Initial Comments:
Based on findings of an unannounced, onsite hospice Medicare complaint survey conducted on March 13 - 14, 2024, and concluded off-site on March 25, 2024, Amedisys Hospice of Lancaster, was found not to be in compliance with the requirements of 42 CFR, Part 418, Subparts A, C &; D, Conditions of Participation: Hospice Care.
As a result of the survey, two (2) condition level deficiencies were cited at 418.54 Initial and Comprehensive assessment of the patient, and 418.56 Interdisciplinary group, care planning and coordination of services along with five (5) standard level deficiencies.
No immediate jeopardy situation was identified.
Plan of Correction:
418.54 CONDITION
INITIAL & COMPREHENSIVE ASSESSMENT OF PATIENT
Name - Component - 00
§418.54 Condition of participation: Initial and Comprehensive assessment of the patient
The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions.
Observations:
Based on review of clinical records (CRs), policy/procedures, and interview with staff, the agency failed to ensure the current comprehensive assessment included an accurate/updated review and documentation of the patient's medications including identification of duplicate drug and dose therapy for one (1) of three (3) CRs reviewed (CR#1); and agency failed to ensure the interdisciplinary group updated the patient comprehensive assessment with an accurate and complete review of all the patient's prescription medications which could affect drug therapy and patient outcomes for one (1) of three (3) clinical records reviewed (CR#1).
Cross Reference:
418.54(c)(6) Drug Profile Tag L530 -- the agency failed to ensure the current comprehensive assessment included an accurate/updated review and documentation of the patient's medications including identification of duplicate drug and dose therapy for one (1) of three (3) CRs reviewed (CR#1).
418.54(d) Update of the comprehensive assessment Tag L533 -- the agency failed to ensure the interdisciplinary group updated the patient comprehensive assessment with an accurate and complete review of all the patient's prescription medications which could affect drug therapy and patient outcomes for one (1) of three (3) clinical records reviewed (CR#1).
Plan of Correction:L0520 418.54 Condition of Participation: initial and Comprehensive Assessment of patient:
1. On 3/29/2024, upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations implemented comprehensive and systematic changes to ensure ALL current patients and future patients received care and services based on an accurate comprehensive assessment of the patients and family's needs in accordance with federal and state regulations; agency policies and procedures; and standards of practice. With review and development and monitoring of a patient-specific plan of care to ensure pain and symptoms are managed timely under hospice physician/Interdisciplinary group (IDG) oversight to ensure patient needs for physical, psychosocial, emotional, and spiritual care. On 3/29/2024, the Administrator/Director of Operations and the Area Vice President of Operations and Regional Director of Clinical Operations provided:
a. Education/Training –
- 4/2/2024- Comprehensive re-education and remediation for ALL Staff on appropriate agency policies related to deficient areas. Review of Agency Policies and Procedures included the following policies:
o AA-003 Assessments,
o AA-005Hospice Plan of care,
o AA-006 Interdisciplinary Team,
o AA-001 Admission
o MM-001 PA Medication Management
- ALL Staff was provided a copy of the above-mentioned policies.
b. Identification/Implementation –
- 3/29/2024 – Initiated that all active patients' plan of care will be reviewed at next IDG and daily monitoring will be done on standup for any new order for medication and change in level of care is followed up with timely to ensure symptoms are controlled and managed and frequencies are adjusted as needed according to the established plan of care per IDG team and hospice medical director with appropriate interventions, coordination of care and an individualized patient-specific plan of care.
- Ongoing, the Administrator/Director of Operations implemented a process to ensure newly hired nurses received ongoing education/training on agency policies and procedures, and documentation requirements related to deficient areas. Ongoing, the Administrator/Director of Operations or the designee will ensure appropriate training for newly hired nurses, as well as ad-hoc skilled competency and staff remediation as needed.
c. Auditing and Monitoring –
- A comprehensive auditing process of clinical documentation was implemented:
o Initiated on 3/29/2024, 100% of patients, who had change in medication or required a level of care change will be audited by next business day to ensure proper follow-up was completed timely for pain & symptom relief and changes to plan of care reflect the current condition of patient as well as medication review has been completed.
o Information from the patient's updated comprehensive assessment will be reviewed to ensure Plan of Care is modified to meet the individualized needs of the patient and must note the patient's progress towards outcome/goals from the plan of care in accordance with the patient's current condition/needs, state and federal regulations, and agency's policies and procedures.
o Appropriate and ongoing coordination of care with all disciplines and to ensure all disciplines are reporting unaddressed or new symptoms to the RN case manager and they are documenting the follow-up done with the patient/patient caregiver (to the extent possible).
o Appropriate delivery of care and interventions provided based on plan of care and patient's needs.
- Auditing to continue monthly for a period of 2 months or until a 100% compliance is met. If compliance is not met after 2 months, the audits will continue for next 2 months and staff remediation will be done as needed to assure compliance.
- Ongoing, an audit of 10% of all patients will be completed to ensure plan of care are individualized, and symptoms are managed and addressed timely.
- Audits will be added to QAPI plan.
- All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriate, but at least annually.
d. Ongoing adherence - The Administrator/Director of Operations will ensure ongoing adherence and monitoring of all aspects of the plan of corrections for cited deficiencies.
e. Completion Date 5/6/2024
418.54(c)(6) STANDARD
CONTENT OF COMPREHENSIVE ASSESSMENT
Name - Component - 00
[The comprehensive assessment must take into consideration the following factors:]
(6) Drug profile. A review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:
(i) Effectiveness of drug therapy
(ii) Drug side effects
(iii) Actual or potential drug interactions
(iv) Duplicate drug therapy
(v) Drug therapy currently associated with laboratory monitoring.
Observations:
Based on review of clinical records (CRs), agency policies, and interview with the agency director, the agency failed to ensure the current comprehensive assessment included an accurate/updated review and documentation of the patient's medications including identification of duplicate drug and dose therapy for one (1) of three (3) CRs reviewed.
Review conducted on March 13, 2024, at approximately 11:00 AM, of clinical records (CRs) revealed:
CR#1 start of care (soc) 6/17/2023:
-Patient's blood pressure medication prescribed by primary care physician, Lisinopril 40 milligrams (MG) by mouth, daily; documented on initial comprehensive assessment 6/17/2023; this same dosage is documented on weekly skilled nurse visit notes from June 16, 2023, until October 4, 2024. Daughter/caregiver administers all patient medications.
-10/4/2023 skilled nurse (SN) visit note: Daughter/caregiver informed licensed practical nurse (LPN) that the lisinopril dosage had been decreased to 20 mg by mouth daily by patient's primary care physician; LPN did not document any communication of medication change to supervisory registered nurse (RN).
-10/10/23 Interdisciplinary Group (IDG) meeting notes documented Lisinopril dosage as 40 MG continues for patient.
-10/18/2023 SN visit note: Documented lisinopril medication dosage decreased to 20 MG daily by RN; verbal order obtained by RN from Medical Director physician at 12:04 PM; new lower dosage order added to patient medication profile; and no deletion of previous lisinopril medication order for 40 MG daily dose performed by RN, [Medication Transcription Error].
-10/24/2023 IDG meeting note: New/added Lisinopril medication dose 20 MG documented; assigned RN for CR#1 documented "Med changes None"; Medication list documented Lisinopril 40 MG and 20 MG, oral daily "Not Related to Terminal Diagnosis" classification; and Medical Director (MD) notes (page 5 of 8) described "MD was present throughout the IDT discussion, reviewed medications for interactions, side effects, and appropriateness. ... Reviewed and agreed with POC and changes made at this IDT."
-SN visit notes for 10/25/23, 11/2/23, 11/8/23, 11/15/23, 11/22/23, and 11/29/23: RNs/LPN documented "Medications reviewed"; and no documented observation of two duplicate doses of Lisinopril medication.
-SN visit notes for 10/25/23, 11/2/23, 11/8/23, 11/15/23, 11/22/23, and 11/29/23: RNs/LPN documented "Medications reviewed"; and no documented observation of two duplicate doses of Lisinopril medication.
-11/7/23, 11/21/23, 12/5/23, 12/19/23, and 1/2/24 IDG meeting minutes document review of medication list with two duplicate doses of Lisinopril listed.
-SN visit notes for 12/6/23, 12/13/23, 12/20/23, 12/27/23, 1/3/24, and 1/10/24: RNs/LPN documented "Medications reviewed"; and no documented observation of two duplicate doses of Lisinopril medication.
-1/17/24 RN/SN narrative note: Patient admitted to skilled nursing facility (SNF) for five-day respite stay; RN performed review of Plan of Care (POC) with SNF RN which contained duplicate orders and doses for lisinopril medication; transfer POC documents given to facility and SNF Medical Director initiated SNF care orders with 2 duplicate doses of lisinopril (total 60 MG by mouth daily at 9:00 AM for 5-day respite stay.
-1/18/24 Agency Clinical Manager RN initiated and obtained verbal order from agency MD to discontinue Lisinopril 40 MG dose order (6/17/23) and 20 MG dose order (10/18/23). RN added Lisinopril 20 MG tablet, oral, daily order into patient's medication profile.
Review conducted on March 13, 2024, at approximately 2:00 PM, of Respite SNF documents revealed: Pages 1 and 2 of 13 "Lisinopril 20 MG by mouth x1/day 9:00 AM and Lisinopril 40 MG by mouth x1/day 9:00 AM, documented as administered on 1/18/24 to 1/22/24; and blood pressure measurement were 1/17/24 3:19 PM 136/72; 1/18/24 6:25 AM 118/58; 1/18/24 11:19 AM 120/68; 1/18/24 7:30 PM 122/72; 1/19/2024 10:42 AM 128/76; 1/19/24 7:48 PM 130/74; 1/20/24 12:56 AM 124/67; 1/20/24 10:16 AM 128/66; and 1/20/24 3:53 PM 122/72"; and patient only received Lisinopril 60 MG doses for five days during SNF admission.
Review conducted on March 13, 2024, at approximately 2:15 PM, of hospice agency patient transfer documents 1/17/24 - "Client Medication Report" revealed: Page 2 of 3, both Lisinopril 20 MG and 40 MG listed on current medication list.
Review conducted on March 13, 2024, at approximately 3:00 PM, of agency policies revealed: Policy AA-003, revised 10/22 Assessments: Page 6 of 6, "(2) The comprehensive assessment must include: (B) a review, repeated as necessary, of the client's medication list. The medication list must include all prescriptions and over-the counter drugs to assure that all drugs are indicated and to identify any potential problems including, ... (v) duplicate drug therapy ...."; policy Guide for Medication Orders, revised 11/203, "the medication POC will include all prescription and over the counter medications, oxygen, and herbal supplements both covered and not covered by the hospice benefit."; policy TX-002 Physician Verbal Orders, Operational Guidelines: ... 6. In the event that a patient or family member relays information about changes in medications, treatments or any other changes in the plan of care, the clinician must call the prescriber back to verify the order including read-back."; and policy AA-015(a) Supervision of Disciplines - RN/LPN, Procedure: ... II. Registered Nurse (RN) ... **The Registered Nurse is supervised by the RN Clinical Manager. III. Licensed Practical Nurse (LPN/LVN) The LPN/LVN is supervised the RN."
Review conducted on March 13, 2024, at approximately 3:00 PM, of agency job titles revealed: HSP Registered Nurse "Reports to HSP Director of Operations/HSP Clinical Manager; Responsible for providing, coordinating, and directing the provision of hospice care according to physician's orders, through the competent application of the nursing process, and based on care center policies and procedures. ... 2. Coordinates the total Plan Of Care and maintains continuity of patient care by collaborating with appropriate staff. Revises plan of care as needed. Completes updated Plan Of Care according to state regulation and communicates changes to attending physician, hospice staff, and contractors providing care.; and ... 9. Assists in assigning LPN and Hospice Assistants to individual patients and supervises their care."; and HSP Licensed Practical Nurse revealed: "Works under the supervision of a Registered Nurse and performs skilled nursing services within scope as delegated by Registered Nurse according to physician's orders.; ... Essential Functions: ... 2. Communicates current health status and needs of patients to the Registered Nurse and other appropriate disciples/staff."
Interview conducted on March 13, 2024, at approximately 3:15 PM, with agency administrator revealed confirmation of lack of coordination, supervision, and accurate communication between agency RNs/LPN, Clinical Manager, physicians, and SNF staff; nursing medication transcription error continued from 10/18/23 to 1/18/24 despite many healthcare staff medication reviews and resulted in SNF staff administering duplicate Lisinopril doses (20 MG and 40 MG) to patient for the five respite care days.
Plan of Correction:L0530 418.56(c)(6) Content of Comprehensive Plan of Care
1. On 3/29/2024, upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations implemented comprehensive and systematic changes to ensure ALL current patients and future patients' plan of care reflected goals based on current patient assessment and current patient services necessary for the palliation and management of the terminal illness and related conditions to include drugs the effectiveness, drug side effects, actual or potential drug interaction and duplicate drug therapy and drug therapy currently associated with laboratory monitoring and treatments necessary to meet the needs of the patient. On 3/29/2024, the Administrator/ Director of Operations and the Area Vice President of Operations and Regional Director of Clinical Operations provided:
a. Education/Training –
- 4/2/2023 - Comprehensive re-education and remediation for ALL Staff on appropriate agency policies related to deficient areas. Review of Agency Policies and Procedures included the following policies:
o AA-001 Admission
o AA-003 Assessments,
o AA-005Hospice Plan of care,
o AA-006 Interdisciplinary Team,
o MM-001 PA Medication management
o TX-005 professional management
o TX-002 Physician Verbal Order
o TX-012 Core Services- Nursing services
o AA-015(a) supervision of disciplines -RN/LPN
b. Identification/Implementation –
- Initiated on 3/29/2024 identification of all active patients' plan of care will be reviewed at next IDG to ensure plan of care reflected goals based on current patient medication are monitored for effectiveness of drug therapy, Drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy currently associated with laboratory monitoring, and current patient services necessary for the palliation and management of the terminal illness and related conditions to include drugs and treatments necessary to meet the needs of the patient.
- With each IDG and order changes, the patient plan of care will be revised to ensure plan of care reflected goals based on current patient assessment and current patient services necessary for the palliation and management of the terminal illness and related conditions to include drugs and treatments necessary to meet the needs of the patient.
c. Auditing and Monitoring –
- Initiated on 4/2/2024, 100% of patients' Plan of care will be audited to ensure plan of care reflected goals based on current patient assessment and current patient services necessary for the palliation and management of the terminal illness and related conditions to include drugs and treatments necessary to meet the needs of the patient,
o including measurable goals and outcomes in coordination/ oversight of the patient's physician/Interdisciplinary Team, and
o appropriate delivery of care and interventions provided based on plan of care and patient's needs.
- Auditing to continue monthly for a period of 2 months or until a 100% compliance is met. If compliance is not met after 2 months, the audits will continue for next 2 months and staff remediation will be done as needed to assure compliance.
- Ongoing, an audit of 10% of all patients will be completed to ensure plan of care reflects goals based on current patient services necessary for the palliation and management of the terminal illness and related conditions.
- Audits will be added to QAPI plan.
- All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriate, but at least annually.
d. Ongoing adherence - The Administrator/Director of Operations will ensure ongoing adherence and monitoring of all aspects of the plan of corrections for cited deficiencies.
e. Completion Date 5/6/2024
418.54(d) STANDARD
UPDATE OF COMPREHENSIVE ASSESSMENT
Name - Component - 00
The update of the comprehensive assessment must be accomplished by the hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) and must consider changes that have taken place since the initial assessment. It must include information on the patient's progress toward desired outcomes, as well as a reassessment of the patient's response to care. The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days.
Observations:
Based on a review of clinical records, agency policies/procedures, and interview with agency administrator, the agency failed to ensure the interdisciplinary group updated the patient comprehensive assessment with an accurate and complete review of all the patient's prescription medications which could affect drug therapy and patient outcomes for one (1) of three (3) clinical records reviewed (CR#1).
Review conducted on March 13, 2024, at approximately 11:00 AM, of clinical records (CRs) revealed:
CR#1 start of care (soc) 6/17/2023:
-Patient's blood pressure medication prescribed by primary care physician (PCP) Lisinopril 40 milligrams (MG)) by mouth, daily, documented on initial comprehensive assessment 6/17/2023; this same dosage is documented on weekly skilled nurse visit notes from June 16, 2023, until October 4, 2024. Daughter/caregiver administers all patient medications.
-10/4/2023 skilled nurse (SN) visit note: Daughter/caregiver informed licensed practical nurse (LPN) that the lisinopril dosage had been decreased to 20 mg by mouth daily by patient's primary care physician; LPN did not document any communication of medication change to supervisory registered nurse (RN).
-10/10/23 Interdisciplinary Group (IDG) meeting notes documented Lisinopril dosage as 40 MG continues for patient.
-10/18/2023 SN visit note: Documented lisinopril medication dosage decreased to 20 MG daily by RN; verbal order obtained by RN from Medical Director physician at 12:04 PM; new dosage order added to patient medication profile; and no deletion of previous lisinopril medication order for 40 MG daily dose performed by RN [Medication Transcription Error].
-10/24/2023 IDG meeting note: New/added Lisinopril medication dose 20 MG documented; RN assigned to oversee patient's care documented "Med changes None"; Medication list documented Lisinopril 40 MG and 20 MG, oral daily "Not Related to Terminal Diagnosis" classification; and Medical Director (MD) notes (page 5 of 8) described "MD was present throughout the IDT discussion, reviewed medications for interactions, side effects, and appropriateness. ... Reviewed and agreed with POC and changes made at this IDT."
-SN visit notes for 10/25/23, 11/2/23, 11/8/23, 11/15/23, 11/22/23, and 11/29/23: RNs/LPN documented "Medications reviewed"; and no documented observation of two doses of Lisinopril medication.
-11/7/23 IDG meeting note: Medical Director (MD) notes (page 3 of 6) described "MD was present throughout the IDT discussion, reviewed medications for interactions, side effects, and appropriateness. ... Reviewed and agreed with POC and changes made at this IDT."; and Medication list documented Lisinopril 40 MG and 20 MG, oral daily "Not Related to Terminal Diagnosis" classification.
-11/18/23 Nurse Practitioner Face-to-Face Encounter Note: No documentation of medications review.
-11/21/23 IDG meeting note: Page 5 of 6, Medication list documented Lisinopril 40 MG and 20 MG, oral daily "Not Related to Terminal Diagnosis" classification.
-12/5/23 IDG meeting note: RN documented "Patient had decrease in his lisinopril to 20 mg from 40 mg daily." (Page. 3 of 7); and page 7 of 7 medication list documented Lisinopril 40 MG and 20 MG, oral daily.
-12/5/23 Hospice Recertification Plan of Care Update (12/14/23 to 2/11/24 period) document: Page 5 of 6, Medication list documented Lisinopril 40 MG and 20 MG, oral daily "Not Related to Terminal Diagnosis" classification.
-SN visit notes for 12/6/23, 12/13/23, 12/20/23, 12/27/23, 1/3/24, and 1/10/24: RNs/LPN documented "Medications reviewed"; and no documented observation of two doses of Lisinopril medication.
-12/19/23 IDG meeting note: Page 6 of 6, medication list documented Lisinopril 40 MG and 20 MG, oral daily.
1/02/24 IDG meeting note: MD notes (page 3 of 6) described "MD was present throughout the IDT discussion, reviewed medications for interactions, side effects, and appropriateness. ... Reviewed and agreed with POC and changes made at this IDT."; and page 5 of 6, medication list documented Lisinopril 40 MG and 20 MG, oral daily "Not Related to Terminal Diagnosis" classification.
-1/17/24 RN/SN narrative note: Patient admitted to skilled nursing facility (SNF) for five-day respite stay; RN performed review of Plan of Care (POC) with SNF RN which contained duplicate orders and doses for lisinopril medication; transfer POC documents given to facility and SNF Medical Director initiated SNF care orders with 2 doses of lisinopril (total 60 MG at 9:00 AM for a 5-day respite stay.
-1/18/24 Agency Clinical Supervisor RN initiated and obtained verbal order from agency MD to discontinue Lisinopril 40 MG dose order (6/17/23) and 20 MG dose order (10/18/23). RN added Lisinopril 20 MG tablet, oral, daily order into patient's medication profile.
-1/22/24 SN narrative note: Patient was discharged from SNF.
-1/24/24 SN visit note: BP 86/42; documentation described evidence of patient's functional physical decline.
Review conducted on March 13, 2024, at approximately 3:00 PM, of agency policies revealed: Policy AA-003Assessments: Page 1 of 6, "Updates to the comprehensive assessment are completed by the IDT (in collaboration with the patient's attending physician (if any) and considers changes that have taken place since the initial or last comprehensive assessment."; page 6 of 6, "(2) The comprehensive assessment must include: ... (B) a review, repeated as necessary, of the client's medication list. The medication list must include all prescriptions and over-the counter drugs to assure that all drugs are indicated and to identify any potential problems including, ... (v) duplicate drug therapy ... ."; Policy AA-005 Hospice Plan of Care: Page 2, "The POC is reviewed and revised as often as necessary, but no less frequently than every 15 day calendar days.; ... Review of the POC shall include but is not limited to: ... 8. Medications the patient is receiving including ... e. Duplicative therapies ...."; and Policy MA-005, Medication Errors: Page 1 of 1, "1. A medication error is defined as an error in delivery of any medication by an employee of the agency. Examples of medication errors include, but are not limited to, the wrong dose, route, frequency, patient, patient, medication, or incorrect patient education.
Interview conducted on March 13, 2024, at approximately 3:30 PM, with agency administrator confirming the above findings.
Plan of Correction:L0533 418.54(d) Update to comprehensive assessment
2. On 3/29/2024, upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations implemented comprehensive and systematic changes to ensure ALL current patients and future patients' plan of care reflected goals based on current patient assessment and current patient services are updated by comprehensive assessment and accomplished with the individuals attending physician, and must consider changes that have taken place since initial assessment and include information on the patient progress toward desired outcomes, as well as reassessment of the patient response to care. This must be completed no less frequently than every 15 days. On 3/29/2024, the Administrator/Director of Operations and the Area Vice President of Operations and Regional Director of Clinical Operations provided:
f. Education/Training –
- 4/2/2023 - Comprehensive re-education and remediation for ALL Staff on appropriate agency policies related to deficient areas. Review of Agency Policies and Procedures included the following policies:
o AA-001 Admission
o AA-003 Assessments,
o AA-005Hospice Plan of care,
o AA-006 Interdisciplinary Team,
o MM-001 PA Medication management
o TX-012 Core Services- Nursing services
o AA-015(a) supervision of disciplines -RN/LPN
g. Identification/Implementation –
- Initiated on 3/29/2024 identification of all active patients' plan of care will be reviewed at next IDG to ensure plan of care reflected goals based updated by comprehensive assessment and accomplished with the individuals attending physician, and must consider changes that have taken place since initial assessment and include information on the patient progress toward desired outcomes for the palliation and management of the terminal illness and related conditions to include drugs and treatments necessary to meet the needs of the patient.
- With each IDG and order changes, the patient plan of care will be revised to ensure plan of care reflected goals based on current patient assessment and current patient services necessary for the palliation and management of the terminal illness and related conditions to include drugs and treatments necessary to meet the needs of the patient.
- Information from the patient's updated comprehensive assessment will be reviewed to ensure Plan of Care is modified to meet the individualized needs of the patient and must note the patient's progress towards outcome/goals from the plan of care in accordance with the patient's current condition/needs, state and federal regulations, and agency's policies and procedures.
h. Auditing and Monitoring –
- Initiated on 4/2/2024, 100% of patients' Plan of care will be audited to ensure plan of care reflected goals based on current patient assessment and current patient services necessary for the palliation and management of the terminal illness and related conditions to include drugs and treatments necessary to meet the needs of the patient,
o including measurable goals and outcomes in coordination/ oversight of the patient's physician/Interdisciplinary Team, and
o appropriate delivery of care and interventions provided based on plan of care and patient's needs.
- Auditing to continue monthly for a period of 2 months or until a 100% compliance is met. If compliance is not met after 2 months, the audits will continue for next 2 months and staff remediation will be done as needed to assure compliance.
- Ongoing, an audit of 10% of all patients will be completed to ensure plan of care reflects goals based on current patient services necessary for the palliation and management of the terminal illness and related conditions.
- Audits will be added to QAPI plan.
- All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriate, but at least annually.
i. Ongoing adherence - The Administrator/Director of Operations will ensure ongoing adherence and monitoring of all aspects of the plan of corrections for cited deficiencies.
j. Completion Date 5/6/2024
418.56 CONDITION
IDG, CARE PLANNING, COORDINATION OF SERVICES
Name - Component - 00
§418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services
The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.
Observations:
Based on review of clinical records (CRs), agency policies, and interview with agency administrator, the agency failed to ensure the interdisciplinary group maintains responsibility for coordination, supervision, and communication of provided care and services to one (1) of three (3) patients reviewed (CR#1); and agency failed to communicate accurate patient information to SNF respite care staff in one (1) of three (3) patients reviewed (CR#1).
Cross Reference:
418.56(e) Coordination of service Tag L554 -- the agency failed to communicate accurate patient information to SNF respite care staff in one (1) of three (3) patients reviewed (CR#1).
418.56(e)(5) Provide for an ongoing sharing of information between all disciplines providing care/services in all settings Tag L557 -- the agency failed to communicate accurate patient information to SNF respite care staff in one (1) of three (3) patients reviewed (CR#1).
Plan of Correction:L0536 418.56 CONDITION OF PARTICIPATION IDG, Care planning, Coordination of services
On 3/29/2024, upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations implemented comprehensive and systematic changes to ensure ALL current patients and future patients' plan of care specifies the hospice care and services necessary to meet the patient and family -specific needs identified in the comprehensive assessment as it related to the terminal illness and related conditions and coordination and communication of accurate information to any outside party such as SNF/hospital/ALF is accurate upon level of care change or transfer/discharge to meet the needs of the patient.
3. . On 3/29/2024, the Administrator/Director of Operations and the Area Vice President of Operations and Regional Director of Clinical Operations provided:
k. Education/Training –
- 4/2/2023 - Comprehensive re-education and remediation for ALL Staff on appropriate agency policies related to deficient areas. Review of Agency Policies and Procedures included the following policies:
o AA-001 Admission
o AA-003 Assessments,
o AA-005Hospice Plan of care,
o AA-006 Interdisciplinary Team,
o MM-001 PA Medication management
o TX-005 professional management
o TX-002 Physician Verbal Order
o TX-012 Core Services- Nursing services
o AA-015(a) supervision of disciplines -RN/LPN
l. Identification/Implementation –
- Initiated on 3/29/2024 identification of all active patients' plan of care will be reviewed at next IDG to ensure all patients' plan of care specifies the hospice care and services necessary to meet the patient and family -specific needs identified in the comprehensive assessment as it related to the terminal illness and related conditions and coordination and communication of accurate information to any outside party such as SNF/hospital/ALF is accurate upon level of care change or transfer/discharge to meet the needs of the patient.
- With each IDG and order changes, the patient plan of care will be revised to ensure plan of care reflected goals based on current patient assessment and current patient services necessary for the palliation and management of the terminal illness and related conditions to include drugs and treatments necessary to meet the needs of the patient.
m. Auditing and Monitoring –
- Initiated on 4/2/2024, 100% of patients' Plan of care will be audited to ensure plan of care reflected goals based on current patient assessment and current patient services necessary for the palliation and management of the terminal illness and related conditions to include drugs and treatments necessary to meet the needs of the patient and all information related to level of care change, transfer/discharge is communicated accurately to outside agency such as hospital/SNF or ALF.
o including measurable goals and outcomes in coordination/ oversight of the patient's physician/Interdisciplinary Team, and
o appropriate delivery of care and interventions provided based on plan of care and patient's needs.
- Auditing to continue monthly for a period of 2 months or until a 100% compliance is met. If compliance is not met after 2 months, the audits will continue for next 2 months and staff remediation will be done as needed to
assure compliance.
- Ongoing, an audit of 10% of all patients will be completed to ensure plan of care reflects goals based on current patient services necessary for the palliation and management of the terminal illness and related conditions.
- Audits will be added to QAPI plan.
- All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriate, but at least annually.
n. Ongoing adherence - The Administrator/Director of Operations will ensure ongoing adherence and monitoring of all aspects of the plan of corrections for cited deficiencies.
o. Completion Date 5/6/2024
418.56(e)(1) STANDARD
COORDINATION OF SERVICES
Name - Component - 00
§418.56(e) Standard: Coordination of services
The hospice must develop and maintain a system of communication and integration, in accordance with the hospice’s own policies and procedures, to-
§418.56(e)(1) Ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided.
Observations:
Based on review of clinical records (CRs), agency policies, and interview with agency administrator, the agency failed to ensure the interdisciplinary group maintains responsibility for coordination, supervision, and communication of provided care and services to one (1) of three (3) patients reviewed (CR#1).
Review conducted on March 13, 2024, at approximately 11:00 AM, of clinical records (CRs) revealed:
CR#1 start of care (soc) 6/17/2023:
-Patient's blood pressure medication prescribed by primary care physician (PCP) Lisinopril 40 milligrams (MG)) by mouth, daily; documented on initial comprehensive assessment 6/17/2023; this same dosage is documented on weekly skilled nurse visit notes from June 16, 2023, until October 4, 2024. Daughter/caregiver administers all patient medications.
-10/4/2023 skilled nurse (SN) visit note: Daughter/caregiver informed licensed practical nurse (LPN) that the lisinopril dosage had been decreased to 20 mg by mouth daily by patient's primary care physician; LPN did not document any communication of medication dosage change to supervisory registered nurse (RN).
-10/10/23 Interdisciplinary Group (IDG) meeting notes documented Lisinopril dosage as 40 MG continues for patient.
-10/18/2023 SN visit note: Documented lisinopril medication dosage decreased to 20 MG daily by RN; RN did not document any verification of new medication dose communication with PCP; verbal order obtained by RN from Medical Director physician at 12:04 PM; new dosage order added to patient medication profile; and no deletion of previous lisinopril medication order for 40 MG daily dose performed by RN [Medication Transcription Error].
-10/24/2023 IDG meeting note: New/added Lisinopril medication dose 20 MG documented; RN assigned to oversee patient's care documented "Med changes None"; Medication list documented Lisinopril 40 MG and 20 MG, oral daily "Not Related to Terminal Diagnosis" classification; and Medical Director (MD) notes (page 5 of 8) described "MD was present throughout the IDT discussion, reviewed medications for interactions, side effects, and appropriateness. ... Reviewed and agreed with POC and changes made at this IDT."
-SN visit notes for 10/25/23, 11/2/23, 11/8/23, 11/15/23, 11/22/23, and 11/29/23: RNs/LPN documented "Medications reviewed"; and no documented observation of two doses of Lisinopril medication.
-SN visit notes for 10/25/23, 11/2/23, 11/8/23, 11/15/23, 11/22/23, and 11/29/23: RNs/LPN documented "Medications reviewed"; and no documented observation of two doses of Lisinopril medication.
-11/7/23, 11/21/23, 12/5/23, 12/19/23, and 1/2/24 IDG meeting minutes document review of medication list with continued list of two doses of Lisinopril 20 MG and 40 MG, by mouth, daily.
-SN visit notes for 12/6/23, 12/13/23, 12/20/23, 12/27/23, 1/3/24, and 1/10/24: RNs/LPN documented "Medications reviewed"; and no documented observation of two doses of Lisinopril medication.
-1/17/24 RN/SN narrative note: Patient admitted to skilled nursing facility (SNF) for five-day respite stay; RN performed review of Plan of Care (POC) with SNF RN which contained duplicate orders and doses for lisinopril medication; transfer POC documents given to facility and SNF Medical Director initiated SNF care orders with 2 doses of lisinopril (total 60 MG at 9:00 AM for 5-day respite stay.
-1/18/24 Agency Clinical Manager RN initiated and obtained verbal order from agency MD to discontinue Lisinopril 40 MG dose order (6/17/23) and 20 MG dose order (10/18/23). RN added Lisinopril 20 MG tablet, oral, daily order into patient's medication profile.
Review conducted on March 13, 2024, at approximately 2:00 PM, of Respite SNF documents revealed: Pages 1-2 of 13 "Lisinopril 20 MG by mouth x1/day 9:00 AM and Lisinopril 40 MG by mouth x1/day 9:00 AM, documented as administered on 1/18/24 to 1/22/24; and blood pressure measurement were 1/17/24 3:19 PM 136/72; 1/18/24 6:25 AM 11/58; 1/18/24 11:19 AM 120/68; 1/18/24 7:30 PM 122/72; 1/19/2024 10:42 AM 128/76; 1/19/24 7:48 PM 130/74;1/20/24 12:56 AM 124/67; 1/20/24 10:16 AM 128/66; and 1/20/24 3:53 PM 122/72"; and patient only received Lisinopril 60 MG doses for five days during SNF admission.
Review conducted on March 13, 2024, at approximately 2:15 PM, of hospice agency patient transfer documents "Client Medication Report" revealed: Page 2 of 3, both Lisinopril 20 MG and 40 MG listed on current medication list.
Review conducted on March 13, 2024, at approximately 3:00 PM, of agency policies revealed: Policy AA-003, revised 10/22 Assessments: Page 6 of 6, "(2) The comprehensive assessment must include: (B) a review, repeated as necessary, of the client's medication list. The medication list must include all prescriptions and over-the counter drugs to assure that all drugs are indicated and to identify any potential problems including, ... (v) duplicate drug therapy ... ."; policy Guide for Medication Orders, revised 11/203, "the medication POC will include all prescription and over the counter medications, oxygen, and herbal supplements both covered and not covered by the hospice benefit."; policy TX-002 Physician Verbal Orders, Operational Guidelines: ... 6. In the event that a patient or family member relays information about changes in medications, treatments or any other changes in the plan of care, the clinician must call the prescriber back to verify the order including read-back."; and policy AA-015(a) Supervision of Disciplines - RN/LPN, Procedure: ... II. Registered Nurse (RN) ... **The Registered Nurse is supervised by the RN Clinical Manager. III. Licensed Practical Nurse (LPN/LVN) The LPN/LVN is supervised the RN."
Review conducted on March 13, 2024, at approximately 3:10 PM, of agency job title positions revealed: HSP Registered Nurse "Reports to HSP Director of Operations/HSP Clinical Manager; Responsible for providing, coordinating, and directing the provision of hospice care according to physician's orders, through the competent application of the nursing process, and based on care center policies and procedures. ... 2. Coordinates the total Plan Of Care and maintains continuity of patient care by collaborating with appropriate staff. Revises plan of care as needed. Completes updated Plan Of Care according to state regulation and communicates changes to attending physician, hospice staff, and contractors providing care.; and ... 9. Assists in assigning LPN and Hospice Assistants to individual patients and supervises their care."; and HSP Licensed Practical Nurse: "Works under the supervision of a Registered Nurse and performs skilled nursing services within scope as delegated by Registered Nurse according to physician's orders.; ... Essential Functions: ... 2. Communicates current health status and needs of patients to the Registered Nurse and other appropriate disciples/staff."
Interview conducted on March 13, 2024, at approximately 3:15 PM, with agency administrator revealed confirmation of lack of coordination, supervision, and accurate communication between agency RNs/LPN, Clinical Manager, physicians, and SNF staff; nursing medication transcription error continued from 10/18/23 to 1/18/24 despite many healthcare staff medication reviews and resulted in SNF staff administering duplicate Lisinopril doses (20 MG and 40 MG) to patient for the five respite care days.
Plan of Correction:The hospice must develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations implemented comprehensive and systematic changes to ensure ALL current patients and future patients received care and services based on an accurate comprehensive assessment of the patients and family's needs in accordance with federal and state regulations; agency policies and procedures; and standards of practice. On 3/29/2024, the Administrator/Director of Operations and the Area Vice President of Operations and Regional Director of Clinical Operations provided L554 418.56(e)(1) Coordination of Services
1. :
a. Education/Training –
- Initiated 4/2/2024 Comprehensive re-education and remediation for ALL Staff on appropriate agency policies related to deficient areas. Review of Agency Policies and Procedures included the following:
o AA-001 admission
o AA-003 Assessments,
o AA-005Hospice Plan of care,
o AA-006 Interdisciplinary Team,
o AA-001 Admission
o TX-005 professional management
b. Identification/Implementation –
- Initiated on 3/29/2024 identification of all active patients plan of care will be review at next IDG to ensure plan of care and reflected goals based on current patient assessment are provided to ensure palliation and management of the terminal illness and related condition are addressed and completed in accordance according to the established plan of care per IDG team and hospice medical director with appropriate interventions, coordination of care and an individualized patient-specific plan of care.
- With each IDG and order changes the patient plan of care will have appropriate revision to the plan of care as reflected in the clinical documentation in accordance with the patient's current condition/needs and agency's policies and procedures in coordination with the patient's physician, Interdisciplinary Team; nursing facility (as applicable) and patient/patient caregiver to the extent possible.
- Information from the patient's updated comprehensive assessment will be reviewed for each service being provided to ensure Plan of Care is modified to meet the individualized needs of the patient and must note the patient's progress towards outcome/goals from the plan of care in accordance with the patient's current condition/needs, state and federal regulations, and agency's policies and procedures.
c. Auditing and Monitoring –
- A comprehensive auditing process of clinical documentation of 100% of patient who had order changes or have Plan of care updated call will be audited next business day to ensure – all meds and treatments were addressed in the individualized plans of care were developed and implemented to ensure palliation and management of terminal illness has been addressed.
o Patient-specific and accurate comprehensive assessment in accordance with federal and state regulations, agency policies and procedures, and industry standards of care as evidenced by ongoing assessment of individualized plan of care with oversight of frequency and if an adjustment needs to occur with the plan of care with physician order and oversight.
o Development, adherence, and ongoing evaluation with appropriate revision to the patient-specific plan of care in accordance with the patient's current condition/needs and agency's policies and procedures; including responsible provider performance of agreed upon repetitive functions; and including measurable goals and outcomes in coordination/ oversight of the patient's physician/Interdisciplinary Team.
o Appropriate and ongoing coordination of care with all disciplines and to ensure all disciplines are reporting unaddressed or new symptoms to the RN case manager and they are documenting the follow up as well as the patient/patient caregiver (to the extent possible).
o Appropriate delivery of care and interventions provided based on plan of care and patient's needs.
- Auditing to continue monthly for a period of 2 months or until a minimum of 90% compliance is met. Ongoing, 10% all patients will be completed with QAPI plan to ensure POC are individualized, and symptoms are managed and addressed timely.
- All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriately, but at least annually.
d. Ongoing adherence - The Administrator/Director of Operations will ensure ongoing adherence and monitoring of all aspects of the plan of corrections for cited deficiencies.
e. Completion Date 5/6/2024
418.56(e)(4) STANDARD
COORDINATION OF SERVICES
Name - Component - 00
[The hospice must develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to-]
(4) Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement.
Observations:
Based on review of clinical records (CRs), agency policy, skilled nursing facility (SNF) documents, and interviews with agency administrators, the agency failed to communicate accurate patient medication information to SNF respite care staff in one (1) of three (3) patients reviewed (CR#1).
Review conducted on March 13, 2024, at approximately 11:00 AM, of clinical records (CRs) revealed:
CR#1 start of care (soc) 6/17/2023:
-1/17/24 RN/SN narrative note: Patient admitted to skilled nursing facility (SNF) for five-day respite stay; hospice RN performed review of Plan of Care (POC) with SNF RN which contained duplicate orders and doses for lisinopril medication; transfer POC documents given to facility and SNF Medical Director initiated SNF admission care orders with 2 doses of lisinopril (total 60 MG)at 9:00 AM for 5-day respite stay.
Review conducted on March 13, 2024, at approximately 2:00 PM, of Respite SNF documents revealed: Pages 1 and 2 of 13 "Lisinopril 20 MG by mouth x1/day 9:00 AM and Lisinopril 40 MG by mouth x1/day 9:00 AM, documented as administered on 1/18/24 to 1/22/24; and blood pressure measurement were 1/17/24 3:19 PM 136/72; 1/18/24 6:25 AM 118/58; 1/18/24 11:19 AM 120/68; 1/18/24 7:30 PM 122/72; 1/19/2024 10:42 AM 128/76; 1/19/24 7:48 PM 130/74; 1/20/24 12:56 AM 124/67; 1/20/24 10:16 AM 128/66; and 1/20/24 3:53 PM 122/72"; and patient only received Lisinopril 60 MG doses for five days during SNF admission.
Review conducted on March 13, 2024, at approximately 2:15 PM, of hospice agency patient transfer documents - "Client Medication Report" revealed: Page 2 of 3, both Lisinopril 20 MG and 40 MG listed on current medication list.
Review conducted on March 13, 2024, at approximately 2:30 PM, of agency policy TX-010 Inpatient Respite Care revealed: "Services provided in the inpatient setting must conform to the hospice's Plan Of Care (POC). The hospice is the professional manager of the patient's care."
Interview conducted on March 13, 2024, at approximately 3:00 PM, with agency administrator revealed confirmation of above findings.
Plan of Correction:L557: §418.56(e) (4) Coordination of Services
1. The hospice must develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations implemented comprehensive and systematic changes to ensure ALL current patients and future patients received care and services based on an accurate comprehensive assessment of the patients and we provide for an ensure ongoing sharing of information between all disciplines providing care and services in all setting, whether the car are services are provided directly or under arrangement and to ensure to meet the family's needs in accordance with federal and state regulations; agency policies and procedures; and standards of practice On 3/29/2024, the Administrator/Director of Operations and the Area Vice President of Operations and Regional Director of Clinical Operations provided:
a. Education/Training –
- Initiated 3/29/2024 Comprehensive re-education and remediation for ALL Staff on appropriate agency policies related to deficient areas. Review of Agency Policies and Procedures included the following policies:
o AA-001 admission
o AA-003 Assessments,
o AA-005Hospice Plan of care,
o AA-006 Interdisciplinary Team,
o AA-001 Admission
o TX-005 professional management
b. Identification/Implementation –
- Initiated on 3/29/2024 identification of all active patients plan of care will be review at next IDG to ensure plan of care and reflected goals based on current patient assessment are provided to ensure palliation and management of the terminal illness and related condition are addressed and completed in accordance according to the established plan of care per IDG team and hospice medical director with appropriate interventions, coordination of care and an individualized patient-specific plan of care.
- With each IDG and order changes the patient plan of care will have revision to the plan of care as reflected in the clinical documentation in accordance with the patient's current condition/needs and agency's policies and procedures in coordination with the patient's physician, Interdisciplinary Team; nursing facility (as applicable) and patient/patient caregiver to the extent possible.
c. Auditing and Monitoring -
- A comprehensive auditing process of clinical documentation of 100% of patient who had order changes or have Plan of care updated call will be audited next business day to ensure – all meds and treatments were addressed in the individualized plans of care were developed and implemented to ensure palliation and management of terminal illness has been addressed.
o Patient-specific and accurate comprehensive assessment in accordance with federal and state regulations, agency policies and procedures, and industry standards of care as evidenced by ongoing assessment of individualized plan of care with oversight of frequency and if an adjustment needs to occur with the plan of care with physician order and oversight.
o Development, adherence, and ongoing evaluation with appropriate revision to the patient-specific plan of care in accordance with the patient's current condition/needs and agency's policies and procedures; including responsible provider performance of agreed upon repetitive functions; and including measurable goals and outcomes in coordination/ oversight of the patient's physician/Interdisciplinary Team.
o Appropriate and ongoing coordination of care with all disciplines and to ensure all disciplines are reporting unaddressed or new symptoms to the RN case manager and they are documenting the follow up as well as the patient/patient caregiver (to the extent possible).
o Appropriate delivery of care and interventions provided based on plan of care and patient's needs.
- Auditing to continue monthly for a period of 2 months or until a minimum of 90% compliance is met. Ongoing, 10% all patients will be completed with QAPI plan to ensure POC are individualized, and symptoms are managed and addressed timely.
- All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriately, but at least annually.
d. Ongoing adherence - The Administrator/Director of Operations will ensure ongoing adherence and monitoring of all aspects of the plan of corrections for cited deficiencies.
e. Completion Date 5/6/2024
418.64(b)(1) STANDARD
NURSING SERVICES
Name - Component - 00
§418.64(b) Standard: Nursing services
§418.64(b)(1) The hospice must provide nursing care and services by or under the supervision of a registered nurse. Nursing services must ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments.
Observations:
Based on review of clinical records (CRs), agency policies, and interview with agency administrator, the agency failed to provide appropriate registered nurse supervision for assigned nursing staff to ensure patient medications are accurate in one (1) for three (3) reviewed patients (CR#1).
Review conducted on March 13, 2024, at approximately 11:00 AM, of clinical records (CRs) revealed:
CR#1 start of care (soc) 6/17/2023:
-Patient's blood pressure medication prescribed by primary care physician (PCP) Lisinopril 40 milligrams (MG)) by mouth, daily, documented on initial comprehensive assessment 6/17/2023; this same dosage is documented on weekly skilled nurse visit notes from June 16, 2023, until October 4, 2024. Daughter/caregiver administers all patient medications.
-10/4/2023 skilled nurse (SN) visit note: Daughter/caregiver informed licensed practical nurse (LPN) that the lisinopril dosage had been decreased to 20 mg by mouth daily by patient's primary care physician; LPN did not document any communication of medication dosage change to supervisory registered nurse (RN).
-10/10/23 Interdisciplinary Group meeting has no documentation of Lisinopril medication changes from clinical manager nurse or registered nurse associated to CR#1.
-10/18/23 SN visit note: Documented lisinopril medication dosage decreased to 20 MG daily by assigned RN; RN did not perform a verification of medication dosage change with PCP; a verbal order obtained by assigned RN from Medical Director physician at 12:04 PM; new dosage Lisinopril order 20 MG, by mouth, daily added to patient medication profile; and no deletion of previous lisinopril medication order for 40 MG daily dose performed by RN [Medication Transcription Error].
-10/24/2023 IDG meeting note: New/added Lisinopril medication dose 20 MG documented; RN assigned to oversee patient's care documented "Med changes None"; Medication list documented Lisinopril 40 MG and 20 MG, oral daily "Not Related to Terminal Diagnosis" classification.
Review conducted on March 13, 2024, at approximately 3:00 PM, of agency policies revealed: Policy AA-003, revised 10/22 Assessments: Page 6 of 6, "(2) The comprehensive assessment must include: (B) a review, repeated as necessary, of the client's medication list. The medication list must include all prescriptions and over-the counter drugs to assure that all drugs are indicated and to identify any potential problems including, ... (v) duplicate drug therapy ... ."; policy Guide for Medication Orders, revised 11/203, "the medication POC will include all prescription and over the counter medications, oxygen, and herbal supplements both covered and not covered by the hospice benefit."; policy TX-002 Physician Verbal Orders, Operational Guidelines: ... "6. In the event that a patient or family member relays information about changes in medications, treatments or any other changes in the plan of care, the clinician must call the prescriber back to verify the order including read-back."; and policy AA-015(a) Supervision of Disciplines - RN/LPN, "Procedure: ... II. Registered Nurse (RN) ... **The Registered Nurse is supervised by the RN Clinical Manager. III. Licensed Practical Nurse (LPN/LVN) The LPN/LVN is supervised the RN."
Review conducted on March 13, 2024, at approximately 3:10 PM, of agency job titles revealed: -HSP Registered Nurse, "Reports to HSP Director of Operations/HSP Clinical Manager; Responsible for providing, coordinating, and directing the provision of hospice care according to physician's orders, through the competent application of the nursing process, and based on care center policies and procedures. ... 2. Coordinates the total Plan Of Care and maintains continuity of patient care by collaborating with appropriate staff. Revises plan of care as needed. Completes updated Plan Of Care according to state regulation and communicates changes to attending physician, hospice staff, and contractors providing care.; and ... 9. Assists in assigning LPN and Hospice Assistants to individual patients and supervises their care."; and HSP Licensed Practical Nurse, "Works under the supervision of a Registered Nurse and performs skilled nursing services within scope as delegated by Registered Nurse according to physician's orders.; ... Essential Functions: ... 2. Communicates current health status and needs of patients to the Registered Nurse and other appropriate disciples/staff."
Interview conducted on March 13, 2024, at approximately 3:15 PM, of agency administrator revealed confirmation for lack of appropriate registered nurse supervision of assigned nursing staff.
Plan of Correction:L0591 418.64(b)(1) Nursing services
1. The hospice must develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations implemented comprehensive and systematic changes to ensure ALL current patients and future patients received care and services based on an accurate comprehensive assessment of the patients and have all services provided by or under the supervision of a registered nurse. The nursing services must ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment and updated assessments. On 3/29/2024, the Administrator/Director of Operations and the Area Vice President of Operations and Regional Director of Clinical Operations provided:
a. Education/Training –
- Initiated 3/29/2024 Comprehensive re-education and remediation for ALL Staff on appropriate agency policies related to deficient areas. Review of Agency Policies and Procedures included the following policies:
o AA-001 admission
o AA-003 Assessments,
o AA-005Hospice Plan of care,
o AA-006 Interdisciplinary Team,
o Tx-002 Physician verbal order
o TX-005 professional management
o Tx -012 Core Nursing services
o AA-015(a) supervision of disciplines -RN/LPN
b. Identification/Implementation –
- Initiated on 3/29/2024 identification of all active patients plan of care will be reviewed by RN case manager at next IDG to ensure plan of care and reflected goals based on current patient assessment are provided to ensure palliation and management of the terminal illness and related condition are addressed and completed in accordance to the established plan of care per IDG team and hospice medical director with appropriate interventions, coordination of care and an individualized patient-specific plan of care.
- With each IDG and order changes, and comprehensive assessment update, the RN case manager will review and revise patient's plan of care as reflected in the clinical documentation in accordance with the patient's current condition/needs and agency's policies and procedures in coordination with the patient's physician, Interdisciplinary Team; nursing facility (as applicable) and patient/patient caregiver to the extent possible.
c. Auditing and Monitoring -
- A comprehensive auditing process of clinical documentation of 100% of patient who had order changes or have Plan of care updated call will be audited next business day to ensure – all meds and treatments and that services were coordinated and documented and addressed in the individualized plans of care were developed and implemented to ensure palliation and management of terminal illness has been addressed with oversight of the registered nurse:
o Patient-specific and accurate comprehensive assessment in accordance with federal and state regulations, agency policies and procedures, and industry standards of care as evidenced by ongoing assessment of individualized plan of care with oversight of frequency and if an adjustment needs to occur with the plan of care with physician order and oversight.
o Development, adherence, and ongoing evaluation with appropriate revision to the patient-specific plan of care in accordance with the patient's current condition/needs and agency's policies and procedures; including responsible provider performance of agreed upon repetitive functions; and including measurable goals and outcomes in coordination/ oversight of the patient's physician/Interdisciplinary Team.
o Appropriate and ongoing coordination of care with all disciplines and to ensure all disciplines are reporting unaddressed or new symptoms to the RN case manager and they are documenting the follow up as well as the patient/patient caregiver (to the extent possible).
o Appropriate delivery of care and interventions provided based on plan of care and patient's needs.
- Auditing to continue monthly for a period of 2 months or until a minimum of 90% compliance is met. Ongoing, 10% all patients will be completed with QAPI plan to ensure POC are individualized, and symptoms are managed and addressed timely.
- All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriately, but at least annually.
d. Ongoing adherence - The Administrator/Director of Operations will ensure ongoing adherence and monitoring of all aspects of the plan of corrections for cited deficiencies.
e. Completion Date 5/6/2024
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