|§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, review of clinical records, facility documentation and facility policies and procedures, and interviews with staff, 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 two of three residents reviewed receiving hospice services (Residents R69 and R88).
Review of facility policy, "Hospice Services," dated December 1, 2018, revealed that it is the policy of the facility to provide collaborative care with Hospice providers to ensure that the resident's end of life preferences and choices are honored.
Review of facility documentation, "Hospice Services Agreement," dated December 8, 2017, revealed that, "Hospice shall promote open and frequent communication with Facility and shall provide Facility with sufficient information to ensure that the provision of Facility Services under this agreement is in accordance with the Hospice Patient's Plan of Care, assessments, treatment planning and care coordination."
Review of Resident R69's Minimum Data Assessment (MDS- an assessment of a resident's need) dated December 26, 2019 revealed the resident was admitted to the facility on October 25, 2018 with diagnoses including dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), transient ischemic attack (TIA-when the blood supply to part of the brain is briefly blocked), anxiety (unpleasant sense of inner turmoil and anguish) and depression (major loss of interest in pleasurable activities characterized by change in sleep patterns, appetite and/or routine).
Review of Resident R69's Hospice Plan of Care, dated October 17, 2019, revealed that the resident will receive skilled nursing visits at least once per week and nurse aide visits three times per week.
Review of Resident R69's hospice documentation that was available in the facility, revealed that there were no nursing notes and no nurse aide notes from January 17, 2020 to February 12, 2020.
Interview on February 12, 2020 at approximately 10:55 a.m. with the Director of Nursing confirmed that there were no nurse aid or skilled nursing notes in the resident's Hospice binder after the date of January 17, 2020.
Review of Resident R69's Occupational Therapy discharge notes, dated May 24, 2019, revealed that "patient was issued a Rock n go chair form hospice ...pt [sic- abbreviation for patient] is laterally leaning to the left side unable to maintain midline with repositioning ...tends to gravitate toward lateral leaning." Further review revealed, "Pt positioned in narrow, high back reclining wheelchair fitted with anti-tippers and lateral support to help pt to maintain upright sitting. Pt also issued wedge cushion to position knees higher than hips for further sitting comfort and safety. Pt appears comfortable and is reclined when she falls asleep."
Review of physician order for Resident R69, dated December 9, 2019, revealed, "Hospice issued rock and go wheelchair."
Progress notes from December 10, 2019 revealed, "Nurse was trying to push resident from dining into room to put her in bed and she rocked herself out of the w/c [sic-abbreviation for wheelchair]"
Review of the facility fall incident report, dated December 10, 2019 revealed, "restlessness noted ...when staff went to assist resident she again began rocking and rocked forward from her chair. Resident is in a rock and go w/c provided by hospice."
Review of the facility fall incident report, dated February 6, 2020 revealed, "Resident is disoriented x3 (people, places and time). Dependent for all locomotion, resident is seated in rock and go w/c, provided by Hospice. Rocks back and forth while in w/c. Resident without an intended destination when she scooted to the floor."
Observation of resident on February 9, 2020 at approximately 9:15 a.m. and February 10, 2020 at approximately 9:05 a.m. in dining area revealed that Resident R69 was seated in a Rock N Go wheelchair. She was reclined back to an approximate 130 degree angle and she was observed to be grasping the armrests and attempting to pull herself up to a more upright position.
Observation of resident on February 9, 2020 at approximately 12:00 p.m. in dining area revealed that Resident R69 was seated in a Rock N Go wheelchair near a table. She was reclined to an approximate 130 degree angle and she was observed to be grasping the armrests and attempting to pull herself up to a more upright position while a staff member was attempting to spoon feed the resident her pureed lunch.
Review of facility document, "Nursing Facility and Hospice Services Agreement," dated June 12, 2019, revealed the nursing facility would coordinate with hospice personnel regarding the resident's plan of care. The Agreement additionally added that both the nursing facility and hospice provide would each prepare and maintain complete and detailed clinical records for resident's receiving hospice care, including, but not limited to, evaluations and treatments.
Review of the clinical record for Resident R88 revealed the resident was readmitted to the facility on September 19, 2019, with diagnoses including, but not limited to, worsening dementia and anxiety.
Review of a physician's order, dated October 17, 2019, instructed staff to have hospice staff evaluate and treat Resident R88.
Review of another physician's order, dated December 9, 2019, revealed, "Hospice issued gerichair."
Review of an IDG (Interdisciplinary Group) hospice note, dated January 15, 2020, for coordination of care, revealed the hospice provider would supply DME (durable medical equipment-wheelchairs, bedside commodes, etc.).
Observation during initial resident screening process on February 9, 2020, at 8:14 a.m. revealed Resident R88 was eating breakfast, with assistance of a staff member, in the dining room on the third floor nursing unit. Resident R88 was sitting upright in a geri chair, unreclined, with lockable tray in place over the resident's lap area.
Observation on February 9, 2020, at 9:21 a.m. revealed the breakfast meal was complete and Resident R88 was finished eating. Resident remained sitting in the unreclined geri chair and was observed to be slowly sliding down the chair, with upper torso partially under the locked tray, was grasping each armrest of the chair and was attempting to stop herself from sliding down. Resident R88 appeared to be unnerved and uncomfortable with her legs dangling unsupported while attempting to keep self from sliding down the chair (bottom portion of geri chair was not in recline position as she was seated upright, so there was no support for the resident's legs). When not being addressed by staff, Resident R88 was yelling out words, approximately every 15 seconds, unintelligible in an Asian dialect (Vietnamese).
Observation on February 9, 2020, at 9:44 a.m. revealed Resident R88 had slid down further in the geri chair and was askew in the chair, yelled out again in the Asian dialect, was grasping onto the tray, and when approached by a staff member, the resident clearly stated in English, "Lift me up!" The staff member was observed to physically lift the resident back up in the chair, then proceeded to wheel her back to her room to have incontinence care provided.
Observation on February 9, 2020, at 9:59 a.m revealed the same staff member brought Resident R88 back to dining area, placed her chair in the same location in the room as it was during breakfast, now with the geri chair in a reclined position. The locked tray was observed to remain in place.
Observation on February 9, 2020, at 10:12 a.m. revealed the locked tray was removed by a staff member. Resident remained in the inclined position.
Observation on February 9, 2020, at 11:52 a.m. revealed Resident R88 remained in inclined position and was sleeping.
Observation on February 10, 2020, at 11:51 a.m. revealed Resident R88's hospice aide was assisting the resident with her lunch meal. Resident R88 was seated in the geri chair, in an upright position, with locked tray in place. Interview with the hospice aide at the time of the observation revealed Resident R88 cannot remove tray on her own because it is designed to be locked in place so that staff can remove it, not the resident.
Further review of the clinical record revealed no documentation that the facility obtained a physician's order for use of a locked tray on Resident R88's geri chair, and no documentation that the interdisciplinary team, along with hospice staff, assessed this geri chair with lockable tray to determine the necessity of this device for the resident's medical diagnoses of dementia and anxiety.
Interview conducted with the Nursing Home Administrator and Director of Nursing on February 10, 2020, at approximately 2:00 p.m. revealed that the facility had not obtained a physician's order to use a lockable tray in conjunction with a geri chair, and confirmed that hospice staff provided this chair for Resident R88 without adequate documentation regarding communication with facility staff regarding the reason for use of lockable tray and assessment of safe and proper body positioning in the geri chair.
Refer to F604 and F688.
The facility failed to provide documentation that adequate communication was maintained between hospice providers and the facility to ensure the needs of residents were addressed and met.
CFR(s): 483.70(o)(1)-(4) Hospice Services
Previously cited 01/29/19
28 Pa Code 201.18(a) Management
28 Pa Code 201.18(b)(1) Management
28 Pa Code 201.14(a) Responsibility of licensee
| ||Plan of Correction - To be completed: 03/17/2020|
a.Resident R 69 and R 88 hospice providers were called, and progress notes were obtained and placed on the chart.
b.Facility will review hospice residents' charts to ensure there is adequate communication between facility and hospice providers and the current documentation of hospice services is readily available.
c.Facility educated hospice providers of expectations of timely and adequate communication, in the form of documentation, being made readily available on resident's charts.
d.Medical Records will audit weekly x4 and monthly x3 the charts of hospice residents to ensure there is adequate communication between facility and hospice providers and the current documentation of hospice services is readily available. Results from the audit will be reviewed at the facility QAPI meeting monthly x 3. Medical Records will create an ongoing spreadsheet ensuring hospice charts are up to date.
e.Completion date of 3/17/2020