Every finding on record at Vital Hospice Care Inc.

It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes: history of pain and its treatment, both pharmacological and non-pharmacological; use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status; characteristics of the pain, including location, frequency, and intensity; how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping); and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review, document review and interview. 2 of 14 (14%) clinical records reviewed revealed the hospice did not ensure that the patient’s pain was assessed as part of a comprehensive assessment at least every 14 days. Agency Policy, “Ongoing Comprehensive Assessments, Policy No. 2-031.1,” stated in part, “The nurse will assess the patient for pain, including the origin, location, during, severity, and relief measures.” Agency policy, “Comprehensive Assessments, Policy No. 2-030.1,” stated in part, “The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient’s condition requires but at a minimum of every 15 days.” Agency policy, “Pain Assessment, Policy No. 2-032.1,” stated in part, “All patients will receive pain assessments. When pain is identified, a more comprehensive pain assessment will be completed. When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible: pain intensity, location, pain quality, onset, duration, alleviating and aggravating factors, present pain management regimen and effectiveness, pain management history, effects of pain, impact on daily life, the patient’s pain goal.” Record 3: The patient elected the hospice benefit on 10/4/2022. The registered nurse (RN) initial comprehensive assessment on 10/4/2022 stated that the patient had 0 pain. The medication profile revealed the patient was taking Norco 10-325mg, 1 every 4 hours scheduled for moderate to severe pain starting 10/21/2022 and Morphine 15mg every 2 hours as needed for severe pain starting 11/22/2022. The RN visit note documentation on 12/15/2022 stated the patient complained of 8/10 pain, Norco given prior to visit, with no further pain assessment documented. The RN visit note documentation on 12/16/2022 stated patient pain level 8/10, Norco given prior to visit, with no further pain assessment documented. The RN comprehensive pain assessment documentation on 12/28/2022 stated 5/10 pain, uncomfortable due to pain, with no pain goal documented. The Licensed Vocational Nurse (LVN) visit note documentation on 3/16/2023 stated 3/10 pain, pain meds given prior to wound care, effective, with no additional information on pain. The LVN visit note documentation on 3/18/2023 stated the patient was given Norco before wound care for comfort, with no additional information on pain. The LVN visit note documentation on 3/20/2023 stated pain medication was given prior to visit, with no additional information on pain. The RN comprehensive assessment documentation on 3/23/2023 stated 8/10 pain all over his body, doctor was notified. There was no documented evidence that a comprehensive pain assessment was completed between 12/29/2022 and 3/22/2023. Record 4: The patient elected the hospice benefit on 12/8/2022. The RN initial comprehensive assessment documentation on 12/8/2022 stated that the patient had 1/10 pain. The medication profile revealed the patient was taking Norco 5-325mg, every 6 hours as needed for moderate to severe pain starting 12/8/2022 and Morphine 15mg every 8 hours as needed for moderate to severe pain starting 12/8/2022. The LVN documentation on 12/10/2022 revealed the patient returned to memory care from the hospital due to a fall and fracture off the patient’s right arm with swelling and purple bruises. The LVN visit note documentation on 1/7/2023 stated the patient rated his pain, verbal, 10/10. The patient reported the pain went down to 7/10 after 30 minutes, with no additional information on pain. The RN visit note documentation on 1/16/2023 stated the patient verbalized pain on shoulder, hands, and hips, had medications for pain management, with no further pain assessment. The RN comprehensive pain assessment documentation on 1/30/2023 stated pain 1/10. The RN visit note documentation on 2/13/2023 stated the patient verbalized pain on shoulders, arms, and hips, had medications for pain management, with no further pain assessment. The RN visit note documentation on 2/27/2023 stated the patient verbalized pain on different parts of his body, shoulders, arms, hands, hips and knees, patient had medications for pain management, with no further pain assessment. The RN visit note documentation on 3/13/2023 stated the patient verbalized pain on his arm, body, and legs, had medications for pain management, with no further pain assessment. There was no documented evidence that a comprehensive pain assessment was completed between 1/31/2023 and 3/27/2023. The Director of Patient Care Services was interviewed on 5/4/2023 and agreed there was no documented evidence that the comprehensive pain assessments were completed according to policy. Agency policy, “Ongoing Comprehensive Assessments, Policy No. 2-031.1,” stated in part, “The nurse will assess the patient for pain, including the origin, location, during, severity, and relief measures.” Agency policy, “Comprehensive Assessments, Policy No. 2-030.1,” stated in part, “The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient’s condition requires but at a minimum of every 15 days.” Agency policy, “Pain Assessment, Policy No. 2-032.1,” stated in part, “All patients will receive pain assessments. When pain is identified, a more comprehensive pain assessment will be completed. When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible: pain intensity, location, pain quality, onset, duration, alleviating and aggravating factors, present pain management regimen and effectiveness, pain management history, effects of pain, impact on daily life, the patient’s pain goal.” Record 3: The patient’s date of election was 10/4/2022. The RN initial comprehensive assessment on 10/4/2022 stated that the patient had 0 pain. The medication profile revealed the patient was taking Norco 10-325mg, 1 every 4 hours scheduled for moderate to severe pain starting 10/21/2022, Morphine 15mg every 2 hours as needed for severe pain starting 11/22/2022. The RN visit on 12/15/2022 stated patient complaints of 8/10 pain, Norco given prior to visit, with no further pain assessment. The RN visit on 12/16/2022 stated patient pain level 8/10, Norco given prior to visit, with no further pain assessment. The RN comprehensive pain assessment on 12/28/2022 stated 5/10 pain, uncomfortable due to pain, with no pain goal documented. The LVN visit on 3/16/2023 stated 3/10 pain, pain meds given prior to wound care, effective, with no additional information on pain. The LVN visit on 3/18/2023 stated patient was given Norco before wound care for comfort, with no additional information on pain. The LVN visit on 3/20/2023 stated pain medication was given prior to visit, with no additional information on pain. The RN comprehensive assessment on 3/23/2023 stated 8/10 pain all over his body, doctor was notified. There was no documented evidence that a comprehensive pain assessment was completed between 12/29/2022 and 3/22/2023. Record 4: The patient’s date of election was 12/8/2022. The RN initial comprehensive assessment on 12/8/2022 stated that the patient had 1/10 pain. The medication profile revealed the patient was taking Norco 5-325mg, every 6 hours as needed for moderate to severe pain starting 12/8/2022, Morphine 15mg every 8 hours as needed for moderate to severe pain starting 12/8/2022. The Licensed Vocational Nurse (LVN) documentation on 12/10/2022 revealed, patient returned to memory care from hospital due to fall, fracture on patient’s right arm with swelling and purple bruises. The LVN visit on 1/7/2023 stated patient rates his pain, verbal, 10/10, pain went down to 7/10 after 30 minutes, with no additional information on pain. The RN visit on 1/16/2023 stated patient verbalized pain on shoulder, hands, and hips, has medications for pain management, with no further pain assessment. The RN comprehensive pain assessment on 1/30/2023 stated pain 1/10. The RN visit on 2/13/2023 stated patient verbalizes pain on shoulders, arms, and hips, has medications for pain management, with no further pain assessment. The RN visit on 2/27/2023 stated patient verbalizes pain on different parts of his body, shoulders, arms, hands, hips and knees, patient has medications for pain management, with no further pain assessment. The RN visit on 3/13/2023 stated patient verbalizes pain on his arm, body, and legs, has medications for pain management, with no further pain assessment. There was no documented evidence that a comprehensive pain assessment was completed between 1/31/2023 and 3/27/2023. The Director of Patient Care services was interviewed on 5/4/2023 and agreed, there was no documented evidence that the comprehensive pain assessments were completed according to policy.

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), the patient or 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. 1 of 14 (7%) clinical records reviewed revealed the hospice did not ensure the spiritual counselor followed the plan of care as ordered. Record 3: The patient elected the hospice benefit on 10/4/2022. The plan of care dated 10/4/2022-12/31/2022 was reviewed and revealed spiritual counselor visits were ordered 1x month for November 2022 and December 2022. There was no documented evidence in the clinical record that spiritual counselor visits were provided during this time frame and no documented reasons for the missed visits. The Director of Patient Care Services was interviewed on 5/2/2023 and agreed, there was no documented evidence of a spiritual counselor visit in November or December 2022 and no documented reasons for the missed visits. Record 3: The patient’s date of election was 10/4/2022. The plan of care for 10/4/2022-12/31/2022 was reviewed and revealed spiritual counselor visits were ordered 1x month for November and December. There was no documented evidence of a spiritual counselor visit, or documented reasons for the missed visits. The Director of Patient Care services was interviewed on 5/2/2023 and agreed, there was no documented evidence of a spiritual counselor visit in November or December 2022 or documented reasons for the missed visits.

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. The plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions. This standard was not met as evidenced by clinical record review and interview. 3 of 14 (21%) clinical records reviewed revealed the written plans of care were not individualized to include planned interventions and patient and family goals related to problems identified on the initial and updated comprehensive assessments. Record 1: The patient elected the hospice benefit on 2/23/2023 with a primary hospice diagnosis of chronic obstructive pulmonary disease. The POC dated 2/23/2023-5/2/2023 was reviewed and stated, "Problem: Respiratory status r/t COPD. Goal: Patient will have optimum level of oxygen". There was no documented evidence of individualized measurable goals or interventions on the POC specifically addressing the patient's respiratory status and oxygen use. In an interview on 5/3/2023, the Director of Patient Care Services agreed with the finding that there was no documented evidence the POC included an individualized and measurable goal related to respiratory status and oxygen use. Record 3: The patient elected the hospice benefit on 10/4/2022 with a primary hospice diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris. The Registered Nurse (RN) assessment on 1/12/2023 stated the patient verbalized he had 6/10 general body pain and bilateral edema of the hands. The POC dated 10/4/2022-5/3/2023 was reviewed and stated, "Problem: Edema on hands bilaterally. Goal: Patient will maintain optimum peripheral circulation." There was no documented evidence of individualized measurable goals or interventions on the POC specifically addressing the management of edema. In an interview on 5/4/2023, the Director of Patient Care Services agreed, there was no documented evidence the POC included an individualized and measurable goal related to the edema. Record 4: The patient elected the hospice benefit on 12/8/2022 with a primary hospice diagnosis of chronic obstructive pulmonary disease. The RN assessment on 12/8/2022 revealed a fall risk assessment score of 16, which indicated the patient was at “high risk” for falls. The Licensed Vocational Nurse documentation on 12/10/2022 revealed the patient returned to memory care from the hospital after experiencing a fall and sustaining a fracture of the right arm with swelling and purple bruises. The POC dated 12/8/2022-5/3/2023 was reviewed. There was no documented evidence of planned interventions or goals for the patient’s safety related to the high fall risk. In an interview on 5/3/2023, the Director of Patient Care Services agreed there was no documented evidence the POC included planned interventions or goals for the patient’s safety related to the high fall risk. Record 1: The patient’s date of election was 2/23/2023. The primary hospice diagnosis was chronic obstructive pulmonary disease. The plan of care for 2/23/2023-5/2/2023 was reviewed. Problem: respiratory status r/t COPD. Goal: patient will have optimum level of oxygen. There was no documented evidence of the patient’s desired level of oxygen. The Director of Patient Care services was interviewed on 5/3/2023 and agreed, there was no documented evidence the plan of care included an individualized and measurable goal for the oxygen level. Record 3: The patient’s date of election was 10/4/2022. The primary hospice diagnosis was atherosclerosis heart disease of native coronary artery without angina pectoris. The Registered Nurse assessment on 1/12/2023 documented patient verbalized he has 6/10 general body pain edema, edema on hands bilaterally. The plan of care for 10/4/2022-5/3/2023 was reviewed. Problem: Edema on hands bilaterally. Goal: Patient will maintain optimum peripheral circulation. There was no documented evidence of the patient’s desired level for edema. The Director of Patient Care services was interviewed on 5/3/2023 and agreed, there was no documented evidence the plan of care included an individualized and measurable goal for the edema. Record 4: The patient’s date of election was 12/8/2022. The primary hospice diagnosis was chronic obstructive pulmonary disease. The Registered Nurse assessment on 12/8/2022 revealed a fall risk assessment of 16, “high risk” of falls. The Licensed Vocational Nurse documentation on 12/10/2022 revealed, patient returned to memory care from hospital due to fall, fracture on patient’s right arm with swelling and purple bruises. The plan of care for 12/8/2022-5/3/2023 was reviewed. There was no documented evidence of planned interventions or goals for the patient’s safety due to the high fall risk. The Director of Patient Care services was interviewed on 5/3/2023 and agreed, there was no documented evidence the plan of care included planned interventions or goals for the patient’s safety due to the high fall risk.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review, interview and observation. 1 of 3 (33%) home visit observations revealed the hospice did not ensure adherence to agency infection control policies and procedures for hand hygiene. Agency Policy, “Hand Hygiene, Policy No. 7-009,” stated in part, “Hand decontamination using an alcohol-based hand rub should be performed: after contact with wound dressings, when moving from a contaminated body site to a clean body site during patient care, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.” During observation of Home Visit #3 (Clinical Record 3) on 5/4/2023 with the Licensed Vocational Nurse (LVN) (Staff 5), the LVN was observed donning gloves, typing on a work tablet with gloved hand, removing wound supplies from a box in patient’s room, removing saturated wound dressing from left elbow, cleaning the wound with wound spray, applying calcium alginate and applying a clean border dressing. The LVN was not observed performing hand hygiene after touching the tablet and before removing the saturated wound dressing. The LVN was not observed performing hand hygiene after removing the saturated wound dressing and before applying calcium alginate and a clean border dressing. In an interview on 5/4/2023, the Director of Patient Care Services agreed that the LVN did not follow the infection control policy on hand hygiene. Agency policy, “Hand Hygiene, Policy No. 7-009,” stated in part, “Hand decontamination using an alcohol-based hand rub should be performed: after contact with wound dressings, when moving from a contaminated body site to a clean body site during patient care, after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.” During observation of Home Visit #3 (Clinical Record 3) on 5/4/2023 with the Licensed Vocational Nurse (LVN) (Staff 5), the LVN was observed donning gloves, typing on work tablet with gloved hand, removing wound supplies from box in patient’s room, removing saturated wound dressing from left elbow, cleaned with wound spray, applied calcium alginate and clean border dressing. The LVN was not observed performing hand hygiene after touching the tablet and before removing the saturated wound dressing. The LVN was not observed performing hand hygiene after removing the saturated wound dressing before applying calcium alginate and clean border dressing. The Director of Patient Care services was interviewed on 5/4/2023 and agreed, the LVN did not follow the infection control policy on hand hygiene.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical record reviewed of a patient who was transferred to the hospital, revealed the hospice did not ensure the discharge summary was forwarded to the receiving facility. Record 12: The patient’s date of hospice election was 12/11/2021. The patient was transferred to the hospital and discharged effective 5/1/2022. There was no documented evidence in the clinical record that the discharge summary was forwarded to the receiving facility. In an interview on 5/3/2023, the Director of Patient Care Services agreed with the finding that there was no documented evidence that the discharge summary was provided to the receiving hospital.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician, a copy of the hospice discharge summary, and a copy of the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical record reviewed of a patient who revoked the hospice benefit, revealed the hospice did not ensure the discharge summary was forwarded to the patient's attending physician. Record 11: The patient’s date of hospice election was 4/30/2022. The patient revoked the hospice benefit and was discharged from the agency effective 6/10/2022. There was no documented evidence in the clinical record that the discharge summary was forward to the patient’s attending physician. In an interview on 5/3/2023, The Director of Patient Care Services agreed with the finding that there was no documented evidence the discharge summary was sent to the patient’s attending physician when the patient revoked the hospice benefit. Record 11: The patient’s date of election was 4/30/2022. The patient was discharged from the agency by revocation effective 6/10/2022. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. Record 12: The patient’s date of election was 12/11/2021. The patient was discharged from the agency upon hospitalization effective 5/1/2022. There was no documented evidence that the discharge summary was sent to the patient’s attending physician or hospital. The Director of Patient Care services was interviewed on 5/3/2023 and agreed, there was no documented evidence that the discharge summary was provided to the patient’s attending physician or hospital.