|§483.70(o) Hospice services.|
§483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.
§483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.
§483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.
§483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.
Based on observations, interviews with resident representatives, interviews with staff, clinical record review, review of facility documentation and review of facility policies, it was determined that the facility failed to ensure that adequate communication was maintained between a hospice (end of life care to support resident and family) provider and the facility, for one of 27 records reviewed (Resident R23).
Review of facility policy, "Hospice Services," dated April 25, 2018, revealed that nursing staff are responsible for "Names and contact information for hospice personnel involved in hospice care of each patient ... Review of the resident's record for pertinent documentation regarding the delivery of hospice care."
Review of facility documentation, "Hospice Services Agreement," dated June 18, 2015, revealed that, "Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each hospice patient."
Observation on June 4, 2019, at 1:30 p.m., revealed a hospice aide providing companionship to Resident R23.
Interview on June 4, 2019, at 4:00 p.m., Resident R23's Representative stated that he did not like the way the hospice aide positioned the resident this morning in her chair and indicated that he had to show the hospice aide how to properly position the resident. Resident R23's Representative also stated that he was unsure if the hospice staff communicate with facility staff related to the care and services provided.
Review of Resident R23's care plan, dated initiated April 15, 2019, revealed that the resident will receive hospice services from her preferred hospice provider.
Review of Resident R23's Hospice Plan of Care, dated April 15, 2019, revealed that the resident will receive skilled nursing visits once or twice per week and nurse aide visits five to seven times per week.
Review of Resident R23's hospice documentation that was available in the facility, revealed that there were no nursing notes, no nurse aide notes and no hospice staff schedule available.
Interview on June 6, 2019 at approximately 11:00 a.m., the Nursing Home Administrator confirmed that above documentation was not available and indicated that she would obtain it from the hospice provider.
Continued review of hospice documentation, received by the facility on June 6, 2019, at 12:32 p.m., revealed a nurse's note, dated April 25, 2019, which indicated, "Hospice aide schedule will be faxed to facility and emailed to family each week. White board to be placed in room for facility staff to leave notes and allow patient to know who is caring for her each day."
Observation on June 7, 2019, at 8:51 a.m., revealed that there was no indication on Resident R23's white board in her room of the hospice staff names, schedules or communication notes.
Follow-up interview on June 7, 2019 at approximately 9:00 a.m., the Nursing Home Administrator confirmed that the hospice aide documentation and hospice staff schedules were still not available and indicated that she would obtain them from the hospice provider.
Continued review of hospice documentation, received by the facility on June 7, 2019, at 10:05 a.m., revealed one week of hospice aide documentation from May 26, 2019, through June 1, 2019, and a schedule of hospice aides for June 8, 2019 through June 14, 2019. There was no additional hospice aide documentation or hospice staff schedules available for review.
The facility failed to ensure that adequate communication was maintained between a hospice provider and the facility.
28 Pa. Code 211.5(f) Clinical records
Previously cited 6/9/17
28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 8/17/18
| ||Plan of Correction - To be completed: 07/17/2019|
Resident #23 is stable and comfortable at this time and continues to receive Hospice services.
Resident #23 has been included in a Hospice Binder by the Unit Manager.
The Binder contains communication and progress notes between the Hospice Provider and Facility Staff.
Hospice provider binders are located in the nursing station (1st and 2nd floor).
The binders will continue to include: communication notes, and Hospice nurse and nurse aide progress notes.
Hospice providers will be in-serviced on the binders, along with the facility staff, by the Director of Nursing/Assistant Director of Nursing by 7/12/19.
The in-service will include training on documentation, communication between the Hospice Provider and facility staff, and coordination of care plans.
The Skilled Nursing Administrator or designee will audit the Hospice Binders weekly for 3 months to confirm that residents on Hospice have a binder and that communication between the hospice provider and the facility staff and progress notes are documented, accessible, and available; and will confirm Hospice care plans are current.
During and following the 3 months, the QAPI team will re-evaluate and initiate necessary action or extend the review period, as needed based on issues identified or trends observed
The Skilled Nursing Administrator is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur