Every finding on record at The Medical Team, Inc.

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 6 (33%) Clinical records reviewed by the agency did not ensure that all goals of care for the patient were measurable. THIS IS A CONTINUED REQUIRED ACTION Clinical Record 5: The patient was admitted to care on 06/14/2024 with a primary diagnosis of Alzheimer's. The Massage Therapist's initial evaluation was 06/17/2024, focusing on range of motion and pain control. One of the goals documented and continued since 06/17/2024 was "Continuity of care among provider is achieved" The problem identified was need for facility care coordination. This goal was not measurable. Clinical Record 6: The patient was admitted to care 05/31/2024 with a primary diagnosis of cerebral atherosclerosis. The Massage Therapist's initial evaluation was 06/01/2024. One of the goals documented and continued since 06/01/2024 was: Continuity of care among provider is achieved. The problem identified was need for facility care coordination. During interview with the administrator and Quality Manager they stated that the goal was not measurable and continued education and support for staff was in place.

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 actual or potential drug interactions. 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 and interview. In 3 of 19 (16%) clinical records reviewed revealed the agency did not ensure the drug profile was updated. Clinical Record 2/Home Visit 2: The patient, an assisted living facility (ALF) resident, elected the hospice benefit on 04/23/2024. During the home visit (Home Visit 2) with the Register Nurse (Personnel Record 1) on 05/22/2024, a medication review was completed by comparing the hospice medication profile with the medication administration record (MAR) from the ALF. The ALF MAR included Furosemide 20MG tablet every day, Lidocaine pain relief patch 4% to left hip incision every morning and removed every night, Multivitamin every day, and Omeprazole Delayed Release 20MG every day. The hospice plan of care dated 04/23/2024 and medication profile current 05/21/2024 did not include a Lidocaine patch, Multivitamin tablet, Omeprazole tablet, and ordered dosing for Furosemide tablet. Clinical Record 3/Home Visit 3: The patient, an assisted living facility (ALF) resident, elected the hospice benefit on 05/01/2024. During the home visit (Home Visit 3) observation with the Medical Social Worker (Personnel Record 3) on 05/22/2024, a medication review was completed by comparing the hospice medication profile with the medication administration record (MAR) from the ALF. The ALF MAR included Ketoconazole 2% shampoo two times a week for dandruff and Nystop 100,000 UNITS/GM powder two times a day as needed. The hospice plan of care dated 05/01/2024 and medication profile current 05/21/2024 did not include Ketoconazole shampoo and Nystop powder. Clinical Record 4/Home Visit 4: The patient, an assisted living facility (ALF) resident, elected the hospice benefit on 07/26/2022. During the home visit (Home Visit 4) with the Chaplain (Personnel Record 4) on 05/22/2024, a medication review was completed by comparing the hospice medication profile with the medication administration record (MAR) from the ALF. The ALF MAR included Promethazine 12.5MG tablet three times a day as needed for nausea or vomiting, Furosemide 40MG every morning, Claritin 10MG tablet daily as needed, and Senna-S 8.6MG-50MG tablet at bedtime. The hospice plan of care dated 05/16/2024 and medication profile current 05/21/2024 did not include did not include Promethazine tablet and the ordered dosing for Furosemide, Claritin, and Senna-S tablet. On 05/24/2024 joint clinical record reviews and interviews were conducted with the Administrator, Regional Quality Manager, Regional Patient Care Manager, and Patient Care Manager who confirmed that the identified plans of care and medication profiles had not been updated to include all medications given by the assisted living facility staff.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, and document review which revealed the hospice: Failed to ensure the hospice care and services provided to patients and families followed the individualized plan of care established by the IDG. {HCPC.19. I/L543}; Failed to ensure that each patient's individualized written Plan of Care included identified problems and planned interventions based upon assessment data from the comprehensive and updated comprehensive assessments (HCPC.21. I/L545}; and Failed to ensure the individualized written plan of care included all services and the frequency of those services required to meet specific patient and family needs {HCPC.21. I/L547}; and Failed to ensure the plans of care included measurable outcomes {HCPC.21. I/L548}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: IDG, Care Planning, Coordination of Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that the hospice care and services provided to patients and families follow the individualized plan of care established by the hospice Interdisciplinary Group (IDG) in collaboration with the attending physician (if any), the patient or the patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 6 of 19 (32%) clinical records reviewed, the agency did not ensure the hospice care and services provided to patients and families followed the individualized plan of care established by the IDG. Clinical Record 4: The patient elected the hospice benefit on 03/17/2024. The volunteer plan of care dated 03/19/2024 included a frequency for the Volunteer to visit one time per week. The clinical record did not contain documented evidence that the Volunteer completed visits with the patient the week of 04/28/2024, 05/05/2024, and 05/12/2024 or documentation of why the visits were not made. Clinical Record 9: The patient elected the hospice benefit on 08/07/2023. The volunteer plan of care dated 11/16/2023 included a frequency for the Volunteer to visit one time per week. The clinical record did not contain documented evidence that the Volunteer completed a visit with the patient the week of 05/12/2024 or documentation of why the visit was not made. Clinical Record 10: The patient elected the hospice benefit on 04/02/2024. The volunteer plan of care dated 04/03/2024 included a frequency for the Volunteer to visit once per week starting the week of 04/28/2024. The clinical record did not contain documented evidence that the Volunteer completed a visit with the patient the week of 05/12/2024 or documentation of why the visit was not made. Clinical Record 13: The patient elected the hospice benefit on 06/30/3023. The initial nursing assessment dated 06/30/2023 included documentation that the patient had a stage one pressure ulcer to the coccyx. The initial plan of care dated 06/30/2023 and last updated on 04/25/2024 included the order for “Hospice Nurse to perform wound care… on coccyx… three times a day. The clinical record did not contain documented evidence that the hospice nurse completed visits three times a day and performed wound care to the coccyx as ordered from 06/30/2023 through the current date. Clinical Record 17: The patient elected the hospice benefit on 05/10/2023 and died in the assisted living facility on 07/27/2023. The bereavement plan of care dated 06/02/2023 included interventions for the Bereavement Coordinator to provide information/referral to community resources and quarterly correspondence cards/newsletters. The Bereavement Coordinator documented a phone call with the bereaved was completed on 08/03/2023. The clinical record did not contain documented evidence that the Bereavement Coordinator updated the bereavement plan of care to include a phone call with the bereaved and provided information/referral to community resources and quarterly correspondence cards/newsletters to the bereaved at six and nine months or why the information/referral and cards/newsletters were not provided. Clinical Record 18: The patient elected the hospice benefit on 10/10/2023 and died in the assisted living facility on 12/18/2023. The bereavement plan of care dated 10/10/2023 included interventions for the Bereavement Coordinator to provide information/referral to community resources and quarterly correspondence cards/newsletters. The Bereavement Coordinator documented phone calls were completed with the bereaved by the Bereavement Volunteer on 01/11/2024 and the Bereavement Coordinator on 01/24/2024. The clinical record did not contain documented evidence that the Bereavement Coordinator had updated the bereavement plan of care to include phone calls with the bereaved and provided information/referral to community resources and quarterly correspondence cards/newsletters to the bereaved at three months or why the information/referral and cards/newsletters were not provided. On 05/24/2024 joint clinical record reviews and interviews were conducted with the Administrator, Regional Quality Manager, Regional Patient Care Manager, and Patient Care Manager who confirmed that the hospice nurse had not completed three visits each day and provided wound care as ordered on the initial and updated plans of care. The leaders also confirmed that the clinical records did not include documentation to indicate the volunteer and bereavement plans of care were followed.

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. In 8 of 19 (42%) clinical records reviewed revealed the agency did not ensure the individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 05/01/2024. The initial psychosocial and emotional assessment completed by the Medical Social Worker (MSW) on 05/01/2024 included documentation that assistance with funeral planning from the MSW was requested. The add-on plan of care orders written 05/01/2024 for the benefit period 05/01/2024 through 07/29/2024 did not include patient and family goals and planned interventions associated with funeral planning needs identified in the comprehensive assessment. Clinical Record 6: The patient elected hospice services on 07/14/2023. The initial nursing assessment dated 07/14/2023 included documentation that the patient was transitioning toward end-of-life as evidenced by Cheynne-Stokes respirations, apnea lasting up to 30 seconds, and increased respiratory secretions. The written plan of care dated 07/14/2023 did not include patient and family goals and planned interventions associated with the patient’s increased respiratory secretions. Clinical Record 8: The patient elected hospice services on 03/01/2024. The initial nursing assessment dated 03/01/2024 included documentation that the patient had increased secretions, dyspnea, difficulty swallowing with recurrent aspiration, and recent diagnoses of COVID-19 and pneumonia. The written plan of care dated 03/01/2024 did not include patient and family goals and planned interventions associated with the patient’s difficulty swallowing and aspiration risk. Clinical Record 11: The patient elected the hospice benefit on 11/16/2023. The initial nursing assessment dated 11/16/2023 included documentation that the patient was a fall risk, with a risk score of six out of ten, and required maximum assistance and a Hoyer lift to transfer to a wheelchair. The initial plan of care dated 11/16/2023 did not include patient and family goals and planned interventions associated with the fall risks identified in the comprehensive assessment. Clinical Record 13: The patient elected hospice services on 06/30/2023. The initial nursing assessment dated 06/30/2023 included documentation that the patient had completed a swallowing study and was deemed at risk for aspiration, required a purred diet, and aspiration precautions were ordered as a safety measure. The written plan of care dated 06/30/2023 did not include patient and family goals and planned interventions associated with the patient’s difficulty swallowing and aspiration risk. Clinical Record 15: The patient elected hospice services on 11/09/2023 with a terminal diagnosis of liver cell carcinoma. The initial nursing assessment dated 11/09/2023 included documentation that the patient had two plus pitting edema of bilateral upper arms, three plus pitting edema of bilateral lower extremities, and a fall risk score of eight out of ten. The written plan of care dated 11/09/2023 did not include patient and family goals and planned interventions associated with the fall risks identified in the comprehensive assessment. Clinical Record 16: The patient elected hospice services on 05/16/2023. The initial nursing assessment dated 05/16/2023 included documentation that the patient had two plus pitting edema of bilateral lower extremities and a nine out of ten-fall risk score. The written plan of care dated 05/16/2023 did not include patient and family goals and planned interventions associated with the fall risks identified in the comprehensive assessment. Clinical Record 18: The patient elected hospice services on 10/10/2023. The initial nursing assessment dated 10/10/2023 included documentation that the patient had a history of seizures and taking Lamotrigine 150MG twice a day to prevent and manage seizures. The written plan of care dated 10/10/2023 did not include patient and family goals and planned interventions associated with the patient’s seizure risk. On 05/24/2024 joint clinical record reviews and interviews were conducted with the Administrator, Regional Quality Manager, Regional Patient Care Manager, and Patient Care Manager who confirmed the written plans of care did not include patient and family goals and planned interventions for problems identified during the initial comprehensive assessments including the risks associated with falls, seizures, and aspiration, the management respiratory secretions, and funeral planning needs.

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 a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed revealed that the agency did not ensure the individualized written plan of care included all services and the frequency of those services required to meet specific patient and family needs. Clinical Record 1: The patient elected the hospice benefit on 08/31/2023 and entered the fourth benefit period on 04/27/2024. The written plan of care order for the benefit period 04/27/2024 through 06/25/2024 included visit frequencies for the Medical Social Worker and Music Therapist. Although the written plan of care included continued goals and interventions associated with skilled nursing, hospice aide, and chaplain services to be provided, the plan of care did not include the frequencies in which skilled nursing, hospice aide, and chaplain visits would be made. Clinical Record 6: The patient elected the hospice benefit on 07/14/2023 and entered the fourth benefit period on 03/10/2024. The written plan of care order for the benefit period 03/10/2024 through 05/08/2024 included continued goals and interventions associated with skilled nursing, hospice aide, and medical social worker services to be provided. The written plan of care (03/10/2024 through 05/08/2024) did not include the frequencies in which skilled nursing, hospice aide, and medical social worker visits would be made. The patient entered the fifth benefit period on 05/09/2024, and the written plan of care, effective on 05/09/2024 through 07/07/2024 included continued goals and interventions associated with hospice aide services to be provided. The written plan of care (05/09/2024 through 07/07/2024) did not include the frequency in which hospice aide visits would be made. Clinical Record 11: The patient elected the hospice benefit on 11/16/2024. The initial nursing assessment dated 11/16/2024 included documentation that the patient had an indwelling suprapubic urinary catheter. The initial plan of care dated 11/16/2024 included an order to irrigate the indwelling catheter with 50ML of normal saline. The plan of care did not include the frequency at which the catheter was to be irrigated. Clinical Record 13: The patient elected the hospice benefit on 06/30/2023 and the frequency of care and services to be provided by skilled nursing, hospice aide, medical social worker (MSW), and chaplain were included on the plan of care dated 06/30/2023. Although nursing, aide, MSW, and Chaplain services were provided, the updated plan of care effective 02/25/2024 through 04/24/2024 did not include frequencies for the services. During the benefit period 04/25/2024 through 06/23/2024, the care and services provided by the hospice aide were continued; however, the plan of care dated 04/25/2024 did not include the frequency of aide services. Clinical Record 16: The patient elected the hospice benefit on 05/16/2023 and entered the fifth benefit period on 03/11/2024. The patient received care and services from skilled nursing, hospice aide, medical social worker (MSW), chaplain, music therapist, and massage therapist through each benefit period. Although care and services were provided, the plan of care effective, 03/11/2024 through 05/09/2024 did not include the frequency of skilled nursing, aide, MSW, and chaplain services. On 05/24/2024 joint clinical record reviews and interviews were conducted with the Administrator, Regional Quality Manager, Regional Patient Care Manager, and Patient Care Manager who confirmed that the identified plans of care did not include the frequency for all care and services.

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 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 12 of 19 (63%) clinical records reviewed revealed the agency did not ensure the plans of care included measurable outcomes. Clinical Record 1: The patient elected hospice services on 08/31/2023. The initial nursing assessment dated 08/31/2023 included documentation that the patient had increased anxiety and agitation with prolonged stimulation and was at risk for falls with a fall risk score of nine out of ten. Although the plan of care, effective 08/31/2023, included goals that the patient’s safety needs would be met and neurological changes would be addressed as appropriate, the written plan did not include measurable outcomes with interventions specific to the patient’s identified fall risk, anxiety, and agitation. Clinical Record 2: The patient elected hospice services on 04/23/2024. The initial nursing assessment dated 04/23/2024 included documentation that the patient’s condition had declined after a fall in which the patient sustained a left hip fracture, was at continued fall risk with a risk score of ten out of ten and had one plus pitting edema to bilateral lower extremities. Although the plan of care, effective 04/23/2024, included goals that the patient’s safety needs would be met and cardiopulmonary symptoms would be reduced or relieved, the written plan of care did not include measurable outcomes with interventions specific to the patient’s identified fall risk and lower extremity edema. Clinical Record 4: The patient elected hospice services on 07/26/2022. The initial nursing assessment dated 07/26/2022 included documentation that the patient had a non-healing intertrochanteric fracture, one plus pitting edema to bilateral lower extremities, and was at risk for falls with a risk score of nine out of ten. Although the initial plan of care for the benefit period (BP) 07/26/2022 through 10/23/2022 and subsequent plan of care updates through the current BP 05/16/2024 through 07/14/2024, included goals that the patient’s safety needs would be met and cardiopulmonary symptoms would be reduced or relieved, the written plan of care did not include measurable outcomes with interventions specific to the patient’s identified fracture, lower extremity edema, and fall risk. Clinical Record 5: The patient elected hospice services on 12/19/2023. The initial nursing assessment dated 12/19/2023 included documentation that the patient was legally blind, required the use of a walker for ambulation, had one plus pitting edema to bilateral lower extremities, and was at risk for falls with a risk score of seven out of ten. Although the plan of care, effective 12/19/2023, included goals that the patient’s safety needs would be met and cardiopulmonary symptoms would be reduced or relieved, the written plan of care did not include measurable outcomes with interventions specific to the patient’s identified fall risk and lower extremity edema. Clinical Record 6: The patient elected hospice services on 07/14/2023. The initial nursing assessment dated 07/14/2023 included documentation that the patient did not respond to verbal or tactile stimuli, had reported agitation and hallucinations, Cheynne-Stokes respirations, and apnea, and was at risk for falls with a risk score of eight out of ten. Although the plan of care, effective 07/14/2023, included goals that the patient’s changes in neurological status would be addressed, safety needs would be met, and pain would be at an acceptable level to the patient, the written plan of care did not include measurable outcomes with interventions specific to the patient’s hallucinations, agitation, cognition, mental status, ability to self-report pain, and identified fall risk. Clinical Record 7: The patient elected hospice services on 02/08/2024. The initial nursing assessment dated 02/08/2024 included documentation that the patient’s conditions included New York Heart Association (NYHA) Class III (three) heart failure with dyspnea at rest and on exertion and was at risk for falls with a risk score of ten out of ten. Although the plan of care, effective 02/08/2024, included goals that the patient’s cardiopulmonary symptoms would be reduced or relieved and safety needs would be met, the written plan of care did not include measurable outcomes with interventions specific to the patient’s dyspnea fall risk. Clinical Record 8: The patient elected hospice services on 03/01/2024. The initial nursing assessment dated 03/01/2024 included documentation that the patient had increased secretions, dyspnea, difficulty swallowing with recurrent aspiration, recent diagnoses of COVID-19 and pneumonia, and was at risk for falls with a risk score of ten out of ten. Although the plan of care, effective 03/01/2024, included goals that the patient’s cardiopulmonary symptoms would be reduced or relieved and safety needs would be met, the written plan of care did not include measurable outcomes with interventions specific to the patient’s increased secretions, dyspnea, and fall risk. Clinical Record 9: The patient elected hospice services on 08/07/2023. The initial nursing assessment dated 08/07/2023 included documentation that the patient had reported dizziness, vertigo, delusions, and paranoia and was at risk for falls with a risk score of ten out of ten. Although the plan of care, effective 08/07/2023, included goals that the patient’s changes in neurological status would be addressed and safety needs would be met, the written plan of care did not include measurable outcomes with interventions specific to the patient’s delusions, paranoia, and identified fall risk. Clinical Record 10: The patient elected hospice services on 08/07/2023. The initial nursing assessment dated 08/07/2023 included documentation that the patient had reported dizziness, vertigo, delusions, and paranoia and was at risk for falls with a risk score of ten out of ten. Although the plan of care, effective 08/07/2023, included goals that the patient’s changes in neurological status would be addressed and safety needs would be met, the written plan of care did not include measurable outcomes with interventions specific to the patient’s delusions, paranoia, and identified fall risk. Clinical Record 12: The initial nursing assessment dated 01/16/2024 included documentation that the patient’s conditions included New York Heart Association (NYHA) Class IV (four) heart failure, an anxiety score of two out of ten, and was at risk for falls with a risk score of six out of ten. Although the written plan of care dated 01/16/2024 included goals that the patient would exhibit signs of symptom reduction or relief and safety needs would be met, the written plan of care did not include measurable outcomes with interventions specific to the patient’s NYHA Class IV symptoms and fall risk. Clinical Record 14: The initial nursing assessment dated 10/26/2023 included documentation that the patient had dyspnea on exertion, one to three plus pitting edema of bilateral lower extremities and was at risk for falls with a risk score of ten out of ten. Although the written plan of care dated 10/26/2023 included goals that the patient would exhibit signs of symptom reduction or relief, reduction or relief of cardiopulmonary symptoms, and safety needs would be met, the written plan of care did not include measurable outcomes with interventions specific to the patient’s dyspnea, edema, and fall risk. Clinical Record 17: The initial nursing assessment dated 05/10/2023 included documentation that the patient was at risk for falls with a risk score of seven out of ten. The nursing visit dated 07/20/2023 included documentation that the patient fell to the floor after rolling out of the bed. Although the written plan of care dated 05/10/2023 included interventions to assess the patient’s safety and instruct on safety measures as applicable and the goal that the patient’s safety needs would be met, the written plan of care did not include measurable outcomes with interventions specific to the patient’s fall risk. On 05/24/2024 joint clinical record reviews and interviews were conducted with the Administrator, Regional Quality Manager, Regional Patient Care Manager, and Patient Care Manager who confirmed the written plans of care did not include measurable outcomes anticipated from the coordination, development, and implementation of the plan of care.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed with bereavement services provided, the agency did not ensure that the bereavement plan of care included the frequency of service delivery. Clinical Record 17: The patient elected the hospice benefit on 05/10/2023 and died at the assisted living facility on 07/27/2023. The identified bereaved were determined to be at low risk for complicated grief by the Interdisciplinary Group (IDG) on 05/10/2023 and a “low risk” bereavement plan of care was developed by the Bereavement Coordinator, in collaboration with the IDG. The bereavement plan of care included interventions to provide an initial sympathy card/letter, standard bereavement form letters, and information/referral to community resources. The bereavement plan of care did not include frequencies in which the initial sympathy card/letter, standard bereavement form letters, and information/referral to community resources would be performed. Clinical Record 18: The patient elected the hospice benefit on 10/10/2023 and died at the assisted living facility on 12/18/2023. The identified bereaved were determined to be at low risk for complicated grief by the Interdisciplinary Group (IDG) on 10/10/2023 and a “low risk” bereavement plan of care was developed by the Bereavement Coordinator, in collaboration with the IDG. The bereavement plan of care included interventions to provide an initial sympathy card/letter, standard bereavement form letters, and information/referral to community resources. The bereavement plan of care did not include frequencies in which the initial sympathy card/letter, standard bereavement form letters, and information/referral to community resources would be performed. Clinical Record 19: The patient elected the hospice benefit on 02/04/2024 and died at the assisted living facility on 03/27/2024. The identified bereaved were determined to be at low risk for complicated grief by the Interdisciplinary Group (IDG) on 02/08/2024 and again on 03/28/2024, and, in collaboration with the IDG, a “low risk” bereavement plan of care was developed by the Bereavement Coordinator. The bereavement plan of care included interventions to provide an initial sympathy card/letter, standard bereavement form letters, and information/referral to community resources. The bereavement plan of care did not include frequencies in which the initial sympathy card/letter, standard bereavement form letters, and information/referral to community resources would be performed. On 05/24/2024 joint clinical record reviews and interviews were conducted with the Administrator, Regional Quality Manager, Regional Patient Care Manager, and Patient Care Manager who confirmed that the identified bereavement plans of care did not include frequencies for all services to be provided.

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 physician orders. This standard was not met as evidenced by clinical record review and interview. In 12 of 19 (58%) clinical records reviewed revealed that the agency did not ensure the patient's clinical record contained physician orders for all care and services provided. Clinical Record 1/Home Visit 1: The election of benefit was dated 08/31/2023. The patient, a resident in an assisted living facility (ALF), entered the fourth benefit period on 04/27/2024. During the home visit (Home Visit 1) with the Hospice Aide (Personnel Record 2) on 05/22/2024, a treatment review was completed by comparing the hospice plan of care with the treatment record from the ALF. The ALF treatment record included instructions to hold Lisinopril 40MG if the patient’s systolic blood pressure was less than 110 or pulse was less than 55. The hospice plan of care dated 04/27/2024 did not include a physician’s order to hold Lisinopril for identified parameters. During the clinical record review, there was documentation of two visits per week completed by the Registered Nurse and two visits per week completed by the Hospice Aide. The clinical record did not contain physician orders for the nursing and hospice aide visits for the benefit period 04/27/2024 through 06/25/2024. Clinical Record 3/Home Visit 3: The election of benefit was dated 05/01/2024. The patient resided in an assisted living facility (ALF). During the home visit (Home Visit 3) with the MSW (Personnel Record 3) on 05/22/2024, a treatment review was completed by comparing the hospice plan of care with the treatment record from the ALF. The ALF treatment record included instructions to check and record the patient’s blood sugar every morning and to hold Metoprolol succinate Extended Release 25MG if the patient’s systolic blood pressure was less than 110 or heart rate was less than 60. The hospice plan of care dated 05/01/2024 did not include a physician’s order for blood sugar checks and to hold Metoprolol succinate for identified parameters. Clinical Record 6: The patient elected hospice services on 07/14/2023. The initial nursing assessment dated 07/14/2023 included documentation that the patient drank one can of Ensure, a nutritional supplement, daily. The clinical record did not contain a physician’s order for Ensure. During the clinical record review, there was documentation of two visits per week completed by the Registered Nurse (RN) from 03/10/2024 through 05/08/2024, three visits per week completed by the Hospice Aide from 03/10/2024 through 03/23/2024, 05/14/2024 and 05/17/2024, and visits completed by the Medical Social Worker (MSW) on 03/20/2024 and 04/02/2024. The clinical record did not contain physician orders for the identified visits completed by the RN, aide, and MSW. Clinical Record 9: The election of the hospice benefit was dated 08/07/2023. The hospice aide care plan dated 03/11/2024 included instructions for the aide to apply Calmoseptine cream to the patient’s coccyx and buttocks with each brief change and to float bilateral heels off the bed with a pillow. The clinical record did not contain physician orders for Calmoseptine or to float heels. Clinical Record 10: The patient elected hospice services on 04/02/2024. The initial nursing assessment dated 04/02/2024 included documentation that the patient drank one can of Boost, a nutritional supplement, daily. The clinical record did not contain a physician’s order for Boost. Clinical Record 12: The patient elected hospice services on 01/16/2024. The initial nursing assessment dated 01/16/2024 included documentation that the patient drank Ensure, a nutritional supplement, as tolerated. The nursing assessment dated 05/18/2024 included documentation that the patient was taking sips of Ensure. The clinical record did not contain a physician’s order for Ensure. Clinical Record 13: The patient elected hospice services on 06/30/3023. The clinical record contained documentation of visits completed by the hospice aide on 04/25/2024, 04/29/2024, 05/07/2024, 05/13/2024, 05/16/2024, 05/20/2024, and 05/23/2024 and documentation of two visits per week completed by the Registered Nurse (RN) for the weeks 02/25/2024 and 03/03/2024. The clinical record did not contain physician orders for the visits completed by the aide and RN. Clinical Record 14: The patient elected hospice services on 10/16/2023. The initial nursing assessment dated 10/26/2024 included documentation that the patient drank one care of Ensure, a nutritional supplement, daily. The hospice aide care plan updated 03/04/2024 included instructions to provide the patient with a protein shake. The clinical record did not contain physician orders for Ensure and protein shakes. Clinical Record 16: The patient elected hospice services on 05/16/2023 and entered the fifth benefit period on 03/11/2024. During the clinical record review, there was documentation of two visits per week completed by the Registered Nurse (RN) from 03/12/2024 through 05/09/2024, three visits per week completed by the Hospice Aide from 03/12/2024 through 03/21/2024, and a visit completed by the Medical Social Worker (MSW) on 04/01/2024. The clinical record did not contain physician orders for the identified visits completed by the RN, aide, and MSW. Clinical Record 17: The patient elected hospice services on 05/10/2023. The hospice aide care plan was updated on 05/16/2023 and 07/08/2023 to include droplet, contact, and airborne isolation precautions while the patient was treated for deep tissue and urinary tract infections respectively. The clinical record did not contain a physician’s order for droplet, contact, and airborne isolation precautions. Clinical Record 18: The hospice aide care plan dated 12/06/2023 included droplet, contact, and airborne isolation precautions while the patient was treated for aspiration pneumonia. The clinical record did not contain a physician’s order for droplet, contact, and airborne isolation precautions. Clinical Record 19: The patient elected the hospice benefit on 02/25/2024 and died in the assisted living facility on 03/27/2024. The bereavement plan of care dated 03/28/2024 for the spouse included interventions for the Bereavement Coordinator to provide initial sympathy card/letter, standard bereavement form letters, information/referral to community resources, and quarterly correspondence cards/newsletters. The Hospice Chaplain documented completed in-person bereavement visits with the bereaved on 03/28/2024, 04/02/2024, 04/03/2024, 04/12/2024, 04/16/2024, 04/26/204, and 05/08/2024. The clinical record did not contain documented evidence that the Bereavement Coordinator had updated the bereavement plan of care to include visits by the Hospice Chaplain. On 05/24/2024 joint clinical record reviews and interviews were conducted with the Administrator, Regional Quality Manager, Regional Patient Care Manager, and Patient Care Manager who confirmed the identified clinical records did not include physician orders for all care and services provided.