Every finding on record at Y.B.G. Healthcare LLC

It is required that the written Patient Bill of Rights includes the right to receive information about the services covered under the hospice benefit. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 3 (100%) home visit observations, the hospice did not ensure that the patient/caregiver received information about the medication(s) that were covered under the hospice benefit. Home Visit 1/Clinical Record3: The patient elected the hospice benefit on 8/17/2023, with terminal diagnosis of Parkinson’s disease. During the home visit observation, review of the medication profile provided to the patient revealed it did not include information to the patient on which medications were covered by the hospice benefit and which medications were the payment responsibility of the patient. Home Visit 2/Clinical Record2: The patient elected the hospice benefit on 7/13/2023, with terminal diagnosis of Alzheimer’s disease. During the home visit observation, review of the medication profile provided to the patient revealed it did not include information to the patient on which medications were covered by the hospice benefit and which medications were the payment responsibility of the patient. Home Visit 3/Clinical Record 4: The patient elected the hospice benefit on 8/25/2023, with terminal diagnosis of Alzheimer’s disease. During the home visit observation, review of the medication profile provided to the patient revealed it did not include information to the patient on which medications were covered by the hospice benefit and which medications were the payment responsibility of the patient. During an interviewed on 9/28/2023, the Administrator stated the drug profile had no place to indicate coverage. In 3 of 3 (100%) clinical records reviewed from the home visits revealed the hospice did not ensure that the patients/families received information about the medications that were covered under the hospice benefit.

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, 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 2 of 10 (20%) clinical records reviewed, the hospice did not ensure that the comprehensive assessment included a complete list of the patient's current medications. Clinical Record 8: The patient elected the hospice benefit on 6/23/2023, with terminal diagnosis of severe anemia. The physician ordered oxygen 2 LPM [two liters per minute] via nasal cannula upon admission dated 6/23/2023. Oxygen was not included on the patient’s medication profile included, as part of the comprehensive assessment. Clinical Record 10: The patient elected the hospice benefit on 8/11/2023, with terminal diagnosis of prostate cancer. Review of the medication profile revealed it included only the names of the medications and did not include the route of administration, dosage, frequency of administration or reason for administration of each medication. The clinical record included a physician order dated 9/3/2023 which ordered oxygen 1 to 5 LPM via nasal cannula. The medication profile was not updated to include oxygen. During an interview on 9/28/2023, the Administrator stated he was not aware that oxygen needed to be put on the medication list. He also stated for Clinical Record 10 he did not know why only the medications were listed and not all the other required components. In 1 of 10 (10%) clinical records reviewed revealed the hospice did not ensure that the drug profile was updated when a new medication was added.

It is required that a hospice aide provides services that are included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed, the agency did not ensure the hospice aide provided care as ordered on the plan of care. Clinical Record 1: The patient elected the hospice benefit on 6/1/2023, with terminal diagnosis of Alzheimer's disease. The hospice aide plan of care assignment dated 6/1/2023 instructed the aide to provide a shower or partial bed bath. The hospice aide documented on the visit note dated 8/25/2023 a tub bath, shower, partial bed bath and complete bed bath. During an interview on 9/28/2023, the Administrator confirmed this finding and stated they will be updating the hospice aide bath instructions/documentation to reflect the exact needs of the patient. In 1 of 10 (10%) clinical records reviewed in which a hospice aide (HA) provided services; it was revealed that the care provided by the HA was not consistent with the HA plan of care.

It is required that each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 4 of 10 (40%) clinical records reviewed, the hospice did not ensure the clinical record contained complete physician orders for wound care. Clinical Record 2: The patient elected the hospice benefit on 7/13/2023, with terminal diagnosis of Alzheimer’s disease. The Registered Nurse (RN) visit note dated 9/26/2023 included documentation that wound care was provided to wounds on the patient’s coccyx and mid back. The RN documented “dressings changed according to the order.” The physician’s order stated "Hydrocellular foam dressing and Medi Honey for pressure wounds on back (coccyx and mid back)." The order did not include what solution should be used to clean the wound or the frequency of the wound dressing change. Clinical Record 3: The patient elected the hospice benefit on 8/17/2023, with terminal diagnosis of Parkinson’s disease. On the RN visit note dated 9/15/2023, the RN documented a new stage 2 wound to the patient’s coccyx. The RN documented "wound cleansed and dressed with foam dressing." The clinical record contained no documented evidence of a physician order for wound care. Clinical Record 6: The patient elected the hospice benefit on 5/5/2023, with terminal diagnosis of Alzheimer’s disease. The RN visit note dated 5/8/2023 included documentation that the patient had skin tears to the right forearm and left hip. The RN documented “wounds cleansed, and new dressing applied.” The clinical record contained no documented evidence of a physician order for the wound care provided. Clinical Record 9: The patient elected the hospice benefit on 7/17/2023, with terminal diagnosis of Alzheimer’s disease. A physician order dated 7/17/2023 stated "wound assess/dressing change each visit as needed to L [left] buttocks stage 1 pressure wound." The physician’s order did not include evidence of what wound cleanser should be used to clean the wound, what dressing product(s) should be used to dress the wound, and the frequency of the wound care. The Administrator was interviewed on 9/28/2023 and stated he will be starting a PIP [performance improvement project] immediately that will focus on educating the nurses and physicians on writing complete wound care orders. In 4 of 4 (100%) records reviewed of patients with wounds revealed the hospice did not ensure the record included a physician’s order for the complete wound care.