|§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 observation, review of clinical records and a hospice contract and staff interviews, it was determined that the facility failed to coordinate hospice services regarding oxygen use for one of 21 residents (Resident R75).
The "Hospice Care Services Agreement" revealed "all physican orders communicated to the Facility on behalf of Hospice in connection with a plan of care shall be in writing and signed by the applicable attending physician or Hospice Physician ..."
Resident R75's clinical record revealed an admission date of 4/18/18, with diagnoses that included chronic obstructive pulmonary disease (constriction of the airways making it difficult to breathe)., pacemaker, and stomach and heart problems. The Significant Change Minimum Data Set (periodic review of resident care needs), dated 6/11/19, revealed that Resident R75 was started on hospice services (care focusing on pain, symptoms, emotion and spiritual needs).
Observation on 9/24/19, at 10:34 a.m. revealed Resident R75 with oxygen supplied through a nasal cannula (tubing to the nose supplying oxygen), running at seven liters of oxygen.
The Hospice "Physician's Plan of Care" orders relating to oxygen, originally dated 7/19/19, revealed Resident R75 could have one to five liters of oxygen via nasal cannula as needed for shortness of breath/end of life care if oxygen saturation was less than 90 percent and 6-10 liters via simple face mask or device of choice as needed for shortness of breath/end of life care if oxygen saturation is less than 90 percent.
The facility Primary Care Physician's (PCP) orders dated 9/01/19, revealed an order for oxygen at three liters via nasal cannula as needed. There was no order signed by the facility PCP to reflect the hospice orders were followed for Resident R75's oxygen usage were being .
Observation on 9/26/19, at 9:16. a.m. revealed Resident R75 with a nasal cannula on and receiving oxygen at seven liters. During an interview on 9/26/19, at the time of the observation Registered Nurse Employee E7 confirmed that the oxygen was set at seven liters through a nasal cannula and also confirmed that the hospice oxygen orders did not get transcribed onto the facility's PCP orders for coordination of care.
During an interview on 9/26/19, at 11:02 a.m. the Director of Nursing confirmed that the hospice orders did not get entered for the facility PCP recapitulation to assure that the hospice orders were followed for Resident R75.
28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 7/20/18
28 Pa. Code 211.12.(d)(1)(3)(5) Nursing services
Previously cited 7/20/18
| ||Plan of Correction - To be completed: 11/13/2019|
1. R75 was not harmed in the deficient act of this facility. This practice was immediately corrected by clarifying physician orders, and ensuring these orders were subsequently reconciled for accuracy.
2. A review was conducted of the 6 current Hospice designated patients ensuring the physician orders were reconciled and correct.
3. The Director of Nursing and/or designee will conduct an in-service with all Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants in conjunction with Hospice contract staff related to the clinical management of residents going forward.
4. An audit performed by the Director of Nursing and/or designee of this review process will be conducted as follows:
All current Hospice designated residents will be audited for reconciliation and accuracy of all orders x 60 days. Results will be reviewed on a monthly basis at the facility's QA meeting.