Valor Hospice

“Based on interview and record review, the Hospice agency failed to meet the Condition of Participation (CoP) for L500 Patient’s Right when they failed to 1.) comply with mandatory reporting requirements to immediately report suspicions of neglect to Adult Protective Services (APS) for one of 19 patients (Patient (P) 15) whose records were reviewed out of a total sample of 19. P15 was noted to be a vulnerable adult on 09/11/24, and the case was not filed with APS until 11/26/24. Additionally, local law enforcement was not notified. These failures had the potential to place P15 at risk of serious injury, harm, or impairment, up to and including death, and 2.) identify, document, and act upon a verbal grievance from the caregivers for one of one patient (P7) reviewed for grievances out of a total sample of 19. This had the potential to cause patient and caregiver concerns to be unaddressed. The agency was notified of the Immediate Jeopardy (IJ) at L517which was related to the failure to comply with mandatory reporting requirements on 01/15/25 at 5:30 PM. In concurrence with Centers for Medicare and Medicaid Services (CMS) review, the removal plan was approved on 01/16/25 at 10:07 AM. The survey team verified implementation of the facility’s IJ removal plan on 01/16/25 at 2:36 PM. Findings include: 1. The agency failed to immediately notify APS of suspicions of neglect for one of 14 active patients (P15) when the patient was first assessed to be vulnerable and unsafe living in his home without caregivers present. (Refer to L517) 2. The agency failed to identify, document, and act upon a verbal grievance from the caregivers of P7. (Refer to L505)”

“Based on review of the agency’s Emergency Preparedness (EP) plan and interview, the agency failed to ensure that the EP plan included a system to track the location of hospice staff on-duty and sheltered patients during an emergency. This had the potential to affect 63 active patients. Findings include: Review of the EP plan dated 11/17/23 indicated no documented evidence of a system to track the locations of hospice staff on-duty and sheltered patients during an emergency. There was no mention that the Administrator would keep up with the staff and patients on his phone and/or no mention of a back-up method if the network went out. During an interview on 01/16/25 at 3:00 PM, the Administrator stated that he would keep up with the staff and patients on his phone; however, had no way of documenting this information if his phone went down.”

“Based on review of the agency’s Emergency Preparedness (EP) plan and interview, the hospice agency failed to ensure that the EP plan had an alternate means for communicating with Federal, State, Tribal, Regional, and local emergency management agencies. This had the potential to affect all 63 active patients. Findings include: Review of the EP plan dated 11/17/23 indicated phone numbers for Federal, State, Tribal, Regional, and local emergency agencies phone numbers, however, there was no evidence of an alternate means for communicating with the agencies in the event phones were not able to be used. During an interview on 01/16/25 at 5:15 PM, the Cluster Leader confirmed there was no secondary communication method for the above mentioned agencies.”

“Based on review of the agency’s Emergency Preparedness (EP) plan and interview, the agency failed to ensure that the EP plan had a means of sharing patient information and medical documentation with other providers to maintain the continuity of care. This failure has the potential to affect 63 current active patients. Findings include: Review of the EP plan dated 11/17/23 indicated no evidence of a communication plan that included a method for sharing information and medical documentation for patients with other providers in the event the patient would be transferred to an alternate care setting. During an interview on 01/16/25 at 5:15 PM, the Cluster Leader confirmed this and stated this information was not in the EP plan.”

“Based on interview, record review, and review of agency policy, the hospice agency failed to identify, document, and act upon verbal grievances from the caregivers for one of one patient (Patient (P) 7) reviewed for grievances out of a total sample of 19. This had the potential to cause patient and caregiver concerns to be unaddressed. Findings include: Review of P7’s “Patient Information Report,” provided by the agency, revealed P7 was admitted to hospice services on 09/27/24 with a terminal diagnosis of pancreatic cancer. Review of P7’s “Visit Note Report,” dated 10/08/24 at 2:38 PM, provided by the agency, and written by Registered Nurse (RN)1, revealed, “. . . Pt [patient] sitting awake in . . . recliner . . . is alert and pleasant. Oriented x 4 . . . c/o [complained of] SOB [shortness of breath] . . . started on [oxygen] . . . education on concentrator given . . . “ Review of P7’s “Client Coordination Report,” dated 10/08/24 and written by RN4, revealed, “. . . Received phone call from [Family Member (F) 7] at 5:09 PM . . . was getting [P7] up to the bathroom and it appeared [P7] had a stroke. [F7] wanted to know what to do. [F7] had some friends over and they were going to help get [P7] into bed. And I will come and do a visit to assess [him/her] . . .” Review of P7’s “Client Coordination Report,” dated 10/08/24, untimed, and written by RN4, revealed, “. . . Called [F7] at 5:30 PM to let [him/her] know I was going to a death visit and asked her how [P7] was doing. [F7] said they had gotten [P7] back into bed. [P7] did appear a little agitated and was responsive. [F7] put her friend on the phone and I suggested that they give [P7] a Lorazepam [anti-anxiety medication] . . . and if not effective give another one in 20 minutes. I said I would be there as soon as I could. I said I would be there after my other visit . . .” Review of P7’s “Visit Note Report,” dated 10/08/24 at 7:11 PM and provided by the agency, revealed, “. . . Death was quick and was a surprise for the family as [he/she] had been doing well over the weekend . . .” Review of the Visit Note Report revealed no documented evidence the caregiver had voiced any grievance related to the delay in the nurse’s arrival for the visit. The arrival time of 7:11 PM for this visit was over two hours after the time of the call requesting assistance at 5:09 PM. During an interview on 01/13/25 at 1:00 PM, the Director of Clinical Services (DCS) stated the agency serviced all of Cochise County, and there were different cities that they visited within the county. The DCS stated the staff had one hour to make it to a patient home after a call was placed requesting a visit. During an interview on 01/14/25 at 10:39 AM, F7 stated on the day that P7 died, the nurse had made a visit to check P7, and about an hour later, P7 went to the bathroom and collapsed. F7 stated the hospice agency was called, and he/she was told that they would try to get someone out. F7 stated he/she knew he/she had talked to a man to begin with and then had talked to a woman. F7 stated the woman told him/her she was on another call and said it would probably be another hour. F7 stated, “I guess I was thinking in my head that they would have someone else.” F7 stated it was close to two hours before the nurse arrived and P7 had passed by that time. F7 stated, “I never received any follow-up calls. I got a form letter [bereavement letter] from the Chaplain – fill name in here, fill name in there. You have our condolences.” F7 stated, “You could have at least filled in our name.” F7 stated, “The chaplain stopped by the house two or three weeks later to say I’m sorry and that [he/she] blamed [himself/herself] for it. [He/she] came one other time, and I didn’t even answer the door. I was so done with it.” F7 stated, “Even the signature [on the form letter] was fill in the blank here.” F7 was asked if he/she had verbalized his/her frustration to anyone with the hospice agency. F7 stated he/she had expressed his/her displeasure about the time it took for the nurse to arrive with the nurse the night P7 passed, with the chaplain two to three weeks after P7 had passed, and another family had “verbalized it to the director up in Tucson and told the director everything that happened.” F7 stated, “No one has called me.” F7 stated there was nothing that could be done now, but he/she did not want anyone else to have to experience these things. During an interview on 01/14/25 at 12;16 PM, the Bereavement Coordinator (BC), who was the chaplain for P7, stated, “My understanding was that there was a complication and [P7] died unexpectedly. The nurse on call had two deaths at the same time.” The BC stated P7’s family was annoyed because they thought the bereavement letter the agency sent was “too generic.” The BC stated he/she believed F7 expressed dissatisfaction with the length of time it took for the nurse to arrive the night P7 passed. The BC stated, “I went as sort of a peacemaker and told him/her we dropped the ball.” The BC stated the former Administrator and the present Director of Clinical Services (DCS) had instructed him/her to take a plant to F7. Review of the agency’s grievance log for 2024 revealed only one grievance for the year. The grievance listed was logged in January 2024. There was no documented evidence of F7’s verbal grievances to RN4, the BC, or any Valor Hospice employee. During an interview on 01/15/25 at 1:12 PM, Human Resources (HR) stated he/she was the agency’s grievance coordinator. HR stated that clinical grievances were handled by the DCS or Clinical Coordinator (CC). HR stated the DCS and CC were supposed to notify him/her of any grievances so they could be logged. HR stated he/she had no knowledge of any grievance related to P7. During an interview on 01/15/25 at 4:12 PM, the DCS and CC were asked about the circumstances surrounding P7’s passing. The DCS stated P7 had a change in condition, the family called, and RN4 said he/she would go to their house. The DCS stated while RN4 was in route to P7, RN4 received a call that someone had died. The DCS stated RN4 called the family of P7 and was told they had gotten P7 into bed. The DCS stated RN4 had completed the death visit, and approximately one and one-half hours later, arrived at P7’s home. The DCS stated P7 had passed prior to the nurse arriving. The DCS stated, “It was an abrupt death. There was just no idea [P7] was going to die like that. We felt bad about it.” The CC stated, “The case manager was shocked he/she had passed.” The CC stated, “There was no sign he/she was actively dying; otherwise, [RN4] would have asked one of us to back him/her up.” The DCS was asked if he/she was aware of the family’s dissatisfaction with the bereavement letter. The DCS stated he/she was aware the family thought it was too generic but did not have knowledge the letter sent had been a copy of the template used for bereavement letters. The DCS was asked what the agency’s policy was on identifying, documenting, and acting upon grievance. The DCS stated, “I was aware it was not an optimal situation. We did not get a formal complaint.” The DCS was asked if per the policy, grievances had to be formally written. The DCS reviewed the policy and stated no. During an interview on 01/15/25 at 5:50 PM, RN4 stated while he/she was completing the death visit on 10/08/24, he/she must have received a call from P7’s family that was missed. RN4 stated he/she called the family back and they stated P7 had passed, and they were wondering why he/she was not there. RN4 stated the family was upset that he/she did not come right away. RN4 stated he/she prepared P7’s body for the funeral home, and F7 had shown he/she some pictures. RN4 stated he/she thought the family was okay then. RN4 stated, “I knew they were upset that I hadn’t gotten there in time and then the unexpected death.” RN4 was asked if he/she had reported to the DCS that the family was upset. RN4 stated she had told the DCS about it in conversation but had not reported it as a grievance. Review of the agency’s undated “Patient and Family Bill of Rights and Responsibilities” form revealed, “. . . Every patient and family served by Valor HospiceCare has the right to . . . Vice grievances and recommend changes in service delivery . . . Concerns should be discussed with your nurse or social worker . . .” Review of the agency’s policy titled, “Complaint/Grievance Process,” dated May 2023, revealed, “. . . Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and Valor Hospice concerning any aspect of services or the application of policies or procedures will be considered a grievance . . . The organization staff member receiving the complaint will discuss, verbally and in writing, the grievance with a supervisor within five (5) days of the alleged grievance. The supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient’s satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt . . . Complaints and any action taken will be documented on a complaint form . . . Resolution information will be communicated in writing to the patient or his/her representative filing the complaint . . . All complaints will be logged, tracked, trended, and filed in the performance improvement office. . .””

“Based on interview, record review, agency policy review, and review of the Arizona Adult Protective Services (APS) website, the hospice agency failed to comply with mandatory reporting requirements to immediately report suspicions of neglect to APS for one of 19 patients (Patient (P) 15) whose records were reviewed out of a total sample of 19. P15 was noted to be unsafe and a vulnerable adult on 09/11/24, and the case was not filed with APS until 11/26/24. Additionally, local law enforcement was not notified. This placed P15 at continued risk of serious injury, harm, and impairment. Findings include: Review of P15’s “Patient Information Report,” provided by the agency, revealed P15 was admitted to hospice services on 09/10/24 with a terminal diagnosis of malignant neoplasm of the prostate. Review of P15’s “Visit Note Reports,” provided by the agency, revealed the following: 09/10/24 and untimed - “. . . Pt [patient] lives alone . . . Has caregivers that come in every day for 2 hours. Unsure if there is someone that sees [him/her] on Sunday. Before arrival, pt was found outside on lower patio area on [his/her] back . . . FD [Fire Department] came and carried [him/her] into [his/her] house. Sunburned lower legs and abrasions to [his/her] back. Applied protective cream to back and Aquaphor to [his/her] knees and lower legs. VS [vital signs] indicated dehydration . . . Very sweet demeanor. Confusion noted. Needs help with 4/6 ADLs [activities of daily living]” 09/11/24 at 3:59 PM - “. . . Pt was not answering but could visualize [him/her] in bed. After several attempts, pt not attempting to get up, RN [Registered Nurse] attempted to come in . . . Pt is very HOH [hard of hearing] and appears confused . . . does not remember hospice nurse coming yesterday and keeps thinking RN is saying [he/she]’s a hostage . . . Pt asked if RN was here to have sex with [him/her] . . . Appears unsafe at home and unsure how [he/she] is able to take care of [himself/herself] after caregiver leaves for the day. Pt had a cellphone next to [him/her], but it would not charge and battery died. RN tried to get phone working but unable to. Pt does not appear to answer [his/her] phone or was even aware [he/she] had a cell phone until RN brought it to [his/her] attention. Pt remained in bed and unable to tell RN if [he/she] was hungry or not . . .” 09/16/24 at 11:53 AM - “. . . Caregiver . . . notices . . . [P15] is becoming more frail and losing weight . . . informs RN that [he/she] sees [P15] 3x a week for 2 hours a day from 10:30 AM -12:30 PM, has someone from [church name withheld] sees [P15] on Tuesdays. And a care giver . . . sees [P15] on Thursdays and Saturdays for 2 hours but no one sees [P15] on Sundays . . . did speak with [family member] after visiting pt for the first time last Wednesdays [sic] and relayed concerns of [P15’s] safety when [P15] is home alone. [Family member] would like to explore options but is firm on [P15] staying home and not placed in a facility. RN requested an increase the time care givers are there and to explore having a care giver in the evening time. [Family member] did not commit to anything at that time . . . [P15] . . . is agreeable to having a HHA [home health aide] checking in on [him/her] 2 x a week. Social work is following this case and has number to reach out to [family member]. [P15] is pleasantly confused, very HOH [hard of hearing] . . . know [he/she] is at home but has no idea what month it is . . .” 09/19/24 at 11:26 AM - “. . . Arrived to find pt on the floor, with pillow under head. Lying in soaking wet briefs and pants were saturated with urine. [He/she] denied falling. Says [he/she] likes the floor . . . required 2 people to assist to [his/her] feet . . . Unknown when last time [he/she] ate, most likely when care giver was there the previous day in the morning time. Stomach can be hard [sic] growling . . . [family member] contacted and notified of pt’s current presentation. Talked to [him/her] about options and resources available for pt and that pt really requires 24/hr care or at the very least an incrase [sic] in the amount of care [he/she] is currently receiving. [Family member] says [he/she] is financially tapped out and that [he/she] chose hospice for this reason to see what options [he/she] had . . .HHA services will be increased ot [sic] 5x a week to ensure safety . . .” 09/23/24 at 3:26 PM - “. . . On arrival [P15] sitting on commode with HHA present. Having a hard time moving bowels. Last BM [bowel movement] unknown. Will start pt on bowel regime. Pt sat on commode for majority of visit and could not move [his/her] bowels. Suppository not advised at this time since pt lives alone and no one will be there tonight to help clean [him/her] up . . . Pts iPhone currently not holding a charge. [Family member] notified. Will bring a new charger for pt to try. Asked [family member] if [P15] food situation could improve and pt provided with easy snacks for him to eat . . .” 09/26/24 at 10:09 AM - “. . . Patient laying on floor with 3 pillows under [his/her] head. Wearing a white shirt with brown stain on right sleeve. Nurse asked patient if [he/she] fell and [he/she] said no . . . Nurse tried to assist patient to [his/her] feet but couldn’t. Called Lift Assist who arrived in about 15 minutes. I think they are familiar with this patient . . .Hypoactive BS [bowel sounds]. Patient needs to have a BM . . . Patient has alert monitor on [his/her] wrist, not sure if it works . . . Thick layer of mouse droppings in cabinet with food covering material. One very large cockroach on the floor . . .” 10/04/24 at 4:21 PM - “. . . Nurse arrived to the entrance door open and large black ants all over the floor. Nurse swept out as many as possible and closed door . . .” 10/10/24 at 11:41 AM - “. . . Pt can’t remember anything . . . said [he/she] did not know who [family member] is, even though it’s his/her [family member] . . . Bedroom with dog poop and urine, RN also cleaned and mopped that up . . .” 10/17/24 at 12:51 PM - “. . . May have had a fall on October 13th when reviewing caregiver notes, [he/she] found him down on the floor and [he/she] has bruising on his back . . . [He/she] remains confused to [himself/herself], very forgetful and can’t remember events that happened 10 minutes ago . . .” 10/28/24 at 12:45 PM - “. . . Can’t remember if someone was here earlier or if [he/she] ate breakfast. Says [he/she] felt hungry . . . [His/her] CG [caregiver] had just left 10 minutes before RN arrived . . .” 10/31/24 at 12:15 PM - “. . . HHA was there earlier and got [him/her] washed up and fed . . . breakfast . . . does not recall anyone seeing him/her today . . .” 11/04/24 at 11:45 AM - “. . . According to sign in book, [P15] had an unwitnessed fall on Sunday. Discovered by friends checking in on [him/her] . . . unable to tell how long [he/she] was down for. Pt is very forgetful and has poor short term memory . . . New onset of stage 2 pressure ulcer on right inner buttocks and surrounding bottom area is red. Pt unable to change [his/her] briefs on [his/her] own and unaware when [he/she] is wet . . . HHA sees pt 5x a week and pt has paid CG 2 hrs [hours] a day . . .” 11/11/24 at 11:45 AM - “. . . is unaware of the date or where [he/she] is. Pt can’t remember a CG being there an hour before RN arrived . . .” 11/21/24 at 10:07 AM - “. . . [Family member] present during this visit . . . Entirety of visit was focused on concerns for pt safety of being alone . . . does agree that pt’s dementia has worsened. Explored options to increase CG hours. Especially for the evening time and attempt to place a camera in [his/her] living room to be able to check on [him/her] when [he/she] is alone. [Family member] does not have additional money . . .” 11/25/24 at 1:12 PM - “. . . After lengthy discussion on pts safety and being at home alone [family member] agreed to placing a camera in [P15]’s home to keep track of pt and ensure [his/her] safety. [Family member] states that financially [he/she] cannot afford additional CG services at this time. [Social Worker] discussed at length what options [he/she] can choose to increase services but [family member] deferred at this time . . . [P15] is confused and does not remember RN . . . Pt has books on his/her bed and a book on his/her chest that he/she appears to be reading but pt unable to tell RN anything about book. [He/she] uses basic stereotypical phrases when talking to RN. Bruising noted on hands and arms. Pt unable to tell RN what happened. [P15] is dependent on all ADLs except the ability to feed [himself/herself] . . .” Review of P15’s “Client Coordination Notes Report,” dated 11/26/24, untimed, and provided by the agency, revealed, “. . . APS report filed, which was accepted . . . Report based on neglect . . .” Review of P15’s “Visit Note Reports,” provided by the facility, revealed the following: 11/29/24 at 2:58 PM - “. . . Brief was wet and required changing. Pt in the past would get up to commode but pt wanted to stay in bed this time and be changed . . . APS came and saw pt . . .” 12/02/24 at 1:46 PM - “. . . Says [he/she]’s ready for breakfast. It’s 2 PM at this time. Pt does not remember CG coming earlier today . . . APS is following the case and visited last week. [Family member] continues to be notified of the ongoing concerns for [P15] safety and inability to live alone and that [he/she] needs an increase in CGs. No additional CGs yet. Camera has been put up in living room to check on him/her . . .” 12/05/24 at 1:38 PM - “Pt on couch. Pants half off. Large BM visualized on [his/her] bed. Unsure if pt had defecated there and then went back to the couch but [his/her] underwear is falling off . . .” 12/09/24 at 11:41 AM - “. . . [Family member] is reminded on an almost weekly basis of the need to increase CG services for [P15] to ensure his/her safety . . . declines at this time and feels there is enough care givers at this time and reports not enough money to do so . . .” 01/02/25 at 11:04 AM - “. . . Last seen by paid CG 24 hours ago. Pt is soaked in urine, including pants, t shirt and sweat shirt and bed sheets. BM also noted in bed. Pt unable to recognize that [he/she] is wet . . . Pt needs more care givers around the clock. [Family member] unwilling to pay at this time. Attempted to reach out to APS covering the case but unsuccessful . . .” 01/06/25 at 10:21 AM - “. . . Upon arrival patient found laying on the floor. [He/she] says [he/she] fell of [sic] the couch. No injuries. Lift Assist called . . . “ 01/09/25 at 11:49 AM - “. . . Laying in bed, cold in [his/her] house despite heat being on. [Family member] notified RN yesterday not to keep the heat up due to cost concerns. Educated [family member] on pt saety [sic] and the need to keep house warm during winter time . . . does not remember having a fall on Monday . . . Hospital bed ordered but will need to take some arrangement between [Durable Medical Equipment provider] and [family member] for drop off and set up . . . [family member] at this time does not want to explore Miller Trust [a trust in Arizona that allows people to qualify for Medicaid long-term care benefits if their income is too high] and appears to be in denial with the increasing needs . . . APS report filed again yesterday due to ongoing safety concerns . . .” Review of P15’s “Client Coordination Notes Report,” dated 01/14/25, written by Social Worker (SW)2 and provided by the facility, revealed, “. . . PC [phone call] to . . . APS investigator . . . we discussed difference between taking in responsibility for pt by [family member] and exploitation. We discussed solutions like private paid CGs, public fiduciary, [Arizona Medicaid]. We discussed the need to care for patients and what neglect looks like. [Social Worker] gave examples of [family member]’s behaviors, [family member] not hiring CGs, [family member] asking to not have house heated due to high cost, pt not having food at home . . .” Review of P15’s entire clinical record revealed no documented evidence APS had been notified of P15’s unsafe living situation and vulnerability from 09/11/24 until 11/26/24, when contact was first made with APS. There was no documented evidence that law enforcement had been notified at any time. During an interview on 01/15/25 at 10:04 AM, RN6, the case manager for P15, stated he/she had identified “pretty quickly” that P15 was unsafe by himself/herself. RN6 stated hospice staff talked with the family member and tried to do what they could to help get more help for P15. RN6 stated he/she believed SW2 had filed a case with APS during November 2024. RN6 was asked what the agency’s policy was on mandatory reporting. RN6 stated, “I’m a nurse, and it [suspicions of neglect and patients being in unsafe situations] has to be reported.” RN6 was asked why P15’s situation was not reported to APS until November 2024. RN6 stated P15 had caregivers and people checking in. RN6 stated he/she was “trying to give the [family member] the chance to come around.” RN6 stated he/she believed law enforcement had been notified as well but could not say that for certain. RN6 stated, “We have just been kind of monitoring. I was retriggered to do it [file a case with APS] last week. I text the [family member] every week. [He/she] doesn’t want to hear from me. Doesn’t want to talk to us. I refiled because something needs to be done.” RN6 stated P6’s situation had been discussed during IDG (Interdisciplinary Group) meetings. During an interview on 01/15/25 at 11:04 AM, SW1 stated APS did not have an enforcement arm, and APS would tell a person to call local law enforcement if a patient was in immediate danger. SW1 stated calling law enforcement was a case-by-case situation, but if you could not take care of yourself, it was a “good argument” to call law enforcement at the same time you called APS. SW1 stated, “If you determine that a person is a vulnerable adult, you call [APS and law enforcement]. Whether they do anything or not.” The surveyor reviewed the 09/11/24 “Visit Note” for P15 with SW1. SW1 stated, “I would consider that to be a vulnerable adult.” During an interview on 01/15/25 at 12:51 PM, SW2, who was the Social Worker assigned to P15, was asked why APS was not notified immediately when it was determined P15 was unsafe and a vulnerable adult. SW2 stated P15’s family member had told the RN case manager that he/she would see if changes could be made but they never would and that the family member said that he/she would try options to help P15 qualify for long-term care placement and that never happened. SW2 stated the agency was hoping for P15 to qualify for Medicaid benefits but that would take at least 45 days to occur. SW2 was asked if law enforcement had been notified. SW2 stated law enforcement would be notified if there was an immediate danger. SW2 defined immediate danger as either a threat to a patient’s own health or someone else’s health and their well-being. During an interview on 01/15/25 at 1:37 PM, the Director of Clinical Services (DCS) was asked what the agency’s policy was on mandatory reporting. He/she stated, “Call APS.” The DCS was asked when APS should be notified, he/she stated, “When it becomes apparent that we cannot get results in a timely manner. If we think there is exploitation or neglect, it would be immediate.” The DCS was asked if P15 was a vulnerable adult. He/she stated, “[He/she] has declined. In the beginning [he/she] had some odd and eccentric behaviors, and [he/she] became more vulnerable.” Review of the Arizona Adult Protective Services website, located at https://des.az.gov/services/basic-needs/adult-protective-services/report-adult-abuse, revealed, “. . . Arizona Adult Protective Services (APS) investigates reports of abuse, neglect and exploitation of vulnerable adults. APS may also become involved when there is a claim of self-neglect, which is when an adult with physical or mental impairments is not able to meet their basic needs (such as food, shelter, health care, managing money, etc.), which then impacts the adults physical health, mental health or general safety. The goal of APS is to prioritize an adults right to make their own decisions while keeping them safe. APS tries to support the vulnerable adults in their current home, and to augment the skills they need to take care of themselves by providing services that can help with challenges the adult may be having. However, APS must always balance the need to protect the safety of the vulnerable adult with the adults right to make their own decisions. APS does not conduct safety checks, but local law enforcement does. Law enforcement and APS work together, and if law enforcement believes an individual is a vulnerable adult, they will contact APS . . .” Review of the Arizonia Adult Protective Services website, located at https://des.az.gov/services/basic-needs/adult-protective-services/mandated-reporters, revealed, “. . . According to A.R.S. 46-454 (A-D)(link is external), the following individuals are required to report or cause reports to be made to a peace officer or to the Adult Protective Services Central Intake Unit. The reports should be made immediately by phone or online . . . Medical personnel including a physician, physician assistant, registered nurse practitioner, licensed practical or registered nurse, certified nursing assistant, emergency medical technician, home health provider, hospital intern or resident, surgeon, dentist, psychiatrist, psychologist, pharmacist, speech, physical or occupational therapist, long-term care provider, social worker, peace officer, medical examiner, guardian, conservator, fire protection personnel, developmental disabilities provider, employee of the Department of Economic Security or other person who has responsibility for the care of a vulnerable adult . . .” Review of the agency’s policy titled, “Assessment of Possible Abuse/Neglect,” dated May 2024, revealed, “. . . Neglect: Failure of a caretaker to supply the patient with the necessary food, clothing, shelter, healthcare, or supervision, or the absence or likelihood of an absence of the necessary food, clothing, shelter, health care, or supervision for a patient . . . Individual Mandated to Report: A professional or the professional’s delegate who is engaged in the care of patients, or in education, social services, law enforcement, or in any of the related occupations, who had knowledge of the abuse or neglect of a patient, or who has reasonable cause to believe that a patient is being or has been abused or neglected . . . Any clinician who discovers, within the course of rendering care, any suspected abuse or neglect will immediately report such occurrences to his/her immediate supervisor . . . The clinician will submit a verbal report of the suspected abuse/neglect to the proper authorities in accordance with state law and complete a suspected abuse and/or neglect investigation report within 24 hours of the incident . . . If patient is in immediate jeopardy, the proper authorities will be contacted by the clinician immediately as required by state or local law . . .””

“Based on record review, interview, and review of the agency policy, the hospice agency failed to ensure that two of 19 Patients (Patient (P) 1 and P2) had their medications reconciled from either the Assisted Living Facility (ALF) and/or Nursing Facility to match the medications that the hospice agency ordered. In addition, the hospice agency failed to ensure that two of 19 Patients (P3 and P4) had physician orders reconciled to make sure oxygen was either at the correct liter and/or discontinued. This deficient practice had the potential to affect the accuracy of medications ordered for the patients. Findings include: Review of agency policy titled “Medication Profile,” revised 05/24, indicated, “...Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications...2. A drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication.” 1.Review of the agency provided “Patient Information Report” indicated that P1 was admitted to hospice on 06/25/24 with a diagnosis of Alzheimers disease. Review of P1s agency provided, undated “Client Medication Report,” indicated orders for, acetaminophen (medication for pain) 650 mg [milligrams], insert one suppository by rectum every four hours as needed (PRN) for fever/pain, starting 06/26/24; alprazolam (medication for anxiety) .25 mg tablet every four hours, starting 07/08/24; bisacodyl 10 mg rectal suppository, insert one suppository by rectum every 12 hours PRN for constipation, starting 06/26/24; and Compazine (medication for nausea and vomiting) give one tablet by rectum every four hours PRN for nausea/vomiting, starting 06/26/24. Review of P1s ALF facility provided “Medication Assistance Record,” dated January 2025, indicated no documented evidence of orders for acetaminophen 650 mg rectal suppository, alprazolam .25 mg every four hours, bisacodyl 10 mg rectal suppository, every 12 hours PRN, and Compazine by rectum every four hours PRN. During an interview on 01/16/25 at 10:30 AM, the Director of Clinical Services (DCS) indicated that the nurses are responsible for checking the orders every two weeks during the interdisciplinary group (IDG) meetings to ensure they are correct. The DCS confirmed that the hospice medications did not match the ALF medications. 2.Review of the agency provided “Patient Information Report” indicated that P2 was admitted to hospice on 10/10/24 with a diagnosis of senile degeneration of the brain. Review of P2s agency provided, undated “Client Medication Report” indicated orders for Compazine five mg, give one tablet or insert rectum every four hours PRN for nausea/vomiting, starting 10/11/24; Bisacodyl 10 mg, insert one suppository by rectum every 12 hours PRN for constipation if no results from milk of magnesia, starting 10/11/24; oxygen three liters continuously via nasal cannula for comfort, starting 10/11/24; and hyoscyamine (medication for secretions) 0.125 mg, give one table by mouth every four hours PRN for excess secretions, starting 10/11/24.” Continued review revealed “oxycodone (medication for moderate to severe pain) five mg every eight hours, starting 10/11/24.” Review of P2s facility provided nursing home “Order Summary Report,” active orders as of 01/14/25, indicated there was no documented evidence of Compazine, Bisacodyl, oxygen, and hyoscyamine being on the “Order Summary Report.” The oxycodone was listed as five mg, one tablet by mouth every six hours PRN for pain scale of six to 10,” starting 04/29/24. The medication was listed as PRN, and not routine. During an interview on 01/16/25 at 10:30 AM, the DCS confirmed that the hospice orders did not match the nursing home orders. The DCS said that the nurses were responsible for checking the orders every two weeks during the IDG meetings to ensure correctness. The DCS said he/she expected the nurses to check the medications at the nursing homes and ALFs to ensure they match the hospice medications. 3. Review of the agency provided “Patient Information Report” indicated that P3 was admitted to hospice on 03/15/24 with a diagnosis of senile degeneration of the brain. Review of P3s agency provided “Client Medication Report,” dated 03/18/24 revealed an order for, “Oxygen two liters PRN via nasal cannula for shortness of breath/sleep apnea symptoms.” During a home visit with Registered Nurse (RN) 3 on 01/14/25 at 12:15 PM, P3 was sitting up in a recliner with oxygen via nasal cannula at 2.5 liters per minute (lpm). During an interview with RN3 on 01/14/25 at 12:30 PM, he/she confirmed the P3’s oxygen was set at 2.5 lpm instead of the ordered 2 lpm. 4.Review of the agency provided “Patient Information Report” indicated that P4 was admitted to hospice on 10/26/24 with a diagnosis of prostate cancer. Review of P4s facility provided “Client Medication Report,” dated 10/29/24 revealed an order for Oxygen two to five liters continuously via nasal cannula as needed for comfort. During a home visit on 01/14/25 at 2:15 PM, there was no oxygen observed in P4s home. P4 and RN6 confirmed that there was no oxygen currently being used. During an interview on 01/14/25 at 3:00 PM with RN6, he/she indicated that it depended on the patient how many times she reviewed the physician orders. RN6 said that since P4 did not take anything routine, she did not look at his/her physician orders often. During an interview on 01/16/25 at 10:30 AM, the DCS indicated that P4s physician orders included an order for oxygen; however, she confirmed that P4 did not have oxygen. She stated that the nurse should be looking at the orders every two weeks and making sure they are correct.”

“Based on observation, interview, review of personnel files, and review of agency policies, the agency failed to implement procedures to potentially prevent the transmission of infections and communicable diseases in one of four home visits with one patient (Patient (P)2) out of four observed. In addition, one of five employees reviewed indicated no evidence of an initial Tuberculosis (TB) test reading and/or a second TB test. This deficient practice had the potential to affect all 63 patients who were currently receiving hospice services. Findings include: 1.Review of the Bereavement Coordinators personnel file indicated that he/she was hired on 08/16/24 and had no evidence of the initial two-step TB being read, and/or no evidence of step two (no sooner than seven days from the first days) TB being given to him/her. During an interview on 01/15/25 at 3:00 PM, the Clinical Coordinator (CC) confirmed that he/she did read the TB test, and it read negative; however, she forgot to document the information. She confirmed that he/she did not receive the second TB test which he/she should have. 2.Review of agency policy titled, “Hand Hygiene,” dated May 2024, indicated, “To prevent cross-contamination and home care-acquired infections... Procedures...3. Hand decontamination using an alcohol-based hand rub should be performed...E. When moving from a contaminated body site to a clean body site during patient care.” Review of the agency provided “Patient Information Report” indicated that P2 was admitted to hospice on 10/10/24 with a diagnosis of senile degeneration of the brain. During a home visit on 01/14/25 at 10:30 AM, Certified Nursing Assistant (CNA)3 was observed completing a bed bath for P2. CNA3 washed her hands and gathered supplies. CNA3 washed P2s chest, both arms, both legs, and feet. With the same gloves, CNA3 obtained a towel and dried P2. CNA3 opened the first drawer in P2s nightstand, obtaining an incontinent brief and a package of wipes, all with the same gloves. CNA3 placed the wipes on the overbed table and the brief on top of the nightstand, which fell to the floor. CNA3 cleaned P2s perineal area with the same gloves and then assisted P2 in rolling over on his/her left side, and washed P2s back and bottom. CNA3 removed his/her gloves and placed a new pair on without performing hand hygiene. CNA3 picked up the brief off the floor and placed it on P2. CNA3 then went into P2s closet, with the same gloves, and obtained two clean blankets and placed them on P2. During an interview on 01/15/25 at 9:45 AM, CNA3 indicated that he/she usually changed gloves after finishing with a patients top half before going to the patients lower half and again prior to applying lotion. CNA3 was unaware that he/she did not change his/her gloves when going from dirty to clean areas. During an interview on 01/15/25 at 12:00 PM, CC stated that gloves should be changed when going from a dirty area to a clean area. The CC said they expected that no clean supplies be dropped on the floor and if they were, they would be considered dirty and would need to obtain other supplies.”

“Based on interview, record review, and policy review, the agency failed to have a signed written statement of revocation of hospice benefits for one of one patient (Patient (P) 12) reviewed for revocation out of a total sample of 19. This failure had the potential to cause disruption of the patient’s Medicare benefits. Findings include: Review of P12’s “Patient Information Report,” provided by the facility, revealed P12 was admitted to hospice services on 01/18/24 with a terminal diagnosis of chronic systolic (congestive) heart failure. Review of P12’s “Client Coordination Note Report,” dated 03/04/24 and provided by the facility, revealed, “. . . Pt and [family member] wanted to discuss possibility of revocation to seek aggressive treatment for [right] great toe . . .” Review of P12’s “Visit Note Report,” dated 03/05/24 at 11:59 AM and provided by the facility, revealed, “. . . Pt . . . verbalized wanting to purse [sic] aggressive treat [treatment] for [right] great toe wound. Reviewed medications and how to dispose of hospice medications. Pt aware that DME [durable medical equipment] wound be picked up . . .” Review of P12’s “IDG (Interdisciplinary Group)” documents, located in the electronic medical record, under the “Medical Records” tab, revealed P12 was discharged from hospice services on 03/05/24. Review of P12’s entire electronic medical record (EMR) revealed no documented evidence of a signed written revocation of hospice benefits. During an interview on 01/16/25 at 10:00 AM, the Clinical Coordinator (CC) was asked to provide P12’s signed revocation of hospice benefits for the 03/05/24 discharge. The CC reviewed the clinical record and stated he/she could not find the document in the EMR. The CC stated that either the Registered Nurse or Social Worker were responsible for having the revocation signed. During an interview on 01/16/25 at 11:00 AM, the CC stated he/she had looked at all the patient’s documents and could not find a signed revocation of hospice benefits. Review of the agency’s policy titled, “Revocation of Hospice Benefit,” dated May 2024, revealed, “. . . A patient and family/caregiver may revoke the election of hospice care at any time. In order to revoke this care, a revocation of election of hospice care statement (NOTR) must be signed and filed in the patient’s clinical record. Revoking the Medicare or Medicaid hospice benefit is the patient’s and family/caregiver’s choice. In revoking these benefits, the individual forfeits coverage for any remaining days in that election period . . . The organization will submit the NOTR to the Medicare contractor (MAC) within 5 calendar days of the date on the notice . . .””