Every finding on record at Visiting Nurse Association of Cleveland Hospice

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 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, document review, observation, and interview. Agency policy #H3.01 "Comprehensive Assessment" (revised 08/2021), read in part, "The comprehensive assessment must take into consideration the following: Drug profile. A review of the entire patient's prescription and over the counter medications. Staff will assess during the initial enrollment with the contracting pharmacy and with each addition or change in the medication profile." In 8 of 19 (42%) clinical records reviewed the agency did not ensure the medication profile contained the patient's current prescription medications and was updated when a new medication was added. Clinical Record 2: The hospice election of benefit was dated 04/13/2023. The physician's order dated 04/04/2024 for the recertification period dated 04/07/2024 ordered: "Oxygen @ 2-4 liters per minute (lpm) via nasal cannula pro re nata/as needed (prn) dyspnea." At the time of the review on 04/30/2024, oxygen was not documented on the medication profile. Clinical Record 5: The hospice election of benefit was dated 01/02/2024.The physician's order dated 03/27/2024 for the recertification period dated 04/01/2024 ordered: "Oxygen @ 2-4 liters per minute (lpm) via nasal cannula pro re nata/as needed (prn) dyspnea." At the time of the review on 04/30/2024, oxygen was not documented on the medication profile. Clinical Record 7: The hospice election of benefit was dated 12/20/2023. The physician's order dated 03/19/2024 for the recertification period dated 03/19/2024 ordered: "Oxygen @ 2-4 lpm via nasal cannula prn dyspnea." At the time of the review on 05/01/2024, oxygen was not documented on the medication profile. Clinical Record 9: The hospice election of benefit was dated 08/10/2023. The physician's order dated 03/22/2024 for the recertification period dated 04/06/2024 ordered: "Oxygen @ 2-3 lpm (may increase to 5 lpm) via nasal cannula prn dyspnea." At the time of the review on 05/01/2024, oxygen was not documented on the medication profile. Clinical Record 10: The hospice election of benefit was dated 11/03/2023. The physician's order dated 02/01/2024 for the recertification period dated 02/01/2024 ordered: "Oxygen @ 2-4 lpm via nasal cannula prn dyspnea." At the time of the review on 05/01/2024, oxygen was not documented on the medication profile. Clinical Record 13/Home Visit 2: The hospice election of benefit was dated 04/19/2024. During the home visit with the Registered Nurse (RN) [Personnel Record 3], the patient had Soothe XP eyedrops at the bedside. The patient stated that they instilled the drops into both eyes 4-5 times per day per their eye doctor. The patient stated that they had begun using the eye drops prior to their admission. At the time of the review on 05/02/2024, Soothe XP eye drops were not documented on the medication profile. Clinical Record 14: The hospice election of benefit was dated 04/18/2024. The physician's order dated 04/18/2024 ordered: "Oxygen @ 2-4lpm via nasal cannula prn dyspnea." At the time of the review on 05/02/2024, oxygen was not documented on the medication profile. Clinical Record 19: The hospice election of benefit was dated 08/16/2023. The communication note entered by the registered nurse dated 08/24/2023 documented, "MD sent prescription for Augmentin 500mg bid x 7days and Mucinex with order for prn visit today to check lungs and vital signs." At the time of the review on 04/29/2024, Augmentin and Mucinex were not documented on the medication profile. During an interview and a joint record review on 05/02/2024, the Director of Patient Care Services (DPCS) confirmed that oxygen was documented on the certification orders and was not transposed onto the medication profiles. The DPCS stated that this was part of a library test in some cases that needed to be removed and that the missing medications identified had since been made.

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. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #H10.01 "Bereavement Program Services" (revised 03/2022) read in part, "The initial Bereavement Risk Assessment is completed by the MSW at or near the time of admission." In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that an initial bereavement assessment was completed. Clinical Record 3: The hospice election of benefit was dated 04/25/2023. The comprehensive assessment was completed on 04/25/2023. At the time of the review on 04/30/2024, there was no documented evidence of the completion of an initial bereavement assessment. Clinical Record 17: The hospice election of benefit was dated 01/27/2024. The comprehensive assessment was completed on 01/27/2024. At the time of the review on 05/02/2024, there was no documented evidence of the completion of an initial bereavement assessment. During an interview and a joint record review on 05/02/2024, the Director of Patient Care Services (DPCS) confirmed there was no evidence of an initial bereavement assessment and that one should have been completed.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by: the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that services were provided in accordance with the plan of care. Clinical Record 4: The hospice election of benefit was dated 09/18/2023. The hospice plan of care dated 03/16/2024 ordered Spiritual Care (PC) services: "PC 1 week 1, 1 every 5 week 5, effective 03/24/2024." At the time of the review on 04/30/2024, there was no documented PC visit the week of 03/24/2024. There was no evidence of a documented missed visit or explanation of why services were not provided as ordered. Clinical Record 13: The hospice election of benefit was dated 04/19/2024. The hospice plan of care dated 04/19/2024 ordered: "PC 1 week 1, 2 week 7, effective 04/21/2024. At the time of the review on 05/02/2024, there were two documented spiritual care (PC) visits for the week of 04/23/2024, dated 04/23/2024 and 04/26/2024. There was no documented explanation of why services were not provided as ordered. During an interview and a joint record review on 05/02/2024, the Director of Patient Care Services (DPCS) stated that the missed visit entry and the corrected PC visit frequency had since been entered into the electronic medical record (EMR), and education would be provided to ensure future compliance.

It is required that each patient’s individualized written plan of care: reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; [and] includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #H3.03 "Interdisciplinary Care Plan" (revised 08/2021), read in part, "Components of the interdisciplinary care plan include... Patient and family goals and interventions based on the identification of the needs of the patient, family and caregivers in the initial, comprehensive and updated comprehensive assessments... Measurable outcomes anticipated from implementing and coordinating the plan of care..." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's plan of care reflected patient and family goals. Clinical Record 4: The hospice election of benefit was dated 09/18/2023. The hospice plan of care dated 03/16/2024 documented the patient's diagnosis of Diabetes Mellitus (DM). The Skilled Nursing (SN) visit notes dated 03/20/2024 through 04/25/2024 documented assessment of the patient's blood sugar levels. The Registered Nurse (RN) visit note dated 04/04/2024 documented the frequency of fingerstick blood sugar checks performed by the patient/caregiver was daily and the patient was utilizing diet and oral hypoglycemic agents to manage the DM. At the time of the review on 04/30/2024, the hospice plan of care dated 03/16/2024 did not document goals related to the patient's DM. During an interview and a joint record review on 05/02/2024, the Director of Patient Care Services (DPCS) stated that the goals were inadvertently omitted had since been corrected

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, document review, and interview. Agency policy #H3.03 "Interdisciplinary Care Plan" (revised 08/2021), read in part, "Components of the interdisciplinary care plan include:... Detail of the scope and frequency of services needed to meet the needs of the patient/family." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's plan of care (POC) included the scope and frequency of services to be provided. Clinical Record 10: The hospice election of benefit was dated 11/03/2023. The hospice plan of care dated 02/01/2024 ordered "MSW and Spiritual (Pastoral Care) as needed." The POC did not document the scope and frequency of services to be provided. During an interview and a joint record review on 05/02/2024, the Director of Patient Care Services (DPCS) confirmed that the social worker and the chaplain wanted to remain involved on an as needed basis. The DPCS verbalized understanding that an as needed frequency does not meet the requirement and that they are involved as needed as part of the interdisciplinary team.

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 the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #H3.03 "Interdisciplinary Care Plan" (revised 08/2021), read in part, "Components of the interdisciplinary care plan include... Patient and family goals and interventions based on the identification of the needs of the patient, family and caregivers in the initial, comprehensive and updated comprehensive assessments...Drugs and treatment necessary to meet the needs of the patient..." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's plan of care included all treatments necessary to meet the patient's needs. Clinical Record 4: The hospice election of benefit was dated 09/18/2023. The hospice plan of care dated 03/16/2024 documented the patient's diagnosis of Diabetes Mellitus (DM). The Skilled Nursing (SN) visit notes dated 03/20/2024 through 04/25/2024 documented assessment of the patient's blood sugar levels. The Registered Nurse (RN) visit note dated 04/04/2024 documented the frequency of fingerstick blood sugar checks performed by the patient/caregiver was daily and the patient was utilizing diet and oral hypoglycemic agents to manage the DM. At the time of the review on 04/30/2024, the POC dated 03/16/2024 did not document the daily blood glucose monitoring. During an interview and a joint record review on 05/02/2024, the Director of Patient Care Services (DPCS) confirmed that the fingerstick blood sugar checks had been inadvertently omitted and had since been corrected.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #H3.03 "Interdisciplinary Care Plan" (revised 08/2021), read in part, "Components of the interdisciplinary care plan include...Patient and family goals and interventions based on the identification of the needs of the patient, family and caregivers in the initial, comprehensive and updated comprehensive assessments...The interdisciplinary care plan will be reviewed and updated as frequently as the patient's condition requires but at a minimum every 15 calendar days." In 7 of 19 (37%) clinical records reviewed, the agency did not ensure that plan of care revisions included information from the patient's updated comprehensive assessment. Clinical Record 2: The hospice election of benefits was dated 04/13/2023. The initial MSW and PC evaluations and plans of care were completed on 04/18/2023. The hospice plan of care dated 04/07/2024 ordered Social Work (MSW) and Spiritual Care (PC) service "1 week 1, q5 week 5 effective 04/21/2024." The Interdisciplinary team (IDT) meeting dated 03/27/2024 and the updated assessments documented plans to continue MSW and PC interventions and goals into the next certification period due to continued psychosocial and spiritual needs. At the time of the review on 04/30/2024, the updated MSW and PC interventions were not included in the 04/07/2024 plan of care. Clinical Record 6: The hospice election of benefit was dated 04/06/2023. The initial MSW and PC evaluations and plans of care were completed on 04/10/2023. The hospice plan of care dated 03/31/2024 ordered MSW and PC services "1 week 9." The IDT meeting dated 03/27/2024 and the updated assessments documented plans to continue MSW and PC interventions and goals into the next certification period due to continued psychosocial and spiritual needs. At the time of the review on 05/01/2024, the updated MSW and PC interventions were not documented in the plan of care dated 04/07/2024. Clinical Record 7: The hospice election of benefit was dated 12/20/2023. The initial MSW and PC evaluations and plans of care were completed on 12/20/2023 and 01/05/2024, respectively. The hospice plan of care dated 03/19/2024 ordered MSW and PC services "1 week 1, q9 week 9, effective 03/31/2024." The IDT meeting dated 03/27/2024 and the updated assessments documented plans to continue MSW and PC interventions and goals into the next certification period due to continued psychosocial and spiritual needs. At the time of the review on 05/01/2024, the updated MSW and PC interventions were not documented in the plan of care dated 03/31/2024. Clinical Record 9: The hospice election of benefit was dated 08/10/2023. An initial MSW and PC evaluation and plan of care were completed on 08/17/2023 and on 08/15/2023, respectively. The hospice plan of care dated 04/06/2024 ordered MSW and PC services "1week1, 1 every 2 week 8, effective 04/07/2024." The IDT meeting dated 03/27/2024 and the updated assessments documented plans to continue MSW and PC interventions and goals into the next certification period due to continued psychosocial and spiritual needs. At the time of the review on 05/01/2024, the updated MSW and PC interventions were not documented in the plan of care dated 04/06/2024. Clinical Record 10: The hospice election of benefit was dated 11/03/2023. The initial MSW and PC evaluations and plans of care were completed on 11/06/2023 and 11/07/2023, respectively. The plan of care dated 02/01/2024 documented: “PC to evaluate and develop a plan of care and MSW to evaluate and develop a plan of care.” The IDT meeting dated 01/31/2024 and updated assessments did not document the plan to continue MSW and PC into the next certification period due to the documented declination of services. At the time of the review on 05/01/2024, MSW and PC interventions had not been removed from the plan of care dated 02/01/2024. Clinical Record 11: The hospice election of benefit was dated 07/21/2023. The initial MSW and PC evaluations and plans of care were completed on 08/01/2023 and 07/26/2023, respectively. The hospice plan of care dated 03/17/2024 ordered MSW services “1 week 1, 1 every 4 week 4” and PC services “1 week 1, 1 q5 week 5, effective 03/31/2024.” The IDT meeting dated 03/13/2024 and updated assessments documented the plan to continue MSW and PC interventions and goals into the next certification period due to continued psychosocial and spiritual needs. At the time of the review on 05/01/2024, the updated MSW and PC interventions were not included in the plan of care dated 03/17/2024. Clinical Record 12: The hospice election of benefit was dated 10/04/2021. The initial MSW and PC evaluations and plans of care were dated as completed on 10/06/2021. The hospice plan of care dated 03/22/2024 ordered MSW services "1 week 1, 1 every 4 week 4," and PC services "1 week 1, 1 q5 week 5." The IDT meeting dated 03/13/2024 and updated assessments documented the plan to continue MSW and PC interventions and goals into the next certification period due to continued psychosocial and spiritual needs. At the time of the review on 05/01/2024, the updated MSW and PC interventions were not included in the plan of care dated 03/22/2024. During an interview and a joint record review on 05/02/2024, the Director of Patient Care Services (DPCS) stated that the POC did not include the interventions and goals formed from the initial and updated comprehensive assessments. The DPCS stated that their team would be reviewing the process within the electronic medical record (EMR) and making changes to ensure future compliance.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed of patients that received Hospice Aide services, the agency did not ensure that hospice aide services were provided as ordered by the Interdisciplinary Group (IDG). Clinical Record 2: The patient elected hospice care on 04/13/2023. The hospice plan of care dated 04/07/2024 ordered HA services "2week8, 1week4." A review of the clinical record on 04/30/3034 revealed one (1) visit documented for the week of 04/23/2024, dated 04/23/2024. There was no evidence of a documented missed visit and no documented reason the services were not provided as per the ordered frequency. During an interview and a joint record review on 05/02/2024, the Director of Patient Care Services (DPCS) stated that a missed visit entry had since been entered for the missing visit.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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 that the patient's records included physician orders. Clinical Record 19: The hospice election of benefit was dated 08/16/2023. The communication note entered by the Registered Nurse (RN) dated 08/24/2023 documented: "MD sent prescription for Augmentin 500 mg bid x 7 days and Mucinex with order for prn visit today to check lungs and vital signs." At the time of the review on 04/29/2024, there was no documented physician order for Augmentin and Mucinex. During an interview and a joint record review on 05/02/2024, the Director of Patient Care Services (DPCS) stated that the nurse had obtained the order but failed to write the order.