Every finding on record at Visiting Nurse Association Health Services

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 that the initial bereavement assessment was documented within the first 5 days from the election of the hospice benefit. Clinical Record 13: The benefit of election was signed on 05/16/2023 and the initial comprehensive assessment was completed on the same date. The initial bereavement assessment was not documented until 09/21/2023 which is day 128 and was 123 days late. During an interview with the vice president of clinical operations, it was confirmed that the assessment was completed late.

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 and supplements, herbal remedies, 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 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 and interview. In 1 of 23 (4%) clinical records reviewed it was revealed that the agency did not ensure that all medication profiles were updated and that discontinued medications were discontinued from the medication profile. Document 2: Policy # 1-029 Medication Profile stated in part; "During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient/client and family/caregiver as well as other clinicians understand the medication regimen." Clinical Record 8: The medication Xarelto 20mg oral daily was ordered on admission on 11/07/2023. During the nursing visit on 02/22/2024, the patient had had some rectal bleeding, The nurse notified the physician and documented that the Xarelto was to be held for 3 days. The next nursing visit documented on 03/01/2024 documented Xarelto still on hold. The next nursing visit on 03/08/2024 documented no longer taking Xarelto. Review of the medication profile on 03/19/2024 the active medication list included Xarelto 20 mg orally daily. During an interview with the case manager and vice president of clinical operations, it was confirmed that the medication profile was not updated, and the patient was no longer taking the Xarelto.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. 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 that the initial bereavement assessment was completed. Clinical Record 4: The patient was admitted to care 10/13/2023 no bereavement assessment documented as of the patient death date 11/02/2023. During an interview with the vice president of clinical services it was stated that the bereavement assessment was missed.

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, document review and interview. In 5 of 23 (22%) records reviewed it was revealed that the agency did not ensure that all problems identified in the initial and updated comprehensive assessment were documented on the plan of care and included interventions for care. Document 2: Policy # 3-008 Comprehensive Assessment stated in part; "The assessment will determine: Patient problems and needs related to the terminal illness." Policy # 3-009 Ongoing Comprehensive Assessment stated in part; "Based on the assessments, the plan of care - including problems, needs, goals, and outcomes will be reviewed and updated by the interdisciplinary group members responsible for the case." Clinical Record 1: The initial comprehensive assessment and subsequent nursing visit notes identified a PEG tube which was draining dark-colored fluid. The initial plan of care dated 01/23/2024 did not document any interventions or orders for dressing changes, or tube care. The PICC (peripherally inserted central line catheter) line documented in the initial comprehensive assessment documented orders for flushing of the line but no site care for cleaning, dressing change, or frequency of site care. Clinical Record 2: The initial plan of care dated 10/04/2023 and plans of care that were updated every 2 weeks until death did not include interventions or goals for the indwelling catheter that was placed 10/12/2023. Clinical Record 3: The initial plan of care was dated 01/14/2024 and a revocation was documented on 01/18/2024. The initial comprehensive assessment identified a stage 4 pressure area treated by the use of a wound vac that was changed by the daughter. The patient resided in an assisted living. The plan of care did not document the detail of which kind of sponge was being used (white or black), the pressure settings of the vac, or the frequency of the dressing change or what to do if the pump malfunctioned. Clinical Record 5: The initial plan of care dated 11/03/2023 did not document any interventions or goals for the foley catheter that was identified on the initial comprehensive assessment. The patient died on 11/06/2023. Clinical Record 9: The comprehensive assessment documented that the patient had a pleural drain that was being drained 3 times a week by the daughter and she was independent. The initial plan of care dated 02/21/2024 did not document any interventions for the care or goals for the pleural drain. Nursing notes documented on revisits that the drainage amount was recorded and completed by a hired caregiver or daughter. During an interview with the vice president of clinical operations, it was confirmed that the interventions were not documented on the plans of care.

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 an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review. In 3 of 16 (19%) clinical records reviewed in which a hospice aide was accepted, it was revealed that the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for all care that the patient required. Clinical Record 1: The hospice aide plan of care was dated 01/23/2024 with no updates and provided directions for a bed bath and shampoo each visit. There was no documentation that there was a PICC line in place and a PEG tube. The PEG tube had a split gauze dressing. The PICC line had an occlusive dressing. Additionally, the patient had a stage 3 decubitus ulcer on the coccyx with a dressing. There were no directions for what to do if any of the dressings were saturated or came off. Clinical Record 18: The hospice aide plan of care was dated 12/18/2023, created when the patient was admitted, and did not include information related to the PEG tube with a split gauze dressing. The aide was assigned the task of a bed bath every visit. The patient was receiving Jevity tube feedings and there was no direction for the aide on what to do if the split gauze dressing was soiled during the bath became wet or was off. The aide documented changing the split gauze dressing and washing around the PEG tube when providing bed baths. Clinical Record 20: The hospice aide plan of care was dated 11/24/2023, created when the patient was admitted. The patient was admitted with a Foley catheter, but no catheter care was documented on the aide plan as of the date of death, 12/02/2023.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by document review and interview. In 2 of 16 (13%) clinical records reviewed in which hospice aide was accepted, it was revealed that the agency did not ensure that the hospice aide followed all duties assigned on the hospice aide plan of care. Clinical Record 1: A hospice aide visit dated 02/06/2024 documented that wound care was done, the wound was packed with a wound sponge and medihoney. The aide plan of care documented on 01/23/2024 ordered the task of bed bath and shampoo and no other tasks. No aide task was ordered for wound care. An interview with the Director of hospice revealed that the aide no longer worked for the agency so could not be interviewed to clarify the documentation. Competencies for this aide revealed sign-off for dry dressing change and ace wrap application. Clinical Record 20: The aide plan of care dated 11/24/2023 documented a task for peri care. The aide documented catheter care performed on 11/26/2023, 11/27/2023, 11/30/2023 and 12/02/2023. The patient did have a Foley catheter during the entire care but it was not ordered as a task for the aide to provide. There were no documented coordination notes that the nurse and aide had discussed this care. The patient died on 12/02/2023. During the interview with the Director of Clinical Services and Director of the Inpatient Unit the review of aide documentation will be monitored more closely.

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 23 (4%) clinical records reviewed it was revealed that the agency did not ensure physician orders were documented for all medication changes that required an order. Clinical Record 8: The medication Xarelto 20mg oral daily was ordered. During the nursing visit on 02/22/2024, the patient had had some rectal bleeding, and the nurse notified the physician and documented Xarelto to be held for 3 days. The next nursing visit documented on 03/01/2024 documented Xarelto still on hold. The next nursing visit on 03/08/2024 documented no longer taking Xarelto. There was no documented physician order for the medication hold or discontinuation of the Xarelto. During an interview the vice president of clinical operations stated that the order was not documented and should have been.

It is required that hospice inpatient facilities provide a sanitary environment by following current standards of practice, including nationally recognized infection control precautions, and avoiding sources and transmission of infections and communicable diseases. This standard was not met as evidenced by interview and observation. During the in-patient facility tour on 03/20/2024, an oxygen concentrator owned by the facility was stored in the medications room. The concentrator was not properly tagged/bagged indicating that the concentrator was ready for usage. The filter in the concentrator was dirty and dusty. During an interview, the vice president of operations confirmed the finding and stated that a new process for cleaning and storage the concentrators would be developed. During the in-patient facility tour on 03/20/2024, an oxygen concentrator owned by the facility was stored in the medications room. The concentrator was not properly tagged/bagged indicating that the concentrator was ready for usage. The filter in the concentrator was dirty and dusty.