. No documentation in the record indicated coordination of care between the facility physician and the hospice physician or interdisciplinary team. A home visit was conducted to patient #4 on 11/08/23. On arrival, patient #4 was visibly short of breath and at times was unable to speak due to shortness of breath. Patient #4 indicated they had "bad," "terrible" pain in the arm and shoulder and "severe" shortness of breath, but that patient had difficulty with quantifying the symptoms on a numeric scale. The hospice nurse (staff member #5) briefly reviewed medications available to the patient for symptom management. The patient stated they did not want to feel sleepy and did not want anything stronger than Tylenol. The nurse offered no non-pharmacologic measures to the patient for shortness of breath or pain management. During record review, staff member #3 confirmed the hospice's expectation for symptom management included documenting the patient's goal, whether or not the goal was being met, introducing or modifying treatments if a patient was experiencing inadequate symptom relief, documenting the problem in the care plan and with the Interdisciplinary Group (IDG).

Based on staff interview and document review, it was determined the hospice failed to ensure each patient's plan of care contained measurable outcomes anticipated from implementing and coordinating the plan of care in five (5) of five (5) medical records reviewed in the survey sample. Medical record #'s 1-5. --- Five (5) clinical records were reviewed in the agency with the Regional Director of Clinical Operations (staff member #3) assisting in the navigation of the electronic record. Five (5) of five (5) of the clinical records reviewed failed to contain documentation of measurable outcomes anticipated from implementing the plan of care. All five (5) medical records reviewed contained goals and anticipated outcomes but failed to contain data elements or parameters to measure these outcomes. An interview was conducted with staff member #4 (Assistant Director of Nursing) on 11/08/23 who confirmed the patient's plans of care lacked measurable goals and stated education was currently underway to train nursing staff in developing measurable goals.

Based on staff interview and document review, it was determined the agency failed to ensure each patient's plan of care contained progress toward outcomes and goals specified in the plan of care in five (5) of five (5) clinical records reviewed in the survey sample. --- Five (5) clinical records were reviewed in the agency with the Regional Director of Clinical Operations (staff member #3) assisting in the navigation of the electronic record. Five (5) of five (5) of the clinical records reviewed failed to contain documentation of progress toward outcomes and goals in the plan of care. An interview was conducted with the Assistant Director of Nursing (staff member #3) on 11/08/23 who confirmed the absence of measurable goals in the patient's plans of care. Staff member #3 acknowledged that the plans of care did not contain measurable goals, so it was not possible to document progress toward them.

Based on staff interview and document review, it was determined the agency failed to ensure the hospice provided for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness in one (1) of five (5) medical records reviewed in the survey sample. Medical record #4. --- Five (5) medical records were reviewed in the agency with the Regional Director of Clinical Operations assisting in the navigation of the electronic record. The medical record for patient #4 contained documentation that the patient was admitted to hospice services on 05/02/23. The record contained nursing documentation of multiple instances of patient complaints of severe dyspnea. The patient rated their dyspnea a 7-8 on a 1-10 numeric scale on 10/18/23, 10/30/23, 11/02/23, and 11/06/23. The medical record contained no documented interventions for dyspnea management, no follow up for severe dyspnea, and no documentation of a patient stated goal for level of dyspnea. The patient did have orders for lorazepam and morphine as needed for shortness of breath, but there was no documentation that these medications were administered and/or that the patient refused to take them. The patient's current care plan and Interdisciplinary Team Meeting notes were reviewed and these documents failed to contain interventions directed toward the patient's dyspnea. An interview was conducted with patient #4's nurse (staff member #5) on 11/06/23. Staff member #5 stated that patient #4 experienced severe shortness of breath. The patient oftentimes could only speak one to two words and took over an hour to eat meals because of rest breaks needed due to breathing concerns. Staff member #5 stated that that the patient's dyspnea was "getting worse." The surveyor asked staff member #5 what interventions or medications were in place to relieve the patient's dyspnea. Staff member #5 initially answered Tylenol, (ordered for pain management and not dyspnea) and then stated that the patient refused to take anything for dyspnea. The patient did not want to feel tired from side effects from medication and was satisfied with the level of dyspnea the patient was currently experiencing. The surveyor asked if the hospice physician or the interdisciplinary team had discussed any other non-pharmacological interventions or treatments for the patient. Staff member #5 stated that the patient lives in a facility and the hospice physician was not permitted to write orders there. Staff member #5 stated all orders must come through the facility physician. Staff member #5 stated that the facility physician was "not really on board" with the hospice philosophy. A home visit was conducted to patient #4 on 11/08/23. O arrival, patient #4 was visibly short of breath and at times was unable to speak due to shortness of breath. Patient #4 indicated they had "bad," "terrible" pain in the arm and shoulder and "severe" shortness of breath, but that patient had difficulty with quantifying the symptoms on a numeric scale. The hospice nurse (staff member #5) briefly reviewed medications available to the patient for symptom management. The patient stated they did not want to feel sleepy and did not want anything stronger than Tylenol. The nurse offered no non-pharmacologic measures to the patient for shortness of breath or pain management. The surveyor again spoke to staff member #5 about communication with the physician regarding patient #4's symptoms after the home visit on 11/08/23. Staff member #5 confirmed all orders for patient #4 came from the facility physician or nurse practitioner and the hospice physician was not permitted to write orders in the facility. The medical record for patient #4 contained no documentation that the facility physician was part of the interdisciplinary team meetings or that the facility physician and the hospice physician had ever communicated. The medical record contained no documentation to support care coordination between the two physicians. The contact between the hospice and the facility was reviewed. The contract indicated that the facility would credential and provide privileges to the hospice physician. Staff member #7 was asked on 11/08/23 whether the hospice physician had requested privileges at the facility. Staff member #7 stated that was typically unnecessary and the physician had not requested such privileges. Staff member #2 indicated on 11/08/23 that the hospice was aware of the concerns with the facility physician and was particularly concerned about patients' medical needs after hours if the hospice physician was unable to provide orders in the facility. Staff member #2 stated the hospice and the facility staff had not had a meeting or any discussions with the nursing facility about the issues with the physicians and care coordination between the hospital and facility.