Survey Report for 151521

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	151521	A. BUILDING __________ B. WING ______________	08/27/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
PROMEDICA HOSPICE	2720 DUPONT COMMERCE COURT, SUITE 210, FORT WAYNE, IN, 46825
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0500
L0500	42909 Based on observation, record review and interview, the hospice failed to ensure all patients received effective pain management and symptom control (See Tag L512); failed to evidence all patients chose their attending physician (See Tag L515); failed to evidence all patients received necessary treatment and services (See Tag L517); and failed to ensure all patients were informed of limitations on services provided (See Tag L519). These practices impacted all patients. The cumulative effect of these systemic problems resulted in the hospice's inability to ensure all patients' rights were maintained as required by the Condition of Participation §418.52 Patient Rights.
L0512	Rights Of The Patient 418.52(c)(1) Corrected On:
	42909 Based on observation, record review and interview, the agency failed to ensure all patients received effective pain management and symptom control or received it in a timely fashion for 3 of 3 patient records reviewed for symptom management (#1, 2, 4), in a sample of 9. Findings include: 1. Review of an agency policy #620 dated 6/2016 titled "Pain Management" stated "All patients have the right to appropriate assessment and management of pain ... consider alternate supportive measures of reducing pain ... consult with physician ...." Review of a reference document published in final edited form titled "J Pain Symptom Manage. 2010 May; 39(5): 803-819. doi:10.1016/j.jpainsymman.2009.09.025" stated "The five most concerning opioid-induced side effects were defined as: respiratory depression, sedation, nausea/vomiting, constipation and delirium ... Recommended treatments [for presence of opioid side effects] included any of the following ... a change in pain medication ... a decrease in pain medication ...." Review of a reference document titled "Providing Care and Comfort at the End of Life / National Institute on Aging" website https://www.nia.nih.gov/health/providing-comfort-end-life stated "Morphine is an opiate, a strong drug used to treat serious pain. Sometimes, morphine is also given to ease the feeling of shortness of breath ...." Review of a reference document titled "Pain Assessment IN Advanced Dementia (PAINAD)" website geriatricpain.org stated "... Monitor changes in the total score over time and in response to treatment to determine changes in pain ...." Prescribing information was reviewed from the Food and Drug Administration (FDA) regarding the medication morphine, on the website https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/202515s000lbl.pdf which stated " ...WARNINGS AND PRECAUTIONS: Dosing errors: Take care when prescribing and administering to avoid dosing errors due to confusion between different concentrations and between mg and mL, which could result in accidental overdose and death. ... May increase the risk of respiratory depression, hypotension, sedation, coma ... May increase respiratory depressant effects ...Hypotensive effect: May cause hypotension in ambulatory patients ...ADVERSE REACTIONS: The most serious adverse reaction encountered is respiratory depression, apnea, circulatory depression, respiratory arrest, shock, and cardiac arrest. Other common frequently observed adverse reactions include: sedation, lightheadedness, dizziness, nausea, vomiting, and constipation ...." Prescribing information was reviewed from the Food and Drug Administration (FDA) regarding the medication Ativan, on the website https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/017794s044lbl.pdf which stated" ...Warmings: Concomitant [naturally accompanying or associated] use of benzodiazepines, including Ativan, and opioids may result in profound sedation, respiratory depression, coma, and death. Because of these risks, reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate ...." Review of Medicare Code of Federal Regulations (CFR) §418.204(a): Special coverage requirements stated for continuous care, "Periods of crisis. Nursing care may be covered on a continuous basis for as much as 24 hours a day during periods of crisis as necessary to maintain an individual at home ... A period of crisis is a period in which the individual requires continuous care to achieve palliation and management of acute medical symptoms." Review of a reference document titled "Early deficits in cortical control of swallowing in Alzheimer's disease" dated 7/23/2010 website: www.ncbi.nlm.nih.gov > pmc > articles > PMC2891325 stated "... Dysphagia, or swallowing impairment, is a growing concern in Alzheimer's Disease (AD). It frequently leads to aspiration pneumonia, a common cause of death in this population [1], particularly in the later stage of AD [1-4] ...." 2. Clinical record review for patient #1 was completed on 8/27/2020 with a hospice election date of 12/12/2019, and primary diagnosis of Essential Hypertension. Patient was discharged from entity A (a skilled nursing facility) to home on 12/9/2019. The clinical record failed to evidence hospice accountability for spilled morphine, tramadol was offered for pain relief prior to initiation of morphine and Ativan, non-medicinal methods of pain relief was practiced, documentation regarding medication box reviewed/checked from the nurse to ensure family administered correctly, delivery of needed oxygen for comfort wasn't delayed, blood pressure medications were not discontinued for patient's low blood pressure readings, and the initiation of continuous care was not delayed as evidenced by: Review of a document received from entity A on 8/4/2020 titled "Discharge Instructions- Interdiscipline V2" for patient #1 dated 12/9/2019 stated the condition of the patient upon discharge from the skilled nurse facility was: "... Blood Pressure 141/73 ... O2 sats 98% ... pain level 0 ... how is the resident being transported? Family car ... dressing/grooming ... 1 person assist ... transfers ... 1 person assist ... bathing ... 1 person assist ... continent of bowel ...." Furthermore, the document indicated the patient was being discharged with home health care (not hospice) and was to receive home health aide, home health nurse, physical therapy, and occupational therapy services. (This document was not part of the hospice record.) Review of a document received from entity A on 8/4/2020 titled "Physician Progress Note (SPN-V2" for patient #1, signed by an entity nurse practitioner on 12/4/2019 stated "... Blood pressure 127/68 ... appears in no acute distress ... lungs clear ... no cough ... heart rate regular ... alert to time, person, place and situation ... normal mood ...." (This document was not part of the agency's clinical record.) Review of documents received from entity A on 8/27/2020 titled "Medication Administration Record" for October, November, and December 2019 evidenced patient #1 had an order for Tramadol 50mg every 6 hours for moderate to severe pain. In October, the medication was administered 11 times. In November, pain level was assessed every shift, was reported once at "1", once at "2", and once at "3". Tramadol was not given in November. In December (patient was discharged 12/9/2019), pain was reported pain level "1" on three shifts, and she did not receive any Tramadol. (This document was not part of the agency's clinical record.) During an interview on 8/27/2020 at 9:30 a.m., when asked if the patient was making good progress in therapy upon discharge, director of nursing for entity A stated "Yes." When asked if the patient was alert, oriented and competent to make her own decisions upon discharge, she said "Yes." Review of a document titled "Visit Note Report" (Hospice start of care) dated and signed 12/12/2020 at 9:41 p.m. by employee P (registered nurse) stated "... Respirations 16 [normal] ... Pain 0 [no pain] ... alert ... oriented to place ... oriented to person ... indicate all observed abnormal cognitive [conscious intellectual activity such as thinking, reasoning, or remembering] functions ... abnormal "new" learning ability ... pain ... Patient response "Are you uncomfortable because of pain?"... Yes ... pain score 0 [no pain] ... pain reported by : Patient alone ... patient is over 18 and able to answer ... worst level in the last 24 hours for pain (0-10) ... 5 ... frequency of pain ... daily, but not constantly ... current level of pain ... none ... was the patient's ability to safely administer medications assessed? No ... Indicate the reason ... Daughter sets up ... Indicate burden of care ... family must administer medications, family/support feels overwhelmed, family/support sleep disturbed with patient's care, patient's care causes extra physical stress, illness causes changes in family lifestyle, family experiencing increased time demands ... Patient takes tramadol 50mg Q6 [hours] prn for back pain ... short of breath when ambulating ... O2 sats 80% on room air [no oxygen was ordered]...." Review of a document titled "Hospice Certification and Plan of Care" start of care date 12/12/2019 indicated a primary diagnosis essential (primary) hypertension (high blood pressure), evidenced that the patient had difficulty breathing with minimal exertion and medications (but not limited to) Tramadol 50mg every 6 hours as needed for back and pelvic pain, losartan 100 mg every day for hypertension, and metoprolol tartrate 100mg every day for hypertension. Review of a document titled "Hospice Physician Order" dated and signed 12/13/2019 at 11:47 a.m. by employee I (registered nurse), and signed by employee H (hospice physician) on 12/16/2019 stated "Start morphine concentrate 20mg/ml give 5mg [0.25ml] SL [under tongue] Q [every] 4 hours prn [as needed] for pain or shortness of breath ... Start lorazepam intensol 2mg/ml give 0.25ml SL Q 4 hours prn for restlessness or shortness of breath ... start atropine 1% give 4 drops SL Q 4 hours prn for secretions." (The orders were received though the patient had not been assessed). Review of a document titled "Visit Note Report" dated and signed 12/13/2019 at 3:28 p.m. by employee I (registered nurse) stated "... respirations 18 ... WNL [within normal limits] ... Blood pressure 129/52 ... Oxygen saturation level (%) 97 [within normal limits] ... pain 0 ... alert ... oriented ... pain ... Patient response "Are you uncomfortable because of pain?" ... No ... pain reported by: Patient alone ... patient is over 18 and able to answer ... patient has no pain ... frequency of pain ... daily, but not constantly ... current level of pain ... none ... alert and oriented x3, occasional forgetfulness ... she is able to make her needs known ...." The document further indicated the caregiver stated the patient was short of breath with minimal exertion, though not evident within the assessment. Review of a document titled "Visit Note Report" (as needed visit for condition change) dated and signed 12/16/2019 at 10:15.m. by employee I (registered nurse) stated "... respirations 16 ... WNL ... Blood pressure 108/52... Oxygen saturation level (%) 94 ... pain 2 ... alert ... oriented ... lethargic ... no abnormal respiratory findings ... lung fields clear bilaterally ... [patient denied difficulty breathing, shortness of breath] ... pain ... Patient response "Are you uncomfortable because of pain?"... Yes ... pain score 2 ... pain reported by: Patient alone ... patient is over 18 and able to answer ... frequency of pain ... less often than daily ... increased lethargy ... episodes of nausea ... writer offered [patient] pain medication x3 during visit and [patient] refused stating that she was fine for now ...." The document revealed the patient received at least one dose of morphine since ordered, the patient exhibited potential side effects of morphine including lethargy and nausea, no evidence of offering tramadol instead of morphine for pain, no evidence of non-medicinal measures to mitigate pain. Review of a document titled "Hospice Physician Order" dated and signed 12/16/2019 at 9:01 a.m. by employee I (registered nurse), and signed by employee H (hospice physician) on 12/31/2019 stated "Start ondansetron 4mg give 1 tab SL [sublingual-under tongue] Q 6 hours prn for nausea or vomiting." Review of a document titled "Visit Note Report" (Hospice on call visit) dated and signed 12/17/2019 at 10:04 p.m. by employee Y (licensed practical nurse) stated "... Respirations 16 ... WNL ... Blood pressure 110/52 ... Pain 0 ... alert ... no abnormal cognitive functions identified ... no abnormal respiratory findings ... lung fields clear bilaterally ... Are you uncomfortable because of pain? No ... talked with daughter ... she noted [patient] sleeping more ...." The record failed to evidence how much morphine was given by family, if tramadol was offered instead, or non-medicinal measures to mitigate pain. The visit was requested by the daughter for decreased urinary output. Review of a document titled "Visit Note Report" (PRN visit for condition change) dated and signed 12/18/2019 at 3:23 p.m. by employee I (registered nurse) stated "... Respirations 16 ... WNL ... blood pressure 93/50 ... pain 2 ... alert ... oriented to place ... person ... forgetful ... lethargic ... anxiety ... abnormal breath sounds ... increased secretions ... crackles [lung sounds indicating presence of fluid] ... upper right ... upper left [lungs] ... does dyspnea significantly affect the patient? No ... Are you uncomfortable because of pain? No. Pain reported by patient alone ... patient is over 18 and able to answer ... patient has no pain ... [patient] was awake ... immediately began crying ... [patient] explained ... her daughter had to leave early today and didn't get the opportunity to say goodbye ...." The document failed to evidence physician notified to potentially discontinue blood pressure medication, or change in condition with respiratory status. Review of a document titled "Visit Note Report" (PRN visit for condition change) dated and signed 12/19/2019 at 12:45 p.m. by employee X (licensed practical nurse) stated "... Respirations 16 ... WNL ... blood pressure 105/57 ... Oxygen saturation level (%) 93 ... pain 0 ... oriented to person ... forgetful ... diminished breath sounds ... Are you uncomfortable because of pain? No ... patient is over 18 and able to answer ... patient has no pain or pain does not interfere with activity or movement ... arrived to [patient] for prn visit for pain control ... writer administered morphine 5mg ... notified [case manager] morphine needed ordered due to [daughter] spilling last evening. [patient] resting with eyes closed." The document indicated the patient denied pain, but the nurse administered morphine. The record failed to evidence documentation of doses family administered, how much morphine was left in bottle after daughter spilled it, patient's response to morphine administered, if tramadol was offered instead, non-medicinal measures taken to mitigate pain, and no evidence patient's pain and symptoms were out of control. Review of a document titled "Hospice Physician Order" dated and signed 12/19/2019 at 12:42 p.m. by employee I (registered nurse), and signed by employee H (hospice physician) on 12/31/2019 stated "Discontinue current morphine concentrate orders. Start morphine concentrate 20mg/ml give 10mg [0.5ml] SL Q 6 hours routine for pain or shortness of breath ... Start morphine concentrate 20mg/ml give 10mg [0.5ml] SL hourly prn for pain or discomfort." Order written prior to employee I assessing the patient on the same day, and was a significant increase in dose and frequency without assessment data to verify need for increase. Review of a document titled "Visit Note Report" (RN hospice continuous care evaluation) dated and signed 12/19/2019 at 2:48 p.m. by employee I (registered nurse) stated "... Respirations 16 ... WNL ... blood pressure 98/49 ... oxygen saturation level (%) 98 ... pain 3 ... alert ... oriented to person ... agitated ... pain is out of control ... current pain score 3 ... Are you uncomfortable because of pain? Yes ... pain score 3 ... patient is over 18 and able to answer ... increased lethargy ... PAINAD assessment ... occasional labored breathing w/ short periods of hyperventilation ... repeated, troubled calling out ... loud moaning or groaning ... crying ... facial grimacing ... body language ... rigid, fists clenched, knees pulled up, pulling or pushing away, striking out ... were prn medications needed for pain since last visit? Yes ... how many ... indicate effectiveness ... 3 doses given ... effective ... [narrative] assess [patient] for continuous care due to increased pain ... and restlessness r/t [related to] disease progression and transition towards actively dying ... writer administered routine dose of lorazepam and this was effective at controlling restlessness ... respirations ... unlabored ... rapid decline ... symptoms out of control ... continuous care will begin as soon as staff members are available ... medications reordered for next day delivery ...." The document evidenced pain management was effective with current dose of morphine, restlessness was controlled with administration of current dose of lorazepam, evidenced the patient stated her pain level was a 3 (mild pain), low blood pressure was not addressed to potentially discontinue blood pressure medication(s), and PAINAD assessment routinely used for patients with advanced cognitive impairment or those who could not answer for self. Review of a document titled "Hospice Physician Order" dated and signed 12/19/2020 at 2:21 p.m. by employee M (registered nurse), and signed by employee H (hospice physician) on 12/23/2019 stated "Start continuous care due to symptoms out of control and medication changes ...." Review of a document titled "Visit Note Report" dated and signed 12/20/2019 at 9:29 a.m. by employee I stated "... pulse 113 ... respirations 18 ... WNL ... Blood pressure 89/50 ... oxygen saturation level (%) 74 ... on room air ... abnormal breath sounds ... hypoxia ... Does the patient require oxygen? Yes ... 2-3 L/MIN VIA NC [2-3 liters per minute via nasal cannula) ... as needed ... currently under treatment ...." The document evidenced patient's oxygen saturation level indicated severe hypoxia/hypoxemia, a below-normal level of oxygen in the blood which required immediate oxygen therapy, there was no oxygen for use in the home at that time, and physician was not contacted to potentially discontinue blood pressure medication(s). Review of a document titled "Visit Note Report" dated and signed 12/20/2019 at 10:18 p.m. by employee E (licensed practical nurse) evidenced the patient's oxygen saturation level of 79%, an entry which stated "... 1830 [6:30 p.m.] O2 [oxygen] company here delivering concentrator [oxygen machine]. Pt [patient] O2 Sat [saturation] on RA [room air] 70 [percent]. Placed on O2 2LNC [2 liters nasal cannula] sat 72%. Increased O2 to 3L/NC O2 Sat78-80% ...." Patient waited over 8 hours for oxygen for symptom relief, and physician was not contacted to potentially discontinue blood pressure medication(s) for blood pressure 89/50, 98/48. Review of a document titled "Hospice Physician Order" dated and signed 12/21/2019 at 11:07 a.m. by employee W (registered nurse), and signed by employee G (medical director) on 12/23/2019 evidenced the following medications were discontinued: allopurinol, chlorthalidone, docusate sodium, levothyroxine, losartan, metoprolol tartrate, probiotic, and tramadol, and lorazepam frequency was changed from every four hours as needed to every four hours routine. Review of a document titled "Visit Note Report" dated and signed 12/21/2019 at 12:20 p.m. by employee W stated "... Patient unable to verbalize ... patient unable to respond ... medications can be given hourly ...." The document failed to evidence a PAINAD assessment was completed, or the nurse informed family about medications discontinued per order. Review of a document titled "Hospice Physician Order" dated and signed 12/22/2019 at 12:32 p.m. by employee W (registered nurse), and signed by employee G (medical director) on 2/11/2020 stated "... change Ativan 0.5ml to be given Q 2 hours routine ... change morphine 0.5ml to be given Q hour routine ... reason: [Ativan] dyspnea [difficulty breathing] and restlessness ... [morphine] pain and dyspnea." The order failed to indicate assessment data to rationalize an increased amount of Ativan/morphine, vital sign or other parameters to withhold the medications. Review of a document titled "Visit Note Report" dated and signed 12/22/2019 at 2:29 p.m. by employee W stated "... Patient unable to verbalize ... patient unable to respond ... obtained orders to change the frequency of Ativan and morphine ... apnea [periods of not breathing] has increased and become longer ...." The document failed to evidence a PAINAD assessment was completed. The frequency of the Ativan was increased from every 4 hours routine to every 2 hours routine, and morphine frequency was increased from every 6 hours routine and every hour as needed to every 1 hour routine. Review of a document titled "Visit Note Report" (continuous/extended care visit) dated and signed 12/22/2019 at 8:04 p.m. by employee E stated "... comatose ... unresponsive ... unresponsive this morning ... hypoxia ... [8:01 a.m.] ... sleeping in bed, sonorous, no apnea noted. Mouth open snoring ... eyes closed. [patient] is unresponsive ... BP [blood pressure] 77/40 ... medicated with morphine 10mg and Ativan 1mg SL ... [9:00] ... gave [patient] a bed bath ... changed linen ... continues to be unresponsive ... [10:00 a.m.] atropine administered for gurgling ... [2:50 p.m.] medicated with morphine and Ativan ... remains unresponsive ... [4:50 p.m.] medicated with morphine and atropine ... [5:43] [patient] took last breath ...." The nursing visit occurred from 8:20 a.m. - 8:04 p.m. During an interview on 8/3/2020 at 11:45 a.m., family indicated patient thought she was going to receive therapy at home to get better. During an interview on 8/5/2020 at 8:02 p.m., family (person K) indicated on 12/22/2019 employee E asked her to administer a syringe of pink/amber colored liquid into mother's mouth, while the patient was unconscious. Person K stated the medication leaked out and onto her face, and employee E yelled at her not to touch it when she went to wipe it off. Employee E told person K it was a dangerous drug. Person K stated she regretted giving the medication because the patient died within minutes after administration. Person K stated "I don't want this to ever happen to someone else ...." During an interview on 8/6/2020 at 11:15 a.m., family (person M) stated "I watched the nurse hand her medication at around 5:40 p.m., she [another family member] gave it, and [patient] died within a few minutes." During an interview on 8/10/2020 at 10:24 a.m., family (person L) stated "[patient] was never deemed unable to make her own decisions prior to this." During an interview on 8/26/2020 at 6:11 p.m., family (person M) indicated on 12/22/2019 there were there. Person M indicated a dose of something was given at about 5:00 p.m. She stated employee E handed it to person K to give, then gave her another syringe about 5:40 p.m. Person M stated when person K administered medication, it dripped out of her mouth and when person K went to wipe it off the patient's face, employee E said "Don't touch ... dangerous." They indicated the patient died within minutes after administration of medication. Furthermore, employee E also said she was leaving at 8:00 p.m. due to no further coverage after that. Person M described employee E as "callous, numb to the dying process." She stated the patient was a naturalist, would not have accepted medications, especially if she would have known it was morphine given to her. Lastly, person M stated "how can a nurse give or instruct family to give a narcotic to a visibly unconscious person? It bothers me to this day." 3. Clinical record review for patient #2 was completed on 8/27/2020 with a hospice election date of 10/2/2018, and primary diagnosis of Alzheimer's disease. The record failed to evidence patient was high risk for aspiration (due to dysphagia) or implemented interventions, failed to evidence the agency promptly responded to patient's potential aspiration related to recurrent emesis (vomiting), or interventions for constipation as evidenced by: Review of all visit notes from 1/2/2019 - 4/29/2019, all failed to evidence the patient's last bowel movement, stated was "unknown." Review of a document titled "hospice CTI [certificate of terminal illness]" dated and signed by physician H on 10/4/2018 stated "... Meals consist of modified diet with honey thick liquids [specific diet and liquids for those at risk for aspiration] diet and is requiring assistance with eating due to dysphagia ...." Review of a document titled "Visit Note Report" (RN Hospice start of care) dated and signed by employee K (registered nurse) on 10/02/2018 at 9:08 p.m. stated (patient history 9/2018) "... She is chin to chest ... Diet changed to honey thick liquids. A swallow study was ordered, but unable to be performed due to rigidity and head drop. She is unable to maintain proper positioning ... Daughter states she coughs after drinking ...." Review of a document titled "Hospice Certification and Plan of Care" for benefit period 10/2/2018 - 12/30/2018 stated "... Nutritional Requirements: Diet as tolerated ...." The document failed to evidence the patient had dysphagia, required a modified diet with honey thick liquids, the patient was at high risk for aspiration, orders to assess for aspiration, interventions to prevent aspiration, or family specific wishes/goals for treatment of aspiration. Review of a document titled "Visit Note Report" dated and signed on 1/2/2019 by employee J (registered nurse) stated "... Patient is at a high nutritional risk ... actions to be taken ... monitor weight ...." The record evidenced documentation of weights being monitored only twice between 01/02/2019 - 4/29/2019. Review of a document titled "Client Coordination Note Report" dated 2/22/2019 entered by employee AA stated "125AM [1:25 a.m.] call came from service. 126AM return call to ... facility nurse reports pt [patient] has lg [large] brown, foul smelling emesis. Hemoccult [sic] tested positive for occult blood in emesis. Reported to [employee Z] to do nurse visit." Review of a document titled "Visit Note Report" dated and signed on 2/22/2019 at 11:00 p.m. by employee Z (registered nurse) stated "... oxygen saturation level (%) 93 ... Was the patient's respiratory system assessed? No ... Indicate reason ... Not appropriate at time of evaluation ... Was the patient's gastrointestinal system addressed? No ... Indicate reason ... Not appropriate at time of evaluation ... Indicate if you communicated with other disciplines involved with this case: No ... patient had large emesis that was siluspected [sic] to be bloody ...." The document failed to evidence the patient was assessed for potential aspiration, any interventions were performed, or family notification of the change in condition. Review of a document titled "Visit Note Report" dated and signed on 2/23/2019 at 8:00 a.m. by employee BB (registered nurse) stated "... On call visit ... patient was reported to have vomited with blood in her vomit ... Medical Director gave new order to push fluids as he believes the patient is dehydrated ...." The document evidenced the patient had increased secretions, her nutritional risk was low, last bowel movement was unknown, and failed to evidence the patient was assessed for aspiration. Review of a document titled "Visit Note Report" dated and signed on 2/24/2019 at 12:00 p.m. by employee CC (licensed practical nurse) indicated the patient's gastrointestinal system was not assessed, and lab results included (but not limited to) elevated white blood cell count (indicative of infection). Review of a document titled "Visit Note Report" dated and signed on 2/27/2019 at 2:22 p.m. by employee J (registered nurse) stated "... Respiratory ... abnormal breath sounds ... hypoxia [insufficient oxygen reaching the blood] ...." Interventions and goals failed to evidence No nursing interventions were performed related to risk for aspiration, GI (gastrointestinal) bleed or elevated white blood cell count. Review of a document dated 3/7/2019 titled "Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report" failed to evidence the IDG reviewed the patient's symptoms, and failed to implement interventions and goals related to risk for aspiration, GI (gastrointestinal) bleed or elevated white blood cell count. Review of a document dated 3/21/2019 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" failed to evidence the IDG reviewed the patient's symptoms, and failed to implement interventions and goals related to risk for aspiration, or elevated white blood cell count, rather only stated "... Monitor GI status for further signs of bleeding ...." Review of a document titled "Visit Note Report" dated and signed on 3/25/2019 at 1:24.m. by employee DD (licensed practical nurse) evidenced new lower extremity edema, lungs were clear, signs of decorticate (abnormal posturing of arms due to brain injury) to both upper extremities, and failed to evidence the agency nurse or physician was notified. Review of a document titled "Visit Note Report" dated and signed on 4/4/2019 at 1:58 p.m. by employee J (registered nurse) evidenced respirations 22 (above normal) and shallow, abnormal heart sounds, irregular heart rhythm, pallor (pale), "distant heart tones", abnormal breath sounds, abnormal rhythm, use of accessory muscles (indicating difficulty breathing), patient on current respiratory treatment, she offered tea to patient and patient drank approximately 200cc (just under 1 ounce). The record failed to evidence any orders for respiratory treatment as of 4/4/2019, if the tea was prepared as honey thick, or the physician was notified for new clinical findings. Review of a document dated 4/4/2019 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" failed to evidence the IDG reviewed the patient's symptoms, and failed to implement interventions and goals related to the change in clinical findings from that day's visit. Review of a document titled "Visit Note Report" dated and signed on 4/10/2020 by employee J (registered nurse) stated "... pureed diet with honey thick liquids, pocketing fluid, excess secretions, difficulty swal
	lowing ... lung sounds diminished throughout with expiratory wheezes noted ...." Review of a document titled "Visit Note Report" dated and signed on 4/17/2020 by employee J (registered nurse) stated "... recent infections ... 4/17/19 URI [upper respiratory infection] ... seen by facility NP [nurse practitioner] today and new orders for mucinex and Bactrim for URI [upper respiratory infection] ...." Review of a document dated 4/18/2019 titled "Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report" failed to evidence the IDG reviewed the patient's symptoms, and failed to implement interventions and goals related to the patient's physical decline with new onset URI, that the patient was a high risk for aspiration, her specialized diet, or monitoring for GI bleed. Review of a document titled "Visit Note Report" dated and signed on 4/24/2020 by employee J (registered nurse) stated "... duonebs [respiratory inhalation breathing treatments] x 14 days ... Dtr [daughter] reported concerns about wheezing and something possibly stuck in her throat earlier this week ... assessed patient lung sounds with wheezes in bilat [bilateral] upper lobes ...." Review of a document received from entity C dated 4/29/2019 at 11:45 a.m. titled "SBAR Communication form" stated "... Cyanotic; possible aspiration ... send to ER." This document was not part of the patient's hospice record submitted by agency. Review of a document titled "Visit Note Report" dated and signed on 4/29/2020 by employee J (registered nurse) for visit time in home 11:16 a.m. - 11:46 a.m., then back from 12:20 - 12:32 p.m. stated "... Visit today due to continued emesis [vomiting] ... suspected GI bleed ... cyanosis [blue/gray skin color from lack of oxygen] ... lung sounds coarse throughout ... patient expired ...." During an interview on 8/3/2020 at 7:41 p.m., family indicated she asked employee J to get a chest X-ray in April (2019) when the patient starting experiencing symptoms of aspiration, and stated she heard the patient "gurgling". Family stated employee J "refused" to get the X-ray, and no one informed her that the patient had been vomiting for a couple of days prior to her death. Furthermore, the family stated the patient died from "internal hemorrhage, "though the death certificate said "Alzheimer's" as cause of death. The family indicated they were upset because the patient didn't die from the Alzheimer's. Lastly, the family indicated the patient's spouse sat with the patient the morning of their death and indicated the patient was cold to touch- on the face and arms. During an interview on 8/6/2020 at 12:16 p.m., person B (a paramedic) indicated on 4/29/2020, a nurse from entity C told him the patient had vomited blood, and had been that way for a couple of days. Person B indicated the hospice nurse had left the facility prior to the patient's death and had to be called back, and the facility nurse instructed him to talk to the patient's family and notify of death. During that time, a document titled "Patient Chart" (an ambulance call log report) was reviewed which stated " ...Unconscious ... Patient has not been feeling well and has been vomiting blood ... Pt was deteriorating last night and had been sweating through the night. Hospice states "pt is on hospice and is a DNR [do not resuscitate] but daughter wants pt transported to hospital to see what's going on ... 12:03 ... Pt has cough/dry heave and coffee ground vomit is running out of the pt mouth ... Time of death 1207 [12:07 p.m.] ... moved back in to bed at [entity C] ...." During an interview on 8/6/2020 at 12:37 p.m., the patient's daughter indicated she was not informed the patient had been vomiting blood for two days, she would have sent her to the ER then. 4. During a home visit for observation of patient #4 on 8/26/2020 at 8:30 a.m., hospice election date of 8/7/2020 with primary diagnosis Alzheimer's disease. Employee A was observed and interviewed. The patient's oxygen saturation fluctuated between 88-92%. When asked if the patient should have had oxygen administered, employee A stated the agency didn't order oxygen unless the patient had "distress" and indicated oxygen was contraindicated at imminent death because it would give the family false re-assurance. When asked if the physician should be notified for oxygen saturation less than 90%, employee A indicated it was up to the physician to decide. When asked if she would give morphine or Ativan to a completely unresponsive patient, she stated "I do not personally here because it's a facility. Otherwise it's a case by case, especially with turning and repositioning."
L0515
L0515	42909 Based on record review and interview, the hospice failed to ensure all patients chose their own attending physician for 1 of 1 patient families interviewed regarding the attending physician (#1) in a total sample of 9. Findings include: Review of agency policy 500-H dated 11/2017 titled "Hospice Only Policy Admission" stated "... The patient's chosen attending physician and hospice medical director or physician designee certify patient eligibility ...." Review of the agency's patient care information handbook (given to patients upon admission to hospice) stated "... Your Rights and Responsibilities ... You may choose your attending physician ...." Clinical record review for patient #1 was completed on 8/27/2020 with hospice election date of 12/12/2019, and primary diagnosis of Essential Hypertension. Patient was discharged from entity A (a skilled nursing facility) to home on 12/9/2020. Review of a document received from entity A on 8/27/2020 titled "Progress Notes" stated "Resident [patient #1] is alert. Oriented to person, place, time and situation ... Effective Date: 12/4/2019 ... Type: Physician Progress Note ...." Review of a document titled "Election of Hospice Benefit" dated 12/12/2019, was not signed by the patient, but signed by person J (a daughter of patient #1). Review of a document titled "Visit Note Report" (RN Hospice Start of Care visit) dated and signed 12/12/2019 at 9:41 p.m. by employee P stated "... alert ... oriented to place ... oriented to person ... patient is over 18 and able to answer ... occasional forgetfulness ...." The document failed to evidence the patient authorized anyone to sign on her behalf to elect physician H as the primary physician. Review of an agency document dated 8/26/2020, titled "Client Coordination Note Report" evidenced per the DPS (director of patient services) that it was an intra-agency email log between agency and entity G, which stated "... Primary Physician [physician I] ... 12/10/19 ... still need to get the order from [physician I] ... 12/11/19 ... [home care nurse] I believe patient is hospice appropriate, but no records to back it up ... 12/12/19 ... Please request records ASAP from [physician I] ... 12/12/2019 ... Patient found eligible per [physician H] ...." The document failed to evidence collaboration from physician I. Review of a document received from the DPS on 7/27/2020 titled "Heartland Home Health Account Liaison Patient Discharge Checklist" dated 12/9/2019 evidenced the patient's primary physician was physician I. Review of a document received on 8/27/2020 from physician I office, dated 12/9/2019 at 2:07 p.m. evidenced documentation of a telephone conference with person J (patient's daughter), which stated "Daughter phones stating she needs orders for patient for a wheelchair and a hospital bed. Patient is being discharged from nursing home today. [Entity A] can't write orders due to there is no diagnosis to support The [sic] chair and bed. Patient has an appointment with [physician I] on 12/18/2019, the NP's [nurse practitioners] in this office are not able to write for DME [durable medical equipment] that the patient needs. Daughter has been informed and will keep the appointment with [physician I]." Review of a questionnaire document received on 8/27/2020 from physician I, dated 8/27/2020 on letterhead from the Indiana Department of Health evidenced physician I was the patient's primary care provider, he did not initiate a referral to the hospice, and was unaware the patient was placed on hospice services. During an interview on 8/6/2020 at 4:10 p.m., the Director of Professional Services (DPS) indicated the agency had no policy for hospice election of benefits. During an interview on 8/25/2020 at 10:00 a.m., when asked if the patient signed the election of benefits (EOB) form (which specified attending physician), the DPS indicated it would go to the patient first if the patient was alert and oriented, if not, then the power of attorney (POA). When asked what documentation was in patient #1's chart which evidenced the patient authorized her daughter to sign on her behalf, the DPS indicted it should be in the start of care narrative, but failed to evidence documentation patient #1 authorized anyone to sign on her behalf or elected physician H as her primary physician. During an interview on 8/25/2020 at 12:00 p.m., when asked if he would expect to see clinical notes/progress reports from the patient's primary physician to corroborate findings, the DPS stated "Yes. Collaboration is the key." When asked where documentation would be located in the clinical record, the DPS stated "... If they choose our [physician] it would be in the start of care narrative ...." During an interview on 8/25/2020 at 3:05 p.m., when asked if she would expect to see clinical notes/progress reports from the patient's primary physician to corroborate findings, the administrator stated "Absolutely." When asked what circumstances was it appropriate for a POA to sign on behalf of a patient, the administrator stated "If patient is not competent or able to sign." During an interview on 8/27/2020 at 3:40 p.m., when asked where patient #1's chart evidenced documentation the patient elected physician H as her attending, the administrator indicated it did not.
L0517
L0517	42909 Based on observation, record review and interview, the hospice failed to ensure its patients were free from neglect and received all treatments and services necessary to meet their needs for 9 of 9 records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9). Findings include: 1. Review of a reference document N Engl J Med 1995 Feb 16; 332(7):437-43 titled "Abuse and Neglect of Elderly Persons" stated "[patient neglect, defined as] "the failure of a designated caregiver to meet the needs of a dependent." Review on 8/26/2020 of a reference document dated 2019, titled Wound, Ostomy and Continence Nurses Society. Wound, Ostomy and Continence Nurses Society's guidance on OASIS-D integumentary items: Best practice for clinicians. Mt. Laurel, NJ: Author stated "... Stage 1 Pressure Injury ... intact skin ... Stage 2 Pressure Injury ... partial thickness skin loss ... wound bed is ... pink or red ... slough [yellow devitalized tissue] ... not present ... Stage 3 Pressure Injury ... full thickness skin loss ... slough ... may be visible ...." 2. Clinical record review for patient #1 was completed on 8/27/2020 with a hospice election date of 12/12/2019, and primary diagnosis of Essential Hypertension. Patient was discharged from entity A (a skilled nursing facility) to home on 12/9/2020, with a referral physical therapy (PT), and occupational therapy (OT) services. The clinical record failed to evidence the patient received PT or OT, the patient's oxygen treatment was delayed, and the order to receive continuous care was delayed. Review of a document from entity A (not included in the hospice record submitted for review by the agency) signed by a nurse from entity A on 12/9/19 stated "... Home Health/Referrals ... Physical Therapy ... Occupational Therapy ...." Review of an agency document dated 12/12/19 titled "Hospice Certification and Plan of Care" for benefit period of 12/9/19 - 3/10/2020 failed to evidence PT or OT was ordered/provided for the patient. Review of a document titled "Hospice Physician Order" dated and signed 12/19/2020 at 2:21 p.m. by employee M (registered nurse), and signed by employee H (hospice physician) on 12/23/2019 stated "Start continuous care due to symptoms out of control and medication changes ...." Review of a document titled "Visit Note Report" dated and signed 12/20/2020 at 9:29 a.m. by employee I (registered nurse) evidenced the patient's oxygen saturation level of 74% (indicated severe hypoxia/hypoxemia, a below-normal level of oxygen in the blood which required immediate oxygen therapy). The note stated "... oxygen concentrator for use if needed ...." There was no oxygen for use in the home at that time. Review of a document titled "Visit Note Report" dated and signed 12/20/2020 at 10:18 p.m. by employee E (licensed practical nurse) evidenced the patient's oxygen saturation level of 79%, an entry which stated "... 1830 [6:30 p.m.] O2 [oxygen] company here delivering concentrator [oxygen machine]. Pt [patient] O2 Sat [saturation] on RA [room air] 70 [percent]. Placed on O2 2LNC [2 liters nasal cannula] sat 72%. Increased O2 to 3L/NC O2 Sat78-80% ...." During an interview on 8/3/2020 at 11:45 a.m., family indicated patient #1 thought she was going to receive therapy at home to get better. During an interview on 8/25/2020 at 12:00 p.m., when asked if it would be appropriate to order oxygen as back up to ensure timely response to symptom management for a patient who was reported to be "very short of breath", the DPS stated "Yes ..." and indicated the physician would be called for an order, it took 2-4 hours to be delivered, and oxygen took precedence over everything else. When asked how soon he would expect continuous care to be initiated once ordered, the DPS stated "When we have someone available ... as soon as possible ...." When asked at what point was it considered to be "too long" to wait for continuous care to start because since continuous care was ordered and then staffed. The DPS did not provide an answer. During an interview on 8/25/2020 at 3:05 p.m., when asked if it would be appropriate to order oxygen as back up to ensure timely response to symptom management for a patient who was reported to be "very short of breath", the administrator stated "Yes." When asked how soon she would expect continuous care to be initiated once ordered, the administrator stated "... like an hour or two." 3. Clinical record review for patient #2 was completed on 8/27/2020 with a hospice election date of 10/2/2018, for the benefit period 1/2/19 - 4/29/2019 and primary diagnosis of Alzheimer's disease. The record failed to evidence SLP [speech language pathologist] or dietician was consulted while the patient received services from the agency, and failed to evidence the physician was ever consulted about an X-ray or the patient ever received a chest X-ray as requested by family. Review of a document titled "Visit Note Report" dated and signed on 1/2/2019 by employee J (registered nurse) stated "... Patient is at a high nutritional risk ... actions to be taken ... monitor weight ...." Review of a document titled "Visit Note Report" dated and signed on 4/10/2020 by employee J (registered nurse) stated "... pureed diet with honey thick liquids, pocketing fluid, excess secretions, difficulty swallowing ... lung sounds diminished throughout with expiratory wheezes noted ...." Review of a document titled "Visit Note Report" dated and signed on 4/17/2020 by employee J (registered nurse) stated "... recent infections ... 4/17/19 URI [upper respiratory infection] ...." Review of a document titled "Visit Note Report" dated and signed on 4/24/2020 by employee J stated "... duonebs [respiratory inhalation breathing treatments] x 14 days ... Dtr [daughter] reported concerns about wheezing and something possibly stuck in her throat earlier this week ... assessed patient lung sounds with wheezes in bilat [bilateral] upper lobes ...." Review of a document titled "Visit Note Report" dated and signed on 4/29/2020 by employee J stated "... Visit today due to continued emesis [vomiting] ... lung sounds coarse throughout ... patient expired ...." Review of a document dated 4/18/2019 titled "Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report" failed to evidence the patient's decline with new onset URI, patient was a high risk for aspiration, her specialized diet, or interventions and goals to assist with those issues. During an interview on 8/3/2020 at 7:41 p.m., family indicated she asked employee J to get a chest X-ray in April (2019) when the patient starting experiencing symptoms of aspiration, and stated she heard the patient "gurgling". Family stated employee J "refused" to get the X-ray, and no one informed her that the patient had been vomiting for a couple of days prior to her death. During an interview on 8/6/2020 at 12:16 p.m., person B (a paramedic) indicated on 4/29/2020, a nurse from entity C told him the patient was vomiting blood, and had been that way for a couple of days. During an interview on 8/27/2020 at 1:27 p.m., when asked if the patient should have had a chest X-ray for potential aspiration due to vomiting and underlying aspiration risk, the DPS indicated the facility physician should have followed up, and hospice was secondary. During an interview on 8/27/2020 at 3:44 p.m., when asked why SLP hadn't been consulted for the patient, the administrator submitted a clinical record document titled "Visit Note Report" signed and dated 10/02/2018 by employee K which stated "... A swallow study was ordered [prior to hospice admission], but unable to be performed ...." No further documentation was submitted that evidenced SLP was consulted while the patient was on service with agency. 4. During a home visit for observation of patient #3 on 8/3/2020 at 1:30 p.m., (hospice election date 5/11/2020), and a primary diagnosis of Parkinson's disease. The patient was observed lying in bed, with tremors, worse on right side, to both upper and lower extremities (patient was right-handed), was non-weight bearing, required hoyer (mechanical lift used to transfer patients, which occurred after hospice admission), and had recently become bedbound upon admission to hospice. Employee D (registered nurse) indicated hoyer training was offered but the family declined due to multiple nurses in the family. During this time, the patient stated "... wish I could figure out how to use a urinal [in bed]." Employee D stated "Yeah, it's hard." Family indicated they got the patient out of bed "last night", but his right foot kept falling off of the foot peg on the wheelchair. Observed wheelchair which lacked straps to secure the feet in place. Employee D indicated she was going to call the medical equipment company for follow up. When asked about patient specific goals, employee D indicated "Safety, maintain mobility as best as possible, adequate intake, prevention of skin breakdown, [and] pain." The patient indicated he wanted to go to his daughter's wedding in October, and stated "I gotta [sic] get up more. That foot thing [falling off of the foot peg on the wheelchair] is really bothering me." Employee D acknowledged previous knowledge of the patient's personal goal. When asked if the agency provides therapy services, employee D stated "No. Maybe a visit or two for safety or transfers." Clinical record review for patient #3 was completed on 8/27/2020 with hospice election date of 5/11/2020, and primary diagnosis of Parkinson's disease. The record failed to evidence PT or OT was consulted for the patient's stated personal goals, or the nurse followed up with the equipment company to ensure the patient's wheelchair could accommodate his physical needs. Review of a document dated 8/3/2020 signed by employee D titled "Visit Note Report" stated "Pt [patient] reports he got out of bed via hoyer lift yesterday and sat up in his wheelchair. Pt was happy with getting out of bed, he states that he doesn't want to be in bed all the time. Pt states his tremors are bothersome ...." The document failed to evidence employee D followed up with the medical equipment company, followed up with the physician for the patient's stated personal goals, which included getting up and able to go to daughter's wedding (transfer/strengthening training- opportunity for PT), difficulty using utensils to eat, and using a urinal in bed (improved upper body movement/control- opportunity for OT). Review of documents dated 8/11 and 8/25/2020 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" failed to evidence the patient's stated concerns from the observed home visit on 8/3/2020 were addressed. During an interview on 8/3/2020 at 11:20 a.m., the DPS indicated the agency didn't provide any PT except short term for safety or transfers. The administrator indicated "Like quality of life." During an interview on 8/5/2020 at 2:47 p.m., when asked if the agency provides OT, the DPS stated "Not typically. We don't typically do therapies. That's more home care." 5. Clinical record review for patient #4 was completed on 8/27/2020, hospice election date of 8/7/2020 with primary diagnosis Alzheimer's disease. The record failed to evidence the physician was contacted for low oxygen saturation readings, failed to evidence the patient's wound was addressed and treated upon admission, was not addressed until 8/19/2020, was not treated until 8/20/2020, the physician was not notified for oxygen saturation levels (%) 73 and 75, and failed to evidence a dietician was consulted for a patient documented as high nutritional risk. During a home visit for observation of patient #4 on 8/26/2020 at 8:30 a.m., employee A was observed and interviewed. The patient's oxygen saturation fluctuated between 88-92%. When asked if the patient should have had oxygen administered, employee A stated, the agency didn't order oxygen unless the patient had "distress" and indicated oxygen was contraindicated at imminent death because it would give the family false re-assurance. When asked if the physician should be notified for oxygen saturation less than 80%, employee A indicated it was up to the physician to decide. When asked if the patient had any open skin areas, employee A indicated the patient had a stage 1 pressure ulcer on her backside, it was treated with calmoseptine (an over the counter barrier cream used for minor skin irritations such as diaper rash), and she would assess it when the aides got there. When asked how often wounds should be assessed, she stated "We are required to do them weekly." At 9:24 a.m., when asked to describe the coccygeal (backside/tailbone) wound, employee A indicated it was a stage 2 (pressure injury), 2.0cm (length) x 1.0cm (width) x 0.1-0.2cm (depth). When asked if there was adipose tissue (fat layer of skin) or slough (dead tissue in a wound) in the wound bed, she answered "No." When asked to describe the wound bed (base of wound), she stated "Granulation tissue (viable new tissue) growing." A full thickness wound was observed, about the size of a quarter, with tan slough in the wound bed. Employee A failed to measure the wound, and changed her statement and acknowledged the wound bed had slough present, it was treated with calmoseptine, and the wound "... looked better than it did." Review of a document titled "Hospice CTI [certificate of terminal illness] signed and dated by employee O on 8/7/2020 at 1:00 p.m. stated ".... Patient has a very significant deep tissue injury to the coccyx [tailbone] ...." Review of a document titled "Plan of Care Update" dated and signed 8/11/2020 by employee A and 8/14/2020 by the medical director stated "... Notify physician when [oxygen] saturation is below 80% ... skin breakdown will be identified and measures to resolve breakdown implemented promptly ...." Review of a document titled "Hospice Physician Order" dated and signed 8/19/2020 at 4:07 p.m. by employee A and 8/21/2020 by the medical director, stated "... Apply calmoseptine to coccyx ... [hospice nurse] to reassess weekly ...." Review of a document titled "Visit Note Report" dated and signed on 8/7/2020 at 10:15 p.m. by employee O (registered nurse) stated "... Oxygen saturation level (%) 73 ... no respiratory treatments utilized ... Patient is at a high nutritional risk ... monitor weight ... indicate integumentary [skin] assessment findings ... pale ... poor turgor [skin elasticity] ...." The document failed to identify the coccyx wound or that the physician was notified of oxygen saturation below 80%. Review of a document titled "Visit Note Report" dated and signed on 8/8/2020 at 10:15 p.m. by employee P (registered nurse) failed to evidence the patient's oxygen saturation was re-assessed, and stated "... indicate integumentary assessment findings ... no problems identified ...." Review of a document titled "Visit Note Report" dated and signed on 8/11/2020 at 11:25 a.m. by employee A (registered nurse) stated "...indicate integumentary assessment findings ... some scabbed areas to BLE [bilateral lower extremities] ... indicate the patient's current integumentary status ... no change ...." Review of a document titled "Visit Note Report" dated and signed on 8/19/2020 at 4:05 p.m. by employee A stated "...indicate integumentary assessment findings ... wound(s) ... indicate the patient's current integumentary status ... deteriorating ... she has a 1cm [centimeter] round tissue injury to coccyx ...." The document failed to evidence any intervention/treatment was performed on the wound. Review of a document titled "Visit Note Report" dated and signed on 8/20/2020 at 9:11 a.m. by employee A stated "...Oxygen saturation level (%) 75 ... hypoxia ... periods of apnea ... indicate integumentary assessment findings ... wound(s) ... indicate the patient's current integumentary status ... deteriorating ... describe the decline ... wound appears to be increasing in size ... coccyx stage 2 ... coccyx wound now has a larger 3cm round area present next to 1cm round tissue injury. Calmoseptine applied ...." The document failed to evidence the physician was notified for oxygen saturation below 80%, or worsening wound. Review of a document titled "Visit Note Report" dated and signed on 8/24/2020 at 9:20 a.m. by employee A stated "... patient unable to respond ... wound assessed ... no, refused care ... wound care not provided ... refused care ...." The patient was unresponsive and not able to refuse care. Review of a document titled "Visit Note Report" dated and signed on 8/25/2020 at 4:52 p.m. by employee A stated "... patient unable to respond ... wound assessed ... no, refused care ... wound care not provided ... refused care ...." The patient was unresponsive and unable to refuse care. 6. Clinical record review for patient #5 was completed on 8/27/2020, with hospice election date of 5/18/2020 and primary diagnosis of unspecified severe protein-calorie malnutrition. The record failed to evidence dietician consult for primary diagnosis, nutritional supplement ordered 11 days after admission, and wound(s) not addressed during IDG meeting as evidenced by: Review of an untitled hospital document dated 4/25/2020 evidenced the patient's weight was "81 lb [pound] 9.6 oz [ounces]. Review of a document titled "Hospice Physician Order" dated and signed on 5/29/2020 at 9:26 a.m. by employee A and signed by physician H on 6/10/2020 (23 days after hospice election date) stated "... Magic cup [nutritional supplement] with meals x 1 month." Review of a document titled "Visit Note Report" dated and signed on 8/18/2020 at 3:48 p.m. by employee A stated "...Patient is at a high nutritional risk ... monitor weight ... skin laceration to mid forehead that is newly infected. Right eye red and swollen ...." The document failed to evidence the physician was notified about the red, swollen eye. Review of a document dated 8/20/2020 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" failed to evidence interventions for the patients wound(s), and nutritional supplement needs. 7. Clinical record review for patient #6 was completed on 8/27/2020, hospice election date of 7/31/2020 with primary diagnosis Alzheimer's disease. The record failed to evidence wound identification and treatment upon admission as evidenced by: Review of a document titled "Visit Note Report" (admission assessment) dated and signed by employee K on 7/31/2020 at 11:45 a.m. indicated the patient's skin was assessed, but failed to identify bilateral heel pressure injuries. Review of a document titled "Hospice Certification and Plan of Care" for certification period 7/31-10/28/2020 signed and dated 7/31/2020 by employees K and Q (registered nurses) and 8/6/2020 by physician H failed to evidence the patient's wounds or interventions. Review of a document titled "Hospice CTI [certificate of terminal illness]" dated and signed by employee R (registered nurse) on 8/3/2020 and 8/6/2020 by physician H stated "... skin concerns consisting of a non stage a bowl [sic- unstageable] 2 x 2 left heel injury as well as a deep tissue injury of the right heel ...." Review of a document titled "Hospice Physician Order" dated and signed by employee A on 8/3/2020 at 10:29 a.m., stated "... For wounds to bilateral heels: ... suspected DTI [deep tissue injury] to right heel and unstagable [sic] to left heel ... facility nurse to provide wound care and RNCM [registered nurse case manager] to reassess weekly ...." During an interview on 8/26/2020 at 10:03 a.m., when asked why the wounds weren't on the initial plan of care, employee A stated "They were unknown until the first visit I did [8/3/2020] ..." and indicated there was eschar [black necrotic skin] on the left heel and the other heel was a suspected deep tissue injury. 8. Clinical record review for patient #7 was completed on 8/27/2020, hospice election date of 6/25/2020 with primary diagnosis of Severe Protein-Calorie Malnutrition. The record failed to evidence a dietician was consulted for the patient's complex needs, a SLP was consulted for new onset difficulty swallowing medications, or medications were provided to the patient in a form which made them easier to swallow in a timely fashion. Review of a document titled "Hospice CTI [certificate of terminal illness]" dated and signed by employee S (registered nurse) on 6/25/2020 and 7/9/2020 by physician H stated "... Patient has difficulty swallowing medications ...." Review of a document titled "Visit Note Report" (admission assessment) dated and signed by employee S on 6/25/2020 at 9:14 p.m. indicated the patient was a high nutritional risk, intervention included "monitor weight", weight loss and blood sugars (Diabetes) out of control, which was monitored by entity H's nurse practitioner. The assessment failed to evidence the patient had difficulty swallowing medications. Review of a document titled "Hospice Physician Order" dated and signed by employee A on 7/1/2020 at 10:01 a.m., evidenced the patient's Tylenol and potassium pills were converted to liquid form (Six days after admission). Review of a document dated 7/9/2020 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" stated "... She [patient] is newly having difficulty swallowing medications ...." The document failed to indicate dietary or SLP was consulted. 9. Clinical record review for patient #8 was completed on 8/27/2020, hospice election date of 5/31/2019 with primary diagnosis Severe Protein-Calorie Malnutrition. The record failed to evidence a dietician was consulted for the patient's complex needs. Review of a document titled "Visit Note Report" (admission assessment) dated and signed by employee S (registered nurse) on 5/31/2019 at 11:41 p.m. indicated the patient was a high nutritional risk, intervention included "monitor weight", patient did not take nutritional supplements, had chronic watery diarrhea (chronic significant colon problems) with 5-10 loose stools daily, appetite very poor, patient stated nothing tasted or sounded good, and lost 32 pounds in 5 months (22% total body weight loss). Review of a document dated 5/19/2020 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" stated "... Patient has experienced weight loss of 65 pounds in recent months ...." The document failed to evidence interventions for nutrition needs. During an interview on 8/6/2020 at 4:10 p.m., the administrator and DPS were asked if a dietician was ordered for patient #8 (primary diagnosis severe protein-calorie malnutrition), the administrator and DPS both stated "No." 10. Clinical record review for patient #9 was completed on 8/27/2020, hospice election date of 3/19/2019 with primary diagnosis Alzheimer's disease. The record failed to evidence all wounds were addressed as ordered by the physician, new wounds were documented which had no orders for treatment, and wound care was performed as ordered by the physician(s). Review of an agency document (not included in the patient's medical record) on 8/3/2020 titled "Complaint Report" dated 6/4/2019 and signed 6/5/2019 by former employee T (director of professional services) for patient #9, initiated by an unnamed physician, alleged wound care orders were not addressed, and a hoyer lift was not addressed for two weeks. When asked about this complaint on 8/3/2020 at 3:55 p.m. during the complaint document review, the administrator and director of professional services (DPS) indicated it was just a difference of opinion between the nursing home physician and the agency, and the DPS further acknowledged there was no follow up with the complainant. Review of a document titled "Wound Record Report" evidenced wounds to: left upper buttock pressure injury with onset date 3/19/2019 and resolved date 3/25/2019, right upper buttock pressure injury with onset date 3/19/2019 and resolved date 3/25/2019, coccyx (tailbone) yeast rash (infection) with onset date 3/26/2019 and resolved date 5/20/2019, sacrum (lower back) pressure injury with onset date 5/13/2019 and resolved date 6/5/2019, and left upper buttock skin tear with onset date 5/28/2019 and resolved date 6/5/2019. Review of a document titled "Hospice Physician Order" dated 5/19/2019 and signed by person P (patient's attending physician) on 6/4/2019 stated "Duoderm [dressing] to coccyx area times two [two areas] change Q3 [every 3] days by Heartland nurse." Review of a document titled "Hospice Physician Order" dated 5/20/2019 and signed by employee FF (hospice physician) stated "Cleanse coccyx wound with saline, pat dry, apply duoderm on Tuesday and Thursday and PRN [as needed] per Heartland nurse." Review of a document titled "Visit Note Report" dated 5/28/2019 and signed by employee GG (registered nurse) stated "... [patient's] buttock skin peeling ...." and failed to evidence hospice physician was notified, or orders for treatment were received. Review of a document titled "Visit Note Report" dated 6/3/2019 and signed by employee GG (registered nurse) stated "... sacral wound is open again and excoriation [chafing, open or closed area on skin] ...." and failed to evidence hospice physician was notified, or orders for treatment were received. Review of a document titled "Visit Note Report" dated 6/6/2019 and signed by employee U (registered nurse) stated "... Discharge was initiated by ... physician ... election date of revocation 6/5/2019 ... reason for discharge ... revoked ...." During an interview on 8/3/2020 at 4:04 p.m., the director of professional services indicated the complaint was just a difference of opinion between the nursing home physician and the agency regarding the wounds. During an interview on 8/6/2020 at 3:25 p.m., the director of professional services stated "Our wound care is palliative [comfort only], not to cure." During an interview on 8/27/2020 at 5:01 p.m., family indicated he was very dissatisfied with the agency, they failed to perform regular wound care, the aides didn't come when they were supposed to, so the patient went to another hospice agency, and was extremely satisfied with their services. During an interview on 8/26/2020 at 12:07 p.m., when asked if the agency tracks all patient wounds as a component of their quality assurance/performance improvement (QAPI) program, the administrator and director of professional services (DPS) indicated they didn't know, and would have to check. No further information was submitted for review. During an interview on 8/27/2020 at 4:10 p.m., the director of professional services acknowledged wound care was not performed as ordered by the physician on all visits. 11. Review of an agency document on 8/06/2020 titled "Clients by Agent Report" was a report of all cases for the dietician for the past 6 months. Thirty-two patients had been seen by the dietician (the agency's unduplicated census for the past 12 months was 1,836). During an interview on 8/5/2020 at 2:30, the administrator indicated the agency dietician saw patients as often as the physician requested, it depended on goals of the patients, she would be present for IDG (interdisciplinary group meetings), but there wouldn't be a note in the patients' clinical records. During an interview on 8/6/2020 at 2:27 p.m., when asked if the agency had a dietician, employee F (registered nurse) stated "Yes." When asked if her patients had dietician services, she indicated she didn't typically have anyone with a dietician. During an interview on 8/6/2020 at 2:45 p.m., when asked if the agency had a dietician, employee E (registered nurse) stated "Yes, I think ...." During an interview on 8/6/2020 at 4:10 p.m., the administrator and DPS indicated they would not expect a dietician to be consulted for a patient with wounds, and the DPS indicated the agency provided only palliative care. 12. Review of an agency document on 8/26/2020 titled "Physical Assessment Report" was a current wound report 8/1 to 8/26/2020. Fifty-three patients had wounds. During an interview on 8/6/2020 at 1:55 p.m. with the administrator and DPS, the DPS indicated he didn't think there were "specific" wound care policies. At 3:15 p.m., the DPS submitted an undated document which failed to identify if it was an agency policy or procedure titled "Standards of Skin Care Practice". The DPS indicated it was a template the agency used for wound care orders, and indicated "Our wound care is palliative (for comfort), not to cure." 13. During an interview on 8/26/2020 at 12:38 p.m., the medical director was asked if a patient was shortness of breath or had low oxygen levels what intervention should be done. The medical director stated "I would order oxygen." When asked how soon he expected continuous care to start once ordered, he stated "Right away. I don't expect it to be started twenty-four hours later." When asked if calmoseptine was appropriate for a stage 2 or 3 pressure injury, he indicated it depended, and he sometimes used aquacel silver (treatment for partial and full thickness pressure injuries). When asked if he was notified for changes in wound conditions or new wounds, he indicated he was, and it was dealt with at that time. During an interview on 8/27/2020 at 2:45 p.m., when asked how soon he expected continuous care to start once ordered, employee H (team physician) stated "As timely as possible ..." and indicated if staff was not available there were other means.
L0536
L0536	42909 Based on observation, record review and interview, the hospice failed to ensure all patients had a plan of care identifying patient and family specific needs (L538); failed to ensure all patients had an individualized plan of care (L545); failed to ensure all patients' plans of care evidenced measurable outcomes/goals (L548); failed to ensure the agency's interdisciplinary group (IDG) updated the patients' plans of care as often as needed for a patient change in condition for all patients (L552); and failed to ensure the agency provided ongoing communication with non-hospice providers providing services unrelated to terminal illness for all patients (L558). These practices impacted patients (1, 2, 3, 4, 5, 6, and 9). The cumulative effect of these systemic problems resulted in the hospice's inability to be in compliance with the Condition of Participation §418.56 Interdisciplinary group, care planning, and coordination of services.
L0538
L0538	42909 Based on observation, record review, and interview, the hospice failed to ensure plans of care addressed patient and family-specific needs for 4 of 4 patient's plans of care reviewed (#1, 2, 4, and 9) in a total sample of 9. Findings include: 1. Review of an agency policy #155 dated 7/2009 titled "Standards of Practice" stated "... Each discipline collects patient health data ... process is systemic and ongoing ... Plan is individualized ... evaluation is systemic and ongoing ... Patient, caregivers, and health care providers are involved ...." Review of an agency policy #901-H dated 4/2017 titled "Interdisciplinary Group & Group Meeting" stated "The ... [IDG] ... is responsible for providing and supervising the care of the hospice patients ...." Review of an undated document titled "Standards of Skin Care Practice" stated "... treatment order will include the following ... Wound location, Cleansing solution, Dressing to be applied to wound bed, Moisture barrier for peri-wound [skin area around wound] ... As needed secure dressing with, frequency of dressing change, Expected duration of need for dressing treatment ...." 2. Clinical record review for patient #1 was completed on 8/27/2020 with hospice election date of 12/12/2019, and primary diagnosis of Essential Hypertension. Patient was discharged from entity A (a skilled nursing facility) to home on 12/9/2020. Review of a document from entity A (not included in the clinical record submitted for review by the agency) signed by a nurse from entity A on 12/9/19 stated "... Home Health/Referrals ... Physical Therapy ... Occupational Therapy ...." Review of a document titled "Visit Note Report" (RN Hospice start of care) signed on 12/12/2019 by employee P (registered nurse) stated "... Indwelling/suprapubic catheter ... [family] burden of care: ... must administer medications ... feels overwhelmed ... sleep disturbed with patient's care ... patient's care causes extra physical stress ... causes changes in family lifestyle ... experiencing increased time demands ...." Review of an agency document dated 12/12/19 titled "Hospice Certification and Plan of Care" for certification period 12/9/19 - 3/10/2020 signed on 12/16/2019 by physician H The plan of care failed to evidence physical therapy (PT) or occupational therapy (OT) was ordered, failed to evidence presence, size, care, frequency of catheter changes, and next catheter change of indwelling urinary catheter, and failed to evidence care coordination with entity N (home care agency. 3. Clinical record review for patient #2 was completed on 8/27/2020 with hospice election date of 10/2/2018, for benefit period of 1/2/19 - 4/29/2019 and primary diagnosis of Alzheimer's disease. Review of a document titled "hospice CTI [certificate of terminal illness]" dated and signed by physician H on 10/4/2018 stated "... Meals consist of modified diet with honey thick liquids [specific diet for those at risk for aspiration] diet and is requiring assistance with eating due to dysphagia ...." Review of a document titled "Hospice Certification and Plan of Care" start of care date 10/2/2018 for certification period 10/2/2018 - 12/30/2018 stated "... Nutritional Requirements: Diet as tolerated ...." The document failed to evidence the patient had dysphagia, required a modified diet with honey thick liquids, the patient was at high risk for aspiration, orders to assess for aspiration, interventions to prevent aspiration, or family specific needs. 4. Clinical record review for patient #4 was completed on 8/27/2020, hospice election date of 8/7/2020 with primary diagnosis Alzheimer's disease. The record failed to evidence the patient's wound was addressed and treated upon admission. During a home visit for observation of patient #4 on 8/26/2020 at 8:30 a.m., employee A was observed and interviewed. When asked if the patient had any open skin areas, employee A indicated the patient had a stage 1 pressure ulcer on her backside, it was being treated with calmoseptine (an over the counter barrier cream used for minor skin irritations such as diaper rash), and she would assess it when the aides got there. When asked how often wounds should be assessed, she stated "We are required to do them weekly." At 9:24 a.m., when asked to describe the coccygeal (backside/tailbone) wound, employee A indicated it was a stage 2 (pressure injury), 2.0cm (length) x 1.0cm (width) x 0.1-0.2cm (depth). When asked if there was adipose tissue (fat layer of skin) or slough (dead tissue in a wound) in the wound bed, she answered "No." When asked to describe the wound bed (base of wound), she stated "Granulation tissue (viable new tissue) growing." She then changed her statement and acknowledged the wound bed had slough present, it was treated with calmoseptine, and the wound "... looked better than it did." Review of a document titled "Hospice CTI [certificate of terminal illness] signed and dated by employee O on 8/7/2020 at 1:00 p.m. stated ".... Patient has a very significant deep tissue injury to the coccyx [tailbone] ...." Review of a document titled "Visit Note Report" dated and signed on 8/7/2020 at 10:15 p.m. by employee O (registered nurse) stated "... indicate integumentary [skin] assessment findings ... pale ... poor turgor [skin elasticity] ...." The document failed to identify the coccyx wound. Review of a document titled "Hospice Certification and Plan of Care" start of care date 8/7/2020 for certification period 8/7/2020 - 11/4/2020 stated failed to evidence presence of wound or orders for wound care, or family needs. 5. Clinical record review for patient #9 was completed on 8/27/2020, hospice election date of 3/19/2019 with primary diagnosis Alzheimer's disease. The plan of care failed to evidence all wounds were addressed, or family specific needs. Review of a document titled "Wound Record Report", entries dated 3/19/2019, which evidenced the patient had a pressure injury to the left upper buttock and a pressure injury to the right upper buttock. Review of a document titled "Hospice certification and Plan of Care" signed by physician FF on 3/27/2019 stated "... pressure ulcer care ... cleanse with wound cleanser ... cover with [protective dressing] weekly ...." The document failed to evidence both wounds were addressed, or family needs. 6. During an interview on 8/5/2020 at 1:35 p.m., the director of professional services indicated patient specific interventions and goals were not evidenced for all patients' plans of care, the patients could have made goals on the plans of care, but the plans of care did not specify the patients made them.
L0545
L0545	42909 Based on record review and interview, the agency failed to develop an individualized plan of care which contained specific patient/family goals and interventions for all needs identified in the comprehensive assessment for all patient records reviewed (#1, 2, 3, 4, 5, 6, 7, 8 and 9). Findings include: 1. Review of an agency policy #155 dated 7/2009 titled "Standards of Practice" stated " ... Plan [plan of care] is individualized ... evaluation is systemic and ongoing ... Patient, caregivers, and health care providers are involved ...." 2. Clinical record review for patient #1 was completed on 8/27/2020 with hospice election date of 12/12/2019, and primary diagnosis of Essential Hypertension. Review of a document from entity A (not included in the clinical record submitted for review by the hospice) signed by a nurse from entity A on 12/9/19 stated "... Home Health/Referrals ... Physical Therapy ... Occupational Therapy ...." Review of a document titled "Visit Note Report" (RN Hospice start of care) signed on 12/12/2019 by employee P (registered nurse) stated "... Indwelling/suprapubic catheter ...."but failed to evidence anything about therapy services. Review of an agency document dated 12/12/19 titled "Hospice Certification and Plan of Care" for benefit period 12/9/19 - 3/10/2020 signed on 12/16/2019 by physician H. The plan of care failed to evidence physical therapy (PT) or occupational therapy (OT) was ordered or goals or interventions related to therapy, failed to evidence goals and interventions for the presence, size, care, frequency of catheter changes, next catheter change of indwelling urinary catheter, and failed to evidence care coordination with entity N (home care agency. 3. Clinical record review for patient #2 was completed on 8/27/2020 with hospice election date of 10/2/2018, for benefit period of 1/2/19 - 4/29/2019 and primary diagnosis of Alzheimer's disease. Review of a document titled "hospice CTI [certificate of terminal illness]" dated and signed by physician H on 10/4/2018 stated "... Meals consist of modified diet with honey thick liquids [specific diet for those at risk for aspiration] diet and is requiring assistance with eating due to dysphagia ...." Review of a document titled "Visit Note Report" (RN Hospice start of care) signed on 10/2/2018 by employee K (registered nurse) stated "... Patient has an illness which ... change the kind and/or amount of food they eat ... tooth or mouth problems ... make it hard ... to eat ... high nutritional risk ... she is chin to chest ... Daughter states coughs after drinking and constantly has a dripping nose and drool ...." Review of a document titled "Hospice Certification and Plan of Care" for benefit period of 10/2/2018 - 12/30/2018 stated "... Nutritional Requirements: Diet as tolerated ...." The document failed to evidence the patient had dysphagia, required a modified diet with honey thick liquids, the patient was at high risk for aspiration, orders to assess for aspiration, or interventions to prevent aspiration. 4. Clinical record review for patient #3 was completed on 8/27/2020 with hospice election date of 5/11/2020, and primary diagnosis of Parkinson's disease. During a home visit for observation of patient #3 on 8/3/2020 at 1:30 p.m., the patient stated "... wish I could figure out how to use a urinal [in bed]." Employee D stated "Yeah, it's hard." Family indicated they got the patient out of bed "last night", but his right foot kept falling off of the foot peg on the wheelchair. Observed wheelchair which lacked straps to secure the feet in place. When asked about patient specific goals, employee D indicated "Safety, maintain mobility as best as possible, adequate intake, prevention of skin breakdown, [and] pain." The patient indicated he wanted to go to his daughter's wedding in October, and stated "I gotta [sic] get up more. That foot thing [falling off of the foot peg on the wheelchair] is really bothering me." Employee D acknowledged previous knowledge of the patient's personal goal. When asked if the agency provides therapy services, employee D stated "No. Maybe a visit or two for safety or transfers." Review of documents dated 8/11 and 8/25/2020 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" failed to evidence the patient's stated concerns from the observed home visit on 8/3/2020 were addressed, or the plan of care was revised to evidence patient's personal goals. 5. Clinical record review for patient #4 was completed on 8/27/2020, hospice election date of 8/7/2020 with primary diagnosis Alzheimer's disease. Review of a document titled "Hospice CTI [certificate of terminal illness] signed and dated by employee O on 8/7/2020 at 1:00 p.m. stated ".... Patient has a very significant deep tissue injury to the coccyx [tailbone] ... currently consuming less than 25% of her meals ...." Review of a document titled "Visit Note Report" (RN Hospice Start of Care) signed and dated 8/7/2020 by employee O (registered nurse) stated "... patient is at high nutritional risk ...." The document failed to identify the deep tissue injury. Review of a document titled "Hospice Certification and Plan of Care" start of care date 8/7/2020 for certification period 8/7/2020 - 11/4/2020 failed to evidence goals and interventions related to high nutritional risk, wound details or care. 6. Clinical record review for patient #5 was completed on 8/27/2020, hospice election date of 5/18/2020 with primary diagnosis Unspecified severe protein-calorie malnutrition. Review of a document titled "Hospice CTI [certificate of terminal illness] signed and dated by physician H on 5/28/2020 stated "... coccyx [tailbone] ... pressure injury ... consuming a little less than 25% of her meals ...." Review of a document titled "Hospice IDG Comprehensive Assessment and Plan of Care Update dated 5/28/2020 failed to evidence interventions or goals related to the patient's pressure injury or malnutrition. Review of a document titled "Hospice Certification and Plan of Care" for benefit period 5/18/2020 - 8/15/2020 failed to goals and interventions related to malnutrition, wound details or care. 7. Clinical record review for patient #6 was completed on 8/27/2020, hospice election date of 7/31/2020 with primary diagnosis Alzheimer's disease. Review of a document titled "Visit Note Report" (admission assessment) dated and signed by employee K on 7/31/2020 at 11:45 a.m. indicated the patient's skin was assessed, but failed to identify bilateral heel pressure injuries. Review of a document titled "Hospice CTI [certificate of terminal illness]" dated and signed by employee R (registered nurse) on 8/3/2020 and 8/6/2020 by physician H stated "... skin concerns consisting of a non stage a bowl [sic- unstageable] 2 x 2 left heel injury as well as a deep tissue injury of the right heel ...." Review of a document titled "Hospice Certification and Plan of Care" for benefit period 7/31-10/28/2020 signed and dated 7/31/2020 by employees K and Q (registered nurses) and 8/6/2020 by physician H failed to goals and interventions related to wound details or care 8. Clinical record review for patient #7 was completed on 8/27/2020, hospice election date of 6/25/2020 with primary diagnosis of Severe Protein-Calorie Malnutrition. Review of a document titled "Hospice CTI [certificate of terminal illness]" dated and signed by employee S (registered nurse) on 6/25/2020 and 7/9/2020 by physician H stated "... Patient has difficulty swallowing medications ...." Review of a document titled "Visit Note Report" (admission assessment) dated and signed by employee S on 6/25/2020 at 9:14 p.m. indicated the patient was a high nutritional risk, intervention included "monitor weight", weight loss and blood sugars (Diabetes) out of control, which was monitored by entity H's nurse practitioner. The admission assessment failed to evidence the patient had difficulty swallowing pills. Review of a document dated 7/9/2020 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" stated "... She [patient] is newly having difficulty swallowing medications ...." The document failed to indicate goals and interventions related to swallowing difficulties, nutritional concerns, or speech language pathologist services. 9. Clinical record review for patient #8 was completed on 8/27/2020, hospice election date of 5/31/2019 with primary diagnosis Severe Protein-Calorie Malnutrition. Review of a document titled "Visit Note Report" (admission assessment) dated and signed by employee S (registered nurse) on 5/31/2019 at 11:41 p.m. indicated the patient was a high nutritional risk, intervention included "monitor weight", patient did not take nutritional supplements, had chronic watery diarrhea (chronic significant colon problems) with 5-10 loose stools daily, appetite very poor, patient stated nothing tasted or sounded good, and lost 32 pounds in 5 months (22% total body weight loss). Review of a document dated 5/19/2020 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" stated "... Patient has experienced weight loss of 65 pounds in recent months...." The document failed to evidence interventions and goals for nutrition needs, and gastrointestinal problems. 10. Clinical record review for patient #9 was completed on 8/27/2020, hospice election date of 3/19/2019 with primary diagnosis Alzheimer's disease. Review of a document titled "Wound Record Report", entries dated 3/19/2019, which evidenced the patient had a pressure injury to the left upper buttock and a pressure injury to the right upper buttock. Review of a document titled "Hospice certification and Plan of Care" signed by physician FF on 3/27/2019 stated "... pressure ulcer care ... cleanse with wound cleanser ... cover with [protective dressing] weekly ...." The document failed to evidence both wounds were addressed, or specific patient/family goals and interventions. Seven of 7 plan of care documents dated from 10/2/2018 to 8/7/2020 stated "... MSW [medical social worker] to evaluate patient and develop plan of care to be signed by physician ... Spiritual care coordinator to evaluate patient and develop plan of care to be signed by physician ... Home health aide service for assistance with personal care and ADL's [activities of daily living] secondary to functional limitations, which prevent self-care. There is no willing or able caregiver to provide for hygiene needs ... Hospice nurse to evaluate patient and develop plan of care to be signed by physician ...." The plans of care failed to be individualized and evidence goals and interventions specific to the needs of the patient as per the updated comprehensive assessments. 11. During an interview on 8/5/2020 at 1:35 p.m., when asked if there were patient or family identified interventions or goals, the director of professional services acknowledged documentation failed to indicate if patient or family stated interventions or goals they wanted. During an interview on 8/6/2020 at 4:10 p.m., the DPS acknowledged patient specific goals were missed.
L0552
L0552	42909 Based on observation, record review and interview, the hospice failed to ensure its interdisciplinary group (IDG) reviewed and/or revised the individualized plans of care for all patients as frequently as the patients' condition required for 3 of 3 patient records reviewed for symptom management (#1, 2, 3) in a total sample of 9. Findings include: 1. Review of an agency policy #901-H dated 4/2017 titled "Interdisciplinary Group & Group Meeting" stated "The ... [IDG] ... is responsible for providing and supervising the care of the hospice patients ... meets regularly ... more frequently in response to a significant change in the individual's condition ...." 2. Clinical record review for patient #1 was completed on 8/27/2020 hospice election date of 12/12/2019, and primary diagnosis of Essential Hypertension for the benefit period 12/12/2019 to 3/10/2020. The patient expired on 12/22/2019. The clinical record failed to evidence an IDG meeting was held upon patient's significant change in condition, and the admission and death at home IDG meetings were held on the same date and time, four days after the patient expired as evidenced by: Review of a document titled "Visit Note Report" indicated the registered nurse completed a hospice continuous care evaluation on 12/19/2019 at 2:48 p.m. by employee I which stated "... agitated ... pain is out of control ... current pain score 3 ... Are you uncomfortable because of pain? Yes ... pain score 3 ... patient is over 18 and able to answer ... increased lethargy ... PAINAD assessment ... occasional labored breathing w/ short periods of hyperventilation ... repeated, troubled calling out ... loud moaning or groaning ... crying ... facial grimacing ... body language ... rigid, fists clenched, knees pulled up, pulling or pushing away, striking out ... were prn medications needed for pain since last visit? Yes ... how many ... indicate effectiveness ... 3 doses given ... effective ... [narrative] assess [patient] for continuous care due to increased pain ... and restlessness r/t [related to] disease progression and transition towards actively dying ... continuous care will begin as soon as staff members are available ...." Review of a document titled "Visit Note Report" dated and signed 12/22/2019 at 12:20 p.m. by employee E stated "... comatose ... unresponsive ... unresponsive this morning ... hypoxia ... [8:01 a.m.] ... [2:50 p.m.] medicated with morphine and Ativan ... remains unresponsive ... [4:50 p.m.] medicated with morphine and atropine ... [5:43] [patient] took last breath ...." Review of a document dated 12/26/2019 at 5:43 p.m. titled "Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report" stated "... IDG meeting reason: New Admission ... which occurred 4 days after the patient's death, failed to evidence the patient expired, evidenced ongoing interventions for the following two weeks (after death). Review of an additional document dated 12/26/2019 at 5:43 p.m. titled "Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report" stated "... IDG meeting reason: Death at Home ... which occurred 4 days after the patient's death, stated "... Identify changes/decline since last IDG meeting ... [patient] deceased ... [patient] dies at home after being on services a short time ...." During an interview on 8/26/2020 at 4:35 p.m., when asked why patient #1's IDG meetings for admission and death at home were held on the same date at the same time, the administrator indicated it was within 14 days and had no further response. During an interview on 8/27/2020 at 12:07 p.m., when asked to clarify IDG meetings for patient #1, the administrator indicated she was admitted on 12/12/2019, the IDG already met, and she was deferred to the 12/26/2019 meeting, stated "We wouldn't necessarily call an IDG meeting ...." 3. Clinical record review for patient #2 was completed on 8/27/2020 with hospice election date of 10/2/2018, for benefit period of 1/2/19 - 4/29/2019 and primary diagnosis of Alzheimer's disease. The clinical record failed to evidence an IDG meeting was held when the patient had changes in condition, but rather only completed every 14 days and goals and interventions failed to be updated per the needs of the patient as evidenced by: Review of a document titled "Client Coordination Note Report" dated 2/22/2019 entered by employee AA stated "125AM [1:25 a.m.] call came from service. 126AM return call to ... facility nurse reports pt [patient] has lg [large] brown, foul smelling emesis. Hemoccult [sic] tested positive for occult blood in emesis. Reported to [employee Z] to do nurse visit." Review of a document titled "Visit Note Report" dated and signed on 2/22/2019 at 11:00 p.m. by employee Z (registered nurse) stated "... patient had large emesis that was siluspected [sic] to be bloody ...." Review of a document dated 3/7/2019 titled "Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report" failed to evidence interventions and goals related to risk for aspiration, GI (gastrointestinal) bleed or elevated white blood cell count. Review of a document dated 3/21/2019 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" failed to evidence interventions and goals related to risk for aspiration, or elevated white blood cell count, and stated "... Monitor GI status for further signs of bleeding ...." Review of a document dated 4/4/2019 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" failed to evidence interventions and goals related to risk for aspiration, or GI bleed. Review of a document titled "Visit Note Report" dated and signed on 4/17/2020 by employee J (registered nurse) stated "... recent infections ... 4/17/19 URI [upper respiratory infection] ... seen by facility NP (nurse practitioner) today and new orders for mucinex and Bactrim for URI [upper respiratory infection] ...." Review of a document dated 4/18/2019 titled "Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report" failed to evidence the patient's decline with new onset URI, patient was a high risk for aspiration, her specialized diet, or monitoring for GI bleed. 4. Clinical record review for patient #3 was completed on 8/27/2020 with hospice election date of 5/11/2020, and primary diagnosis of Parkinson's disease. During a home visit for observation of patient #3 on 8/3/2020 at 1:30 p.m., the patient was observed lying in bed, with tremors, worse on right side, to both upper and lower extremities. During this time, the patient stated "... wish I could figure out how to use a urinal [in bed]." Employee D stated "Yeah, it's hard." Family indicated they got the patient out of bed "last night", but his right foot kept falling off of the foot peg on the wheelchair. Observed wheelchair lacked straps to secure the feet in place. Employee D indicated she was going to call the medical equipment company for follow up. When asked about patient specific goals, employee D indicated "Safety, maintain mobility as best as possible, adequate intake, prevention of skin breakdown, [and] pain." The patient indicated he wanted to go to his daughter's wedding in October, and stated "I gotta [sic] get up more. That foot thing [falling off of the foot peg on the wheelchair] is really bothering me." Employee D acknowledged previous knowledge of the patient's personal goal. Review of a document dated 8/3/2020 signed by employee D titled "Visit Note Report" stated "Pt [patient] reports he got out of bed via hoyer lift yesterday and sat up in his wheelchair. Pt was happy with getting out of bed, he states that he doesn't want to be in bed all the time. Pt states his tremors are bothersome ...." The document failed to evidence employee D followed up with the medical equipment company, followed up with the physician for the patient's stated personal goals, which included getting up and able to go to wedding (transfer/strengthening training- opportunity for PT), difficulty using utensils to eat, and using a urinal in bed (improved upper body movement/control- opportunity for OT), and an IDG meeting wasn't completed to address the needs of the patient until another 8 days. Review of documents dated 8/11 and 8/25/2020 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" failed to evidence the patient's stated concerns from the observed home visit on 8/3/2020 were addressed, or the plan of care was revised. During an interview on 8/6/2020 at 4:10 p.m., when asked about IDG involvement with patient #3's stated personal goals and potential need for therapy, the director of professional services (DPS) stated "It would have to be discussed with a physician. IDG isn't until next week." When asked if the agency made patients wait up to two weeks for the next IDG meeting, the DPS stated "Not necessarily." 5. During an interview on 8/25/2020 at 3:05 p.m., when asked what would trigger an IDG meeting more frequently than every 15 days, the administrator indicated care plan meetings are like IDG meetings, for things like unsafe situation, or stressful caregivers. During an interview on 8/26/2020 at 9:05 a.m., employee A (registered nurse) indicated IDG meetings are every two weeks, if something happens in between, it's addressed 2 weeks later at the next meeting.
L0558
L0558	42909 Based on record review and interview, the hospice failed to ensure communication with other non-hospice healthcare providers furnishing services for 3 of 3 records reviewed of patient's with other non-hospice providers (#1, 2, 3) in a total sample of 9. 1. Review of an agency policy #250-H dated 7/2009 titled "Continuity of Care" stated "Hospice assures continuity of care for the patient/caregiver in home, outpatient and inpatient settings ... Coordinates patient's plan of care and services by regular communication and documentation with staff in facility caring for hospice patient ... plan of care ... updated on a regular basis reflecting current patient status and need." 2. Clinical record review for patient #1 was completed on 8/27/2020 with hospice election date of 12/12/2019, and primary diagnosis of Essential Hypertension. Review of a document titled "Visit Note Report" dated and signed 12/17/2019 at 8:20 a.m. by employee EE (social worker) stated "... [entity N - home care services] staff is staying with her ...." The clinical record failed to evidence documentation of care coordination with entity N or the patient's family. 3. Clinical record review for patient #2 was completed on 8/27/2020 with hospice election date of 10/2/2018, for benefit period of 1/2/19 - 4/29/2019 and primary diagnosis of Alzheimer's disease. The clinical record failed to evidence care coordination between entity C (where patient resided) and the hospice agency until two days prior to patient's death. During an interview on 8/6/2020 at 12:16 p.m., person B (a paramedic) indicated on 4/29/2020, a nurse from entity C told him the patient was vomiting blood, and had been that way for a couple of days ...." The clinical record failed to evidence care coordination between entity C and the agency regarding vomiting blood for two days. During an interview on 8/6/2020 at 12:37 p.m., the patient's daughter indicated she was not informed the patient had been vomiting blood for two days, she would have sent her to the ER then, and maybe the outcome could have been different and she might have lived, and stated "I was only made aware the morning of [4/29/2019], maybe about 11:00 [a.m.], I'm not sure." During an interview on 8/27/2020 at 1:27 p.m., when asked if the patient should have had a chest X-ray for potential aspiration due to vomiting and underlying aspiration risk, the DPS indicated the facility physician should have followed up, and hospice was secondary. 4. Clinical record review for patient #3 was completed on 8/27/2020 with hospice election date of 5/11/2020, and primary diagnosis of Parkinson's disease. The record failed to evidence documentation of care coordination with entity O (home care agency). During an interview on 8/3/2020 at 3:30 p.m., employee D indicated patient also received aide services from entity O, they called about once monthly, and the other agency was not part of the IDG.
L0602
L0602	42909 Based on record review and interview, it was determined the agency failed to ensure non-core services including physical therapy, occupational therapy, and speech language pathology services was provided directly by the agency or under written agreement. Findings include: Review of the agency's admission packet on 08/03/2020 contained an undated booklet titled "Heartland Hospice Care Patient Information Handbook" which stated "... Your Hospice Care Team ... Licensed therapists provide services ... may include physical, occupational and speech therapy ...." Review of an agency policy #220 on 08/03/2020 dated 6/16 titled "Description of Services" stated "... Care is provided ... according to the patient's needs and desires ... Physical Therapy ... Occupational Therapy ... Speech Language Pathology ...." During an interview on 8/5/2020 at 3:10 p.m., when asked to provide a physical therapist job description, the director of professional services (DPS) indicated did not have a physical therapist job description, the agency did not employ physical therapists, therapists were contracted, and the same went for occupational therapy and speech language pathology. During an interview on 8/5/2020 at 3:40 p.m., when asked if the agency had any therapy contracts, the administrator stated "We don't have any therapy contracts. We share with home care [a separate agency with its own unique provider number, owned by the same corporation]." When asked if the agency had a contract with the home care agency for therapists, the administrator indicated it wasn't necessary because it was the same company. During an interview on 8/6/2020 at 4:10 p.m., when asked if the agency had written contracts for physical therapists, occupational therapists and speech language pathologists, the administrator and DPS both stated "No." During an interview on 8/25/2020 at 11:27 a.m., when asked if Heartland Home Health Care and Hospice and Heartland Home Care were two seperate agencies, the administrator stated "Yes." When asked if there were any written contracts between the agencies, the administrator stated "No."
L0603
L0603	42909 Based on observation, record review and interview, it was determined the agency failed to ensure physical therapy, occupational therapy, and speech language pathology services was available and offered to all patients (L604). The cumulative effect of these systemic problems resulted in the agency's inability to ensure all patients' were offered and/or received physical therapy, occupational therapy, and speech language pathology services as required by the Condition of Participation §418.72 Physical therapy, occupational therapy, and speech language pathology services.
L0604
L0604	42909 Based on observation, record review and interview, it was determined the agency failed to ensure physical therapy (PT), occupational therapy (OT), and/or speech language pathology (SLP) services were available and offered to all patients for 3 of 3 focused record reviews in a total sample of 9. Findings include: 1. Review of the agency's admission packet on 08/03/2020 contained an undated booklet titled "Heartland Hospice Care Patient Information Handbook" which stated "... Your Hospice Care Team ... Licensed therapists provide services ... may include physical, occupational and speech therapy ...." 2. Review of an agency policy #220 on 08/03/2020 dated 6/16 titled "Description of Services" stated "... Care is provided ... according to the patient's needs and desires ... Physical Therapy ... to restore the patient to the highest functional level of strength, range of motion, mobility and independence ... Occupational Therapy ... to increase the patient's ability to carry out normal day to day functioning ... increase upper extremity function and promote independence ... Speech Language Pathology ... treatment programs to maximize effectiveness for the patient ...." 3. Review of an agency document on 8/3/2020 titled "Agent Visit Time Report" evidenced a total of five patients were seen by physical therapy for the past 6 months which included 2 patients that received 3 visits each, 1 patient received 2 visits, and 2 patients received 1 visit each. Total unduplicated census for the past 12 months was 1,836. 4. Review of an agency document on 8/26/2020 titled "QI [quality improvement] Event Report" for patient falls 6/1 - 8/26/2020 evidenced 147 patients sustained at least 1 fall, with a total of 277 patient falls for the timeframe selected. 5. Review of an untitled agency policy #005-A last updated 12/18 identified by the administrator as the organizational chart failed to evidence PT, OT, or SLP at the branch level of the agency. 6. During a home visit for patient #3 on 8/3/2020 at 1:30 p.m., with admit date 5/11/2020, primary diagnosis Parkinson's disease, the patient was observed lying in bed, with tremors, worse on right side, to both upper and lower extremities (patient was right-handed), was non-weight bearing, required hoyer for transfers (occurred after hospice admission), and had recently become bedbound upon admission to hospice. Employee D (registered nurse, case manager) indicated hoyer training was offered but the family declined due to multiple nurses in the family. During this time, the patient stated "... wish I could figure out how to use a urinal [in bed]." Employee D stated "Yeah, it's hard." Family indicated they got the patient out of bed "last night", but his right foot kept falling off of the foot peg on the wheelchair. Observed wheelchair lacked straps to secure the feet in place. Employee D indicated she was going to call the medical equipment company for follow up. When asked about patient specific goals, employee D indicated "Safety, maintain mobility as best as possible, adequate intake, prevention of skin breakdown, [and] pain." The patient indicated he wanted to go to his daughter's wedding in October, and stated "I [gotta] get up more. That foot thing [falling off of the foot peg on the wheelchair] is really bothering me." Employee D acknowledged previous knowledge of the patient's personal goal. When asked if the agency provides therapy services, employee D stated "No. Maybe a visit or two for safety or transfers." 7. Clinical record review for patient #1 was completed on 8/27/2020 with admit date 12/12/2019, and primary diagnosis of Essential Hypertension. Patient was discharged from entity A (a skilled nursing facility) to home on 12/9/2020 with discharge referral for home health. The clinical record failed to evidence how the patient transitioned from home health to hospice, and failed to evidence she received PT and OT. Review of a document from entity A (not included in the agency clinical record) titled "Discharge Instructions- Interdiscipline V2" signed by a nurse from entity A on 12/9/19 stated "... Home Health/Referrals ... Physical Therapy ... Occupational Therapy ...." Review of a document from entity A (not included in the agency clinical record) dated 12/9/19 titled "OT - Therapist Progress & Discharge Summary" stated "... Post discharge recommendations ... recommended to participate with home health ... for safety with transition ... and to complete HEP [home exercise program] daily ...." Review of a document from entity A (not included in the agency clinical record) dated 12/9/19 titled "PT - Therapist Progress & Discharge Summary" stated "... Pt will continue rehab with home health ...." During an interview on 8/3/2020 at 11:45 a.m., family indicated the patient thought she was going to receive therapy at home to get better. During an interview on 8/27/2020 at 9:30 a.m., when asked if the patient made good progress with therapy services prior to discharge to home, the director of nursing at entity A stated "Yes." Review of an agency document dated 12/12/19 titled "Hospice Certification and Plan of Care" for certification period 12/9/19 - 3/10/2020 failed to evidence PT or OT was ordered for the patient. 8. Clinical record review for patient #2 was completed on 8/27/2020 with admit date 10/2/2018, for date range 1/2/19 - 4/29/2019 and primary diagnosis of Alzheimer's disease. The record failed to evidence SLP was consulted while the patient received services from the agency. Review of a document titled "Visit Note Report" dated and signed on 4/10/2020 by employee J (registered nurse) stated "... pureed diet with honey thick liquids, pocketing fluid, excess secretions, difficulty swallowing ... lung sounds diminished throughout with expiratory wheezes noted ...." Review of a document titled "Visit Note Report" dated and signed on 4/17/2020 by employee J stated "... recent infections ... 4/17/19 URI [upper respiratory infection] ...." Review of a document titled "Visit Note Report" dated and signed on 4/24/2020 by employee J stated "... duonebs [respiratory inhalation breathing treatments] x 14 days ... Dtr [daughter] reported concerns about wheezing and something possibly stuck in her throat earlier this week ... assessed patient lung sounds with wheezes in bilat [bilateral] upper lobes ...." Review of a document titled "Visit Note Report" dated and signed on 4/29/2020 by employee J stated "... Visit today due to continued emesis ... lung sounds coarse throughout ... patient expired ...." Review of a document dated 4/18/2019 titled "Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report" failed to evidence the patient's decline with new onset URI, patient was a high risk for aspiration, or her specialized diet. During an interview on 8/3/2020 at 7:41 p.m., family indicated she asked employee J to get a chest X-ray in April (2019) when the patient starting experiencing symptoms of aspiration, and stated she heard the patient "gurgling". Family stated employee J "refused" to get the X-ray. During an interview on 8/6/2020 at 12:16 p.m., person B (a paramedic) indicated on 4/29/2020, a nurse from entity C told him the patient was vomiting blood, and had been that way for a couple of days. During an interview on 8/27/2020 at 1:27 p.m., when asked if the patient should have had a chest X-ray for potential aspiration, the DPS indicated the facility physician should have followed up, and hospice was secondary. During an interview on 8/27/2020 at 3:44 p.m., when asked why SLP hadn't been consulted for the patient, the administrator submitted a clinical record document titled "Visit Note Report" signed and dated 10/02/2018 by employee K stated "... A swallow study was ordered [prior to hospice admission], but unable to be performed ...." No further documentation was submitted that evidenced SLP was consulted while the patient was on service with agency. 9. Clinical record review for patient #3 was completed on 8/27/2020 with admit date 5/11/2020, and primary diagnosis of Parkinson's disease. Review of a document dated 8/3/2020 signed by employee D titled "Visit Note Report" stated "Pt [patient] reports he got out of bed via hoyer lift yesterday and sat up in his wheelchair. Pt was happy with getting out of bed, he states that he doesn't want to be in bed all the time. Pt states his tremors are bothersome ...." The document failed to evidence employee D followed up with the medical equipment company, followed up with the physician for the patient's stated personal goals, which included getting up and able to go to wedding (transfer/strengthening training- opportunity for PT), difficulty using utensils to eat, and using a urinal in bed (improved upper body movement/control- opportunity for OT). Review of documents dated 8/11 and 8/25/2020 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" failed to evidence the patient's stated concerns from the observed home visit on 8/3/2020 were addressed. 10. During an interview on 8/3/2020 at 11:20 a.m., the DPS indicated the agency didn't provide any PT except short term for safety or transfers. The administrator indicated "Like quality of life." 12. During an interview on 8/5/2020 at 2:47 p.m., when asked if the agency provides OT, the DPS stated "Not typically. We don't typically do therapies. That's more home care." 13. During an interview on 8/6/2020 from 1:46 p.m. - 2:10 p.m., when the agency fall policy was requested, the administrator and DPS indicated the agency policy #160 dated 7/09 titled "Employee Safety/Patient Safety" included the agency policy on falls. Review of the policy failed to evidence patient interventions for patients assessed as high fall risk during clinical assessment or interventions for patients who sustained falls. No further evidence was submitted. 14. During an interview on 8/6/2020 at 1:46 p.m., the DPS indicated the agency did not have policies on therapy services (PT, OT, SLP). Nothing further was submitted. 15. During an interview on 8/6/2020 at 2:45 p.m., when asked what services the agency provided, employee E (a licensed practical nurse/LPN) stated "RN [registered nurse], LPN, massage therapy, music therapy, chaplain, that's about it. [sic] And social worker." 16. During an interview on 8/6/2020 at 2:27 p.m., when asked what services the agency provided, employee F stated "RN, case manager, aide, music, massage, respite, inpatient, equipment and spiritual [care]." 17. During an interview on 8/6/2020 at 4:20 p.m., when asked what the purpose for physical therapy services was, the DPS indicated it was primarily for safety in transfers, and the "rule of thumb" was 3 visits, otherwise Medicare looked at it (physical therapy services) as curative. When asked about PT for patient #3, the DPS indicated it would have to have been discussed with the physician, the interdisciplinary team meeting wasn't until next week, and acknowledged the patient specific goal was "missed." When asked if the patient had to wait up to 2 weeks for intervention, the DPS stated "Not necessarily." 18. During an interview on 8/25/2020 at 3:50 p.m., when asked who maintained all human resource (HR) records, the DPS stated "Home care side maintains all HR records. I haven't looked at any HR records." 19. During an interview on 8/25/2020 at 3:53 p.m., when asked if the agency utilized OT, the administrator stated "... don't use OT." 20. During an interview on 8/26/2020 from 12:38 - 2:15 p.m., when asked if the agency have PT, OT and SLP staffed, the medical director stated "We don't usually for Hospice ..." and indicated if they need therapy, they would go to the home health side. When asked about therapy for patient #3's personal goal to attend his daughter's wedding in a wheelchair, the medical director stated "Personally, I don't think PT would make him strong enough to go for that." When asked if he was aware of the condition of participation for therapy services, the medical director stated "Yes, but it usually doesn't work. We can do three days ...." At 1:45 p.m., the medical director asked if the surveyor would be available tomorrow (8/27/2020), and stated "... every state is different and I would like to learn ...." and indicated he did not know all of the (hospice) regulations.
L0648
L0648	42909 Based on observation, record review and interview, the hospice failed to ensure it provided care which optimized comfort and dignity for all patients (L650); failed to ensure it offered and provided physical, occupational and speech-language therapies for all patients (L652); failed to ensure evidence of written agreements with individuals as applicable who provided care to all patients (L655); failed to ensure all individuals received orientation about the hospice philosophy who provided care to all patients (L661); and failed to ensure all individuals received initial orientation that addressed specific job duties who provided care to all patients (L662). These practices had the potential to impact all patients. The cumulative effect of these systemic problems resulted in the agency's inability to ensure effective management and administration of hospice care and services to its patients as required by the Condition of Participation §418.100 Organization and administration of services.
L0650
L0650	42909 Based on observation, record review and interview, the hospice failed to ensure all patients received care that optimized comfort and dignity for 3 of 3 patient records reviewed for symptom management (#1, 2, 3) in a total sample of 9. Findings include: 1. Clinical record review for patient #1 was completed on 8/27/2020 with hospice election date of 12/12/2019, and primary diagnosis of Essential Hypertension for benefit period 12/12/2019 to 3/10/2020. The patient expired on 12/22/2019. The record evidenced the patient was able to answer for herself, but caregiver(s) answered on her behalf, and patient was administered strong opioid medications when she was unresponsive and unconscious. Review of a document titled "Visit Note Report" dated and signed 12/13/2019 at 3:28 p.m. by employee I (registered nurse) stated "... respirations 18 ... WNL [within normal limits] ... Blood pressure 129/52 ... Oxygen saturation level (%) 97 [within normal limits] ... pain 0 ... alert ... oriented ... pain ... Patient response "Are you uncomfortable because of pain?" ... No ... pain reported by: Patient alone ... patient is over 18 and able to answer ... patient has no pain ... frequency of pain ... daily, but not constantly ... current level of pain ... none ... alert and oriented x3, occasional forgetfulness ... she is able to make her needs known ...." The document evidenced the patient had no pain, the patients respirations were within normal limits, but the caregiver stated the patient was short of breath with minimal exertion. The patient did not answer for herself, when it was evidenced she had the ability to, the document failed to evidence the nurse educated the patient/family on use of tramadol for pain or non-medicinal methods to mitigate pain, the patient stated she had no pain, but new opioid medications were ordered. Review of a document titled "Visit Note Report" dated and signed 12/22/2019 at 12:20 p.m. by employee E stated "... comatose ... unresponsive ... unresponsive this morning ... hypoxia ... [8:01 a.m.] ... sleeping in bed, sonorous, no apnea noted. Mouth open snoring ... eyes closed. [patient] is unresponsive ... BP [blood pressure] 77/40 ... medicated with morphine 10mg and Ativan 1mg SL ... [9:00] ... gave [patient] a bed bath ... changed linen ... continues to be unresponsive ... [10:00 a.m.] atropine administered for gurgling ... [2:50 p.m.] medicated with morphine and Ativan ... remains unresponsive ... [4:50 p.m.] medicated with morphine and atropine ... [5:43] [patient] took last breath ...." During an interview on 8/6/2020 at 11:15 a.m., family (person M) stated "I watched the nurse hand her medication at around 5:40 p.m., she [another family member] gave it, and she [patient] died within a few minutes." During an interview on 8/10/2020, family (person L) stated "[patient] was never deemed unable to make her own decisions prior to this." During an interview on 8/25/2020 at 12:00 p.m. with the DPS, When asked when would morphine and Ativan be ordered, he stated for anxiety, shortness of breath or pain, it was determined by the physician, and the goal was comfort, but not to the point of sedation. When asked if he would expect morphine or ativan to be given to a completely unresponsive patient, he indicated it depended on the situation, and there was definitely a difference between decline and overmedication. During an interview on 8/25/2020 at 3:05 p.m. with the administrator, when asked if it was customary to administer morphine or Ativan to a completely unresponsive patient, she indicated it was based on the nurse's assessment, could be that they finally got symptoms under control, should consult physician, and reduce medications if necessary. During an interview on 8/27/2020 at 9:30 a.m., when asked if the patient was making good progress in therapy upon discharge, director of nursing for entity A stated "Yes." When asked if the patient was alert, oriented and competent to make her own decisions upon discharge, she said "Yes." 2. Clinical record review for patient #2 was completed on 8/27/2020 with hospice election date of 10/2/2018, and primary diagnosis of Alzheimer's disease. Review of all visit notes from 1/2/2019 - 4/29/2019, all failed to evidence the patient's last bowel movement, stated was "unknown." The record failed to evidence patient was high risk for aspiration (due to dysphagia) or implemented interventions, and failed to evidence the agency promptly responded to patient's potential aspiration related to recurrent emesis (vomiting). Review of a document titled "hospice CTI [certificate of terminal illness]" dated and signed by physician H on 10/4/2018 stated "... Meals consist of modified diet with honey thick liquids [specific diet for those at risk for aspiration] diet and is requiring assistance with eating due to dysphagia ...." Review of a document titled "Hospice Certification and Plan of Care" start of care date 10/2/2018 for certification period 10/2/2018 - 12/30/2018 stated "... Nutritional Requirements: Diet as tolerated ...." The document failed to evidence the patient had dysphagia, required a modified diet with honey thick liquids, the patient was at high risk for aspiration, orders to assess for aspiration, interventions to prevent aspiration, or family specific wishes/goals for treatment of aspiration. Review of a document titled "Visit Note Report" dated and signed on 2/22/2019 at 11:00 p.m. by employee Z (registered nurse) stated "... oxygen saturation level (%) 93 ... Was the patient's respiratory system assessed? No ... Indicate reason ... Not appropriate at time of evaluation ... Was the patient's gastrointestinal system addressed? No ... Indicate reason ... Not appropriate at time of evaluation ... Indicate if you communicated with other disciplines involved with this case: NO ... patient had large emesis that was siluspected [sic] to be bloody ...." The document failed to evidence the patient was assessed for potential aspiration. Review of a document titled "Visit Note Report" dated and signed on 4/17/2020 by employee J (registered nurse) stated "... recent infections ... 4/17/19 URI [upper respiratory infection] ... seen by facility NP (nurse practitioner) today and new orders for mucinex and Bactrim for URI [upper respiratory infection] ...." Review of a document dated 4/18/2019 titled "Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report" failed to evidence the patient's decline with new onset URI, patient was a high risk for aspiration, her specialized diet, or monitoring for GI bleed. Review of a document titled "Visit Note Report" dated and signed on 4/24/2020 by employee J (registered nurse) stated "... duonebs [respiratory inhalation breathing treatments] x 14 days ... Dtr [daughter] reported concerns about wheezing and something possibly stuck in her throat earlier this week ... assessed patient lung sounds with wheezes in bilat [bilateral] upper lobes ...." Review of a document titled "Visit Note Report" dated and signed on 4/29/2020 by employee J (registered nurse) for visit time in home 11:16 a.m. - 11:46 a.m., then back from 12:20 - 12:32 p.m. stated "... Visit today due to continued emesis [vomiting] ... suspected GI bleed ... cyanosis [blue/gray skin color from lack of oxygen] ... lung sounds coarse throughout ... patient expired ...." Review of a document received from entity C dated 4/29/2019 at 11:45 a.m. titled "SBAR Communication form" stated "... Cyanotic; possible aspiration ... send to ER." This document was not part of the patient's clinical record submitted by agency. During an interview on 8/3/2020 at 7:41 p.m., family indicated she asked employee J to get a chest X-ray in April (2019) when the patient starting experiencing symptoms of aspiration, and stated she heard the patient "gurgling". Family stated employee J "refused" to get the X-ray, and no one informed her that the patient had been vomiting for a couple of days prior to her death. Furthermore, the family stated the patient died from "internal hemorrhage, "though the death certificate said "Alzheimer's" as cause of death. The family indicated they were upset because the patient didn't die from the Alzheimer's. Lastly, the family indicated the patient's spouse sat with the patient the morning of their death and indicated the patient was cold to touch- on the face and arms. During an interview on 8/6/2020 at 12:16 p.m., person B (a paramedic) indicated on 4/29/2020, a nurse from entity C told him the patient had vomited blood, and had been that way for a couple of days. Person B indicated the hospice nurse had left the facility prior to the patient's death and had to be called back, and the facility nurse instructed him to talk to the patient's family and notify of death. During that time, a document titled "Patient Chart" (an ambulance call log report) was reviewed which stated ". Unconscious ... Patient has not been feeling well and has been vomiting blood ... Pt was deteriorating last night and had been sweating through the night. Hospice states "pt is on hospice and is a DNR [do not resuscitate] but daughter wants pt transported to hospital to see what's going on ... 12:03 ... Pt has cough/dry heave and coffee ground vomit is running out of the pt mouth ... Time of death 1207 [12:07 p.m.] ... moved back in to bed at [entity C] ...." During an interview on 8/6/2020 at 12:37 p.m., the patient's daughter indicated she was not informed the patient had been vomiting blood for two days, she would have sent her to the ER then, and maybe the outcome could have been different and she might have lived, and stated "I was only made aware the morning of [4/29/2019], maybe about 11:00 [a.m.], I'm not sure." During an interview on 8/27/2020 at 1:27 p.m., when asked if the patient should have had a chest X-ray for potential aspiration due to vomiting and underlying aspiration risk, the DPS indicated the facility physician should have followed up, and hospice was secondary. 3. Clinical record review for patient #3 was completed on 8/27/2020 with hospice election date of 5/11/2020, and primary diagnosis of Parkinson's disease. The record failed to evidence PT or OT was consulted for the patient's stated personal goals, or the nurse followed up with the equipment company to ensure the patient's wheelchair could accommodate his physical needs. During a home visit for observation of patient #3 on 8/3/2020 at 1:30 p.m., with admit date 5/11/2020, primary diagnosis Parkinson's disease, the patient was observed lying in bed, with tremors, worse on right side, to both upper and lower extremities. During this time, the patient stated "... wish I could figure out how to use a urinal [in bed]." Employee D stated "Yeah, it's hard." Family indicated they got the patient out of bed "last night", but his right foot kept falling off of the foot peg on the wheelchair. Observed wheelchair lacked straps to secure the feet in place. Employee D indicated she was going to call the medical equipment company for follow up. When asked about patient specific goals, employee D indicated "Safety, maintain mobility as best as possible, adequate intake, prevention of skin breakdown, [and] pain." The patient indicated he wanted to go to his daughter's wedding in October, and stated "I gotta [sic] get up more. That foot thing [falling off of the foot peg on the wheelchair] is really bothering me." Employee D acknowledged previous knowledge of the patient's personal goal. Review of a document dated 8/3/2020 signed by employee D titled "Visit Note Report" stated "Pt [patient] reports he got out of bed via hoyer lift yesterday and sat up in his wheelchair. Pt was happy with getting out of bed, he states that he doesn't want to be in bed all the time. Pt states his tremors are bothersome ...." The document failed to evidence employee D followed up with the medical equipment company, followed up with the physician for the patient's stated personal goals, which included getting up and able to go to wedding (transfer/strengthening training- opportunity for PT), difficulty using utensils to eat, and using a urinal in bed (improved upper body movement/control- opportunity for OT). Review of documents dated 8/11 and 8/25/2020 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" failed to evidence the patient's stated concerns from the observed home visit on 8/3/2020 were addressed. During an interview on 8/3/2020 at 11:20 a.m., the DPS indicated the agency didn't provide any PT except short term for safety or transfers. The administrator indicated "Like quality of life." During an interview on 8/5/2020 at 2:47 p.m., when asked if the agency provides OT, the DPS stated "Not typically. We don't typically do therapies. That's more home care." During an interview on 8/27/2020 at 1:55 p.m., when asked if changes in condition, edema, decorticate posturing should be reported to a registered nurse, the administrator stated "Yes".
L0652
L0652	42909 Based on observation, record review and interview, the hospice failed to ensure physical therapy (PT), occupational therapy (OT), and/or speech language pathology (SLP) services were available and offered for 3 of 3 (#1, 2, and 3) records reviewed of patients who had a need for therapy services, in a total sample of 9. Findings include: 1. Review of an agency policy #220 on 08/03/2020 dated 6/16 titled "Description of Services" stated "... Care is provided ... according to the patient's needs and desires ... Physical Therapy ... to restore the patient to the highest functional level of strength, range of motion, mobility and independence ... Occupational Therapy ... to increase the patient's ability to carry out normal day to day functioning ... increase upper extremity function and promote independence ... Speech Language Pathology ... treatment programs to maximize effectiveness for the patient ...." Review of an untitled agency policy #005-A last updated 12/18 identified by the administrator as the organizational chart failed to evidence PT, OT, or SLP at the branch level of the agency. Review of the agency's admission packet on 08/03/2020 contained an undated booklet titled "Heartland Hospice Care Patient Information Handbook" which stated "... Your Hospice Care Team ... Licensed therapists provide services ... may include physical, occupational and speech therapy ...." 2. Review of an agency document on 8/3/2020 titled "Agent Visit Time Report" evidenced a total of five patients were seen by physical therapy for the past 6 months which included 2 patients that received 3 visits each, 1 patient received 2 visits, and 2 patients received 1 visit each. 3. Review of an agency document on 8/26/2020 titled "QI [quality improvement] Event Report" for patient falls 6/1 - 8/26/2020 evidenced 147 patients sustained at least 1 fall, with a total of 277 patient falls for the timeframe selected, and could have benefited from therapy services. During an interview on 8/6/2020 from 1:46 p.m. - 2:10 p.m., when the agency fall policy was requested, the administrator and DPS indicated the agency policy #160 dated 7/09 titled "Employee Safety/Patient Safety" included the agency policy on falls. Review of the policy failed to evidence patient interventions for patients assessed as high fall risk during clinical assessment or interventions for patients who sustained falls. No further evidence was submitted. 4. Clinical record review for patient #1 was completed on 8/27/2020 with hospice election date of 12/12/2019, and primary diagnosis of Essential Hypertension. Patient was discharged from entity A (a skilled nursing facility) to home on 12/9/2020 with discharge referral for home health. The clinical record failed to the patient received PT and OT. Review of a document from entity A signed by a nurse from entity A on 12/9/19 stated "... Home Health/Referrals ... Physical Therapy ... Occupational Therapy ...." Review of a document from entity A dated 12/9/19 titled "OT - Therapist Progress & Discharge Summary" stated "... Post discharge recommendations ... recommended to participate with home health ... for safety with transition ... and to complete HEP [home exercise program] daily ...." Review of a document from entity A dated 12/9/19 titled "PT - Therapist Progress & Discharge Summary" stated "... Pt will continue rehab with home health ...." Review of an agency document dated 12/12/19 titled "Hospice Certification and Plan of Care" for certification period 12/9/19 - 3/10/2020 failed to evidence PT or OT was ordered for the patient. During an interview on 8/3/2020 at 11:45 a.m., family indicated the patient thought she was going to receive therapy at home to get better. During an interview on 8/27/2020 at 9:30 a.m., when asked if the patient made good progress with therapy services, the director of nursing at entity A stated "Yes." 5. Clinical record review for patient #2 was completed on 8/27/2020 with hospice election date of 10/2/2018, for benefit period of 1/2/19 - 4/29/2019 and primary diagnosis of Alzheimer's disease. The record failed to evidence SLP was consulted/offered while the patient received services from the agency. Review of a document titled "Visit Note Report" dated and signed on 4/10/2020 by employee J (registered nurse) stated "... pureed diet with honey thick liquids, pocketing fluid, excess secretions, difficulty swallowing ... lung sounds diminished throughout with expiratory wheezes noted ...." Review of a document titled "Visit Note Report" dated and signed on 4/17/2020 by employee J (registered nurse) stated "... recent infections ... 4/17/19 URI [upper respiratory infection] ...." Review of a document titled "Visit Note Report" dated and signed on 4/24/2020 by employee J (registered nurse) stated "... duonebs [respiratory inhalation breathing treatments] x 14 days ... Dtr [daughter] reported concerns about wheezing and something possibly stuck in her throat earlier this week ... assessed patient lung sounds with wheezes in bilat [bilateral] upper lobes ...." Review of a document titled "Visit Note Report" dated and signed on 4/29/2020 by employee J (registered nurse) stated "... Visit today due to continued emesis ... lung sounds coarse throughout ... patient expired ...." Review of a document dated 4/18/2019 titled "Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report" failed to evidence the patient's decline with new onset URI, patient was a high risk for aspiration, or her specialized diet. During an interview on 8/3/2020 at 7:41 p.m., family indicated she asked employee J to get a chest X-ray in April (2019) when the patient starting experiencing symptoms of aspiration, and stated she heard the patient "gurgling". Family stated employee J "refused" to get the X-ray. During an interview on 8/6/2020 at 12:16 p.m., person B (a paramedic) indicated on 4/29/2020, a nurse from entity C told him the patient was vomiting blood, and had been that way for a couple of days. During an interview on 8/27/2020 at 1:27 p.m., when asked if the patient should have had a chest X-ray for potential aspiration, the DPS indicated the facility physician should have followed up, and hospice was secondary. During an interview on 8/27/2020 at 3:44 p.m., when asked why SLP hadn't been consulted for the patient, the administrator submitted a clinical record document titled "Visit Note Report" signed and dated 10/02/2018 by employee K stated "... A swallow study was ordered [prior to hospice admission], but unable to be performed ...." No further documentation was submitted that evidenced SLP was consulted while the patient was on service with agency. 6. Clinical record review for patient #3 was completed on 8/27/2020 with hospice election date of 5/11/2020, and primary diagnosis of Parkinson's disease. During a home visit for patient #3 on 8/3/2020 at 1:30 p.m., the patient was observed lying in bed, with tremors, worse on right side, to both upper and lower extremities (patient was right-handed), was non-weight bearing, required hoyer for transfers (occurred after hospice admission), and had recently become bedbound upon admission to hospice. Employee D (registered nurse, case manager) indicated hoyer training was offered but the family declined due to multiple nurses in the family. During this time, the patient stated "... wish I could figure out how to use a urinal [in bed]." Employee D stated "Yeah, it's hard." Family indicated they got the patient out of bed "last night", but his right foot kept falling off of the foot peg on the wheelchair. Observed wheelchair lacked straps to secure the feet in place. Employee D indicated she was going to call the medical equipment company for follow up. When asked about patient specific goals, employee D indicated "Safety, maintain mobility as best as possible, adequate intake, prevention of skin breakdown, [and] pain." The patient indicated he wanted to go to his daughter's wedding in October, and stated "I [gotta] get up more. That foot thing [falling off of the foot peg on the wheelchair] is really bothering me." Employee D acknowledged previous knowledge of the patient's personal goal. When asked if the agency provides therapy services, employee D stated "No. Maybe a visit or two for safety or transfers." Review of a document dated 8/3/2020 signed by employee D titled "Visit Note Report" stated "Pt [patient] reports he got out of bed via hoyer lift yesterday and sat up in his wheelchair. Pt was happy with getting out of bed, he states that he doesn't want to be in bed all the time. Pt states his tremors are bothersome ...." The document failed to evidence employee D followed up with the medical equipment company, followed up with the physician for the patient's stated personal goals, which included getting up and able to go to wedding (transfer/strengthening training- opportunity for PT), difficulty using utensils to eat, and using a urinal in bed (improved upper body movement/control- opportunity for OT). Review of documents dated 8/11 and 8/25/2020 titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" failed to evidence the patient's stated concerns and need for therapy from the observed home visit on 8/3/2020 were addressed. During an interview on 8/6/2020 at 4:20 p.m., when asked about PT for patient #3, the DPS indicated it would have to have been discussed with the physician, the interdisciplinary team meeting wasn't until next week. During an interview on 8/26/2020 from 12:38 - 2:15 p.m. the medical director was asked about therapy for patient #3's personal goal to attend his daughter's wedding in a wheelchair. The medical director stated "Personally, I don't think PT would make him strong enough to go for that." 7. During an interview on 8/3/2020 at 11:20 a.m., the DPS indicated the agency didn't provide any PT except short term for safety or transfers. The administrator indicated "Like quality of life." During an interview on 8/5/2020 at 2:47 p.m., when asked if the agency provides OT, the DPS stated "Not typically. We don't typically do therapies. That's more home care." During an interview on 8/6/2020 at 1:46 p.m., the DPS indicated the agency did not have policies on therapy services (PT, OT, SLP). During an interview on 8/6/2020 at 2:27 p.m., when asked what services the agency provided, employee F stated "RN, case manager, aide, music, massage, respite, inpatient, equipment and spiritual [care]." During an interview on 8/6/2020 at 2:45 p.m., when asked what services the agency provided, employee E (a licensed practical nurse/LPN) stated "RN [registered nurse], LPN, massage therapy, music therapy, chaplain, that's about it. [sic] And social worker." During an interview on 8/6/2020 at 4:20 p.m., when asked what the purpose for physical therapy services was, the DPS indicated it was primarily for safety in transfers, and the "rule of thumb" was 3 visits, otherwise Medicare looked at it (physical therapy services) as curative. When asked if a patient had to wait up to 2 weeks for intervention, the DPS stated "Not necessarily." During an interview on 8/25/2020 at 3:50 p.m., when asked who maintained all human resource (HR) records, the DPS stated "Home care side maintains all HR records. I haven't looked at any HR records." Furthermore, when asked if the agency utilized OT, the administrator stated they"... don't use OT." During an interview on 8/26/2020 from 12:38 - 2:15 p.m., when asked if the agency have PT, OT and SLP staffed, the medical director stated "We don't usually for Hospice ..." and indicated if they need therapy, they would go to the home health side. When asked if he was aware of the condition of participation for therapy services, the medical director stated "Yes, but it usually doesn't work. We can do three days ...." Lastly, the medical director indicated he did not know all of the regulations.
L0655
L0655	42909 Based on record review and interview, the hospice failed to ensure physical therapy, occupational therapy, and speech-language pathology services were supported by written agreements that evidenced all services were authorized by the agency, the agency retained administrative and financial management, and the agency retained oversight of staff and services for all arranged services that ensured the provision of quality care. Findings include: Review of an agency document on 8/3/2020 titled "Agent Visit Time Report" evidenced a total of five patients were seen by physical therapy, by persons D, E, and F, for the past 6 months which included 2 patients that received 3 visits each, 1 patient received 2 visits, and 2 patients received 1 visit each. During an interview on 8/6/2020 at 4:10 p.m., when asked if the agency had written contracts with physical therapists, occupational therapists, speech-language therapists, or entity G for shared therapy services, the administrator and director of professional services (DPS) both stated "No." Employee records were reviewed for persons D, E, and F on 8/25/2020 at 3:44 p.m., which failed to evidence written agreements. During that time when asked who maintained all human resource (HR) records, the DPS stated "Home care side maintains all HR records. I haven't looked at any HR records." Furthermore, the administrator and DPS acknowledged persons D, E, and F saw patients for the agency, but were not agency employees or contracted staff.
L0661
L0661	42909 Based on record review and interview, the hospice failed to provide orientation about the hospice philosophy to all employees and contracted staff who had patient and family contact for 3 of 3 physical therapist employee records (persons D, E, and F- not employees or contracted staff of agency) reviewed. Findings include: Review of an agency document on 8/3/2020 titled "Agent Visit Time Report" evidenced a total of five agency patients were seen by persons D, E, and F within the last 6 months. During an interview on 8/6/2020 at 1:46 p.m., the DPS (director of professional services) indicated the agency did not have policies for therapy services, they did not have a contract with therapists or entity G, and the staff was trained and checked off (competencies) by entity G (not the hospice agency). Employee records were reviewed for persons D, E, and F on 8/25/2020 at 3:44 p.m., during that time when asked who maintained all human resource (HR) records, the DPS stated "Home care side maintains all HR records. I haven't looked at any HR records." When asked how the agency ensured training about the hospice philosophy was completed for all therapists, the DPS did not provide an answer. Furthermore, the administrator and DPS acknowledged persons D, E, and F saw patients for the agency, but were not agency employees or contracted staff and the HR records failed to evidence hospice training. During an interview on 8/26/2020 at 12:38, the medical director indicated the administrator and DPS were responsible for training the therapists.
L0662
L0662	42909 Based on record review and interview, the hospice failed to provide an initial orientation for each employee that addressed the employee's agency specific job duties for 3 of 3 physical therapist employee records (persons D, E, and F- not employees or contracted staff of agency) reviewed. Findings include: Review of an agency document on 8/3/2020 titled "Agent Visit Time Report" evidenced a total of five agency patients were seen by persons D, E, and F within the last 6 months. During an interview on 8/5/2020 at 3:10 p.m., when asked for job descriptions for therapists, the director of professional services (DPS) indicated the agency did not have job descriptions for therapists (physical, occupational or speech). During an interview on 8/6/2020 at 1:46 p.m., the DPS indicated the agency did not have policies for therapy services, they did not have a contract with therapists or entity G, and the staff was trained and checked off (competencies) by entity G (not the hospice agency). Employee records were reviewed for persons D, E, and F on 8/25/2020 at 3:44 p.m., during that time when asked who maintained all human resource (HR) records, the DPS stated "Home care side maintains all HR records. I haven't looked at any HR records." When asked how the agency ensured training about the hospice philosophy was completed for all therapists, the DPS did not provide an answer. Furthermore, the administrator and DPS acknowledged persons D, E, and F saw patients for the agency, but were not agency employees or contracted staff and the HR records failed to evidence hospice orientation. During an interview on 8/26/2020 at 12:38, the medical director indicated the administrator and DPS were responsible for training the therapists.
L0669
L0669	42909 Based on record review and interview, the medical director failed to take responsibility for the medical component of the hospice's patient care program by ensuring all staff followed federal conditions of participation for hospice providers and applicable facility policies and procedures related to (but not limited to) patient rights, interdisciplinary group, care planning and coordination of services, physical therapy, occupational therapy and speech-language pathology, administration of drugs and biologicals, and discrepancies which involved accountability of controlled drugs. Findings include: 1. Review on 8/27/2020 of agency policy last revised 9/2018 titled "Medical Director Roles and Responsibilities" stated "... Medical Director is responsible for: Overall coordination, execution, and monitoring of the medical component of the hospice's patient care program ...." 2. See tags L500, L512, L515, L517, L536, L538, L545, L552, L558, L652, L692, and L700 for further detail. 3. During an interview on 8/26/2020 at 12:38 p.m., the medical director indicated he, the nurses, nurse practitioner(s), director of professional services and administrator were responsible for the medical component of the agency.
L0692
L0692	42909 Based on record review and interview, the hospice failed to ensure the interdisciplinary group (IDG) determined/approved the family was able to safely administer drugs to the patient in the home for 1 of 1 interviewed families regarding medication administration (#1), in a total sample of 9. Findings include: Review of an agency policy #670 dated 07/2019 titled "Management and Disposal of Controlled Substances in the Patient's Home" stated "... The IDG through care planning and coordination determine the ability of the patient/and or family to safely self-administer drugs and biologicals in the home ...." Review of an agency policy #901-H dated 4/2017 titled "Interdisciplinary Group & Group Meeting" stated "The ... [IDG] ... is responsible for providing and supervising the care of the hospice patients ... meets regularly ... more frequently in response to a significant change in the individual's condition ...." Clinical record review for patient #1 was completed on 8/27/2020 with hospice election date of 12/12/2019, and primary diagnosis of Essential Hypertension for benefit period 12/12/2019 to 3/10/2020. The clinical record evidenced the admission and death at home IDG meetings were held on the same date and time on 12/26/2019, four days after the patient expired. Review of a document titled "Visit Note Report" (RN Hospice start of care) dated and signed 12/12/2020 at 9:41 p.m. by employee P (registered nurse) stated "...was the patient's ability to safely administer medications assessed? No ... Indicate the reason ... Daughter sets up ...." The document failed to evidence the nurse assessed the daughter to ensure the patient's medications were correctly set up, so medications were given correctly. During an interview on 8/27/2020 at 3:40 p.m., the administrator and director of professional services (DPS) acknowledged the IDG did not approve the family to administer drugs to the patient, and the DPS asked to see the federal regulation which stated they needed to.
L0700
L0700	42909 Based on record review and interview, the hospice failed to ensure a discrepancy for a controlled drug (morphine) was immediately investigated by the pharmacist and administrator, and failed to evidence a written account of the investigation was available for 1 of 1 records reviewed for drug accountability, (#1) in a total sample of 9. Findings include: Clinical record review for patient #1 was completed on 8/27/2020 with hospice election date of 12/12/2019, and primary diagnosis of Essential Hypertension for benefit period 12/12/2019 to 3/10/2020. Review of a document titled "Visit Note Report" (PRN visit for condition change) dated and signed 12/19/2019 at 12:45 p.m. by employee X (licensed practical nurse) stated "...notified [case manager] morphine needed ordered due to [daughter] spilling last evening. [patient] resting with eyes closed." The document failed to evidence number of doses family administered, or how much morphine was left in bottle after daughter reported she spilled it. During an interview on 8/6/2020 at 2:45 p.m., employee E indicated she would contact the RN case manager if a huge amount of morphine spilled, would just wipe it up if it was just a splash. Furthermore, she acknowledged she would ask a family member to administer a medication, and couldn't remember if she ever asked a family member to administer medications. During an interview on 8/6/2020 at 2:27 p.m., employee F indicated unaccounted medications would be reported and an investigation would be done. During an interview on 8/6/2020 at 5:13 p.m., when asked about procedure for spilled/unaccounted morphine, the director of professional services (DPS) stated "We weren't present when it spilled, he reported it when he found out." When asked if there should have been an investigation, the DPS stated "Not necessarily." During an interview on 8/25/2020 at 12:00 p.m. with the DPS, when asked about the procedure for spilled/unaccounted morphine, he indicated staff should call (agency) right away, contact physician and he would decide what to do. During an interview on 8/26/2020 at 12:38 p.m. with the medical director, when asked the procedure for unaccounted narcotics (morphine), he indicated an investigation would be initiated, urine drug screen for patient/family if possible, and stated "... all hands on deck- pharmacy, me, nurses, PCM [patient case manager], everyone is notified."