Hospice of the West

“Upon patient record review, 1 of 23 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: Medications include Bactrim 1 application as needed topical apply one application to affected area once daily as needed. Does not specify site.”

“Upon patient client record review, 2 of 23 (Patient #1,7) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: 7/16/25 S0C supervisory visit documented yes, but no aide visits had been made at that time. Patient #7: 7/14/25 S0C supervisory visit documented yes, but no aide visits had been made at that time.”

“Based on interview, review of facility policies and procedures, review of facility documentation, and review of patient medical records, it has been determined that Hospice has failed to protect and promote the exercise of patient rights as detailed in Hospice’s policies and procedures for 12 (twelve) out of 12 (twelve) patients reviewed, Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 & 12, including, but not necessarily limited to, the right to have grievances investigated according to policies and procedures, the right to receive effective pain management and symptom control for conditions related to terminal illnesses, the right to express concern and/or dissatisfaction with treatment or care and not be subject to discrimination or reprisal, the provision of services as specified in the patient plan of care, and the ability of patients and/or their caregivers to participate actively in treatment with his or her feedback being treated with respect. Findings include: Facility policy titled, “;...Incident and Adverse Events....” revealed: “;...Adverse Event...any event that deviates from accepted practice, is potentially harmful, and/or has resulted in harm to a patient, family member, employee, volunteer, visitor or their property. It includes any happening that is not consistent with the routine operation of Hospice or the routine care of a particular patient/client. Adverse events...include...Medication and treatment errors...Patient/client dissatisfaction...Client/patient/family injury, including falls...Incident...An unusual circumstance that may result or did result in personal injury of an employee...Serious incident/adverse event...An adverse event is considered “;serious” if, in the view of the investigator, it results in any of the following outcomes...Death...a life-threatening adverse event...Inpatient hospitalization or prolongation of existing hospitalization...A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions...All incidents/adverse events are reported to and investigated by the Chief Clinical Officer or designee to determine the appropriate corrective action and response. This will be accomplished through the completion of an incident report and/or verbal communication during normal business hours. After hours, all incidents should be reported to the Administrator...on-call immediately...Any employee who is involved in, witnesses or discovers any event that is not consistent with routine operations and/or has resulted in, or has the potential to result in, injury or harm, is required to complete a written incident/adverse report...A root cause analysis is conducted when there is a sentinel event...The Clinical Director, in collaboration with the QAPI Committee, tracks and trends all reports of incident/adverse events in order to analyze their causes, implement preventative actions/performance improvement and mechanisms that include feedback and learning throughout the hospice and evaluate the effectiveness of preventative/corrective actions...The Clinical Director prepares a quarterly incident/adverse events report to submit to the hospice Administrator...And Governing Body, as applicable....” Facility policy titled, “...Availability 24/7....” revealed: “...drugs and biologicals are available 24 hours a day/7 days per week...Contractual agreements are maintained with pharmacies int he hospice’s service area to assure that medications are readily available....” Facility policy titled, “;...Patient Complaint/Grievance Reporting....” revealed: “;...Hospice patient/caregivers are informed of their right to lodge complaints...without fear of discrimination...All complaints are documented in a complaint log by the Clinical Director no more than 5 (five) business days from the date the complaint was first received...Appropriate personnel will conduct a documented investigation of all written or verbal complaints received by the hospice immediately upon notification of complaint/grievance. Documentation will include stated grievance...investigation findings and analysis as well as written resolution. To resolve complaints, three attempts are made to contact the person filing the complaint by telephone. If telephone contact is unsuccessful, a letter is sent. Each...attempted contact...or action taken...is documented with the original complaint...Complaints or concerns expressed on a written survey are reviewed initially by the Clinical Director...Follow up is initiated whenever possible...Corrective action is implemented as appropriate...The Hospice will notify the patient/family regarding grievance...investigation findings...by phone or written by request...Complaints are tracked and regularly reviewed by QAPI committee quarterly to identify patterns or trends and performance improvement opportunities....” Facility policy titled, “;...Revocation of the Medicare Hospice Benefit....” revealed: “;...Reasons a patient may choose to revoke the Medicare Hospice benefit may include...Dissatisfaction with Care Hospices services...To revoke the election of Hospice care, the individual or representative must file a statement with Care Hospice that includes the following information...A signed statement that the individual...revokes the...election for Medicare coverage of Hospice care...The date that the revocation is to be effective...The RN Case Manager or designee notifies the patients attending physician....” Facility policy titled, “;...Plan of Care....” revealed: “;...The plan is established by the attending physician, the medical director or physician designee and 2 members of the IDG in collaboration with the patient/representative/primary caregiver at the start of care...The comprehensive Plan of Care is developed within 5 days of admission...The written plan is reviewed every 15 days...Review of the patient plan of care is documented...The Hospice...plan of care...reflects...the following...Treatments, drugs, biologicals and interventions to manage pain and symptoms of the terminal illness: including dosage/frequency/route....” Facility policy titled, “;...Pharmacy Services....” revealed: “;...Pharmaceutical services are provided in accordance with accepted professional standards...and services are available on a 24 hour basis...In addition to ordering, administration, storage, disposal and record keeping of drugs...responsibilities include...Providing information regarding the safe and appropriate use of drugs to other health professionals...Providing a pharmacist comprehensive medication review based on information from the RNs initial assessment within 5 days of admission and no longer than every 15 days thereafter...Appropriateness of the dose, frequency and route of administration....” Facility policy titled, “;...Pain and Symptom Management....” revealed: “;...The Care Hospice nurse assesses every patients pain and other symptoms as part of the initial assessment...The patients pain and other symptoms related to the terminal condition are thoroughly assessed during the comprehensive assessment of the patient by the RN case manager or designee...The patients preferences for pain management are reflected in the pain control measures selected...Procedures and protocols for pain assessment and management are developed and implemented using a numerical or other rating scale for pain assessment...If a patients pain score is above their acceptable rating or a patient states their pain level is not acceptable...If appropriate...the...medical director will be notified and the nurse will carry out the recommended action...as ordered by the physician...Pain will be reassessed within 24 hours...Pain is re-assessed during every home visit, any time a patient states his/her pain level has changed, and whenever pain medications or dosages have changed....” Facility policy titled, “;...Patient Rights and Responsibilities....” revealed: “;...The patient has the right to be fully informed of the are/services to be provided...The patient has the right to exercise his or her rights as a patient of the hospice, which includes the right to...Make decisions about their medical care including the acceptance of medical...treatment...Voice grievances regarding treatment...and to not be subjected to discrimination or reprisal for exercising his or her rights...Receive effective pain management and symptom control from the hospice for conditions related to terminal illness...Refuse care or treatment...Be free from mistreatment, neglect...Recommend changes in policies and procedures, personnel or care/services...Have grievances/complaints investigated regarding treatment or care that is or fails to be furnished....” “;...Optum Hospice Pharmacy Services, LLC Pharmacy Services Agreement....” signed May 5, 2023 by representative of Optum Hospice Pharmacy Services, LLC and signed April 25, 2023 by representative of Care Hospice & its Affiliates revealed: “;...Client agrees to utilize only Optum to provide it with any of the prescription benefit management services comparable to those described herein during the term of this agreement...Optum may provide services under this Agreement through subcontractors....” A PowerPoint was attached to the service agreement regarding a change of subcontractors that occurred on March 4, 2024. Information was requested regarding the delivery practices and procedures for the previous subcontractor but this information was not provided. The subcontractor as of March 4, 2024 was OnePoint. “;...OnePoint Patient Care Quick Reference Guide....” revealed: “;...After Hours Support is available 24 hours a day, 365 days a year, for urgent new admissions...Weekdays...Morning...Departure time...10:00 a.m....Delivered by...3:00 p.m....Evening...Cut Off time...1:30 p.m...Departure time...2:30 p.m...Delivered by...8:00 p.m...Late Night (In Town Only)...Cut Off Time...6:00 p.m...Departure time...7:00 p.m...Delivered by...12:00 a.m...Weekends/Holidays...Morning...Departure time...10:00 a.m....Delivered by...6:00 p.m...Evening...Departure time...2:30 p.m....Delivered by...8:00 p.m....Late Night...Departure time...6:00 p.m...Delivered by..11:00 p.m...STAT—in town...During Standard Business Hours ONLY...STAT...Within 5 Hours of ordering...After Hours/On Call...Outside Standard Business Hours...Departure Time...First Come, First Served...Delivered By...Urgent Delivery (2-5 hours)...Delivery Windows...All NEW ORDERS will be delivered the SAME DAY unless otherwise specified...All REFILLS will be delivered the NEXT BUSINESS DAY unless otherwise specified...Refills placed Friday, Saturday, or Sunday are delivered the following Monday...order by Thursday if needed over the weekend...STAT service is available with a 3 HOUR DELIVERY when and where traffic and weather allow...$25 service charge will apply...ON-CALL service will be provided AFTER BUSINESS HOURS FOR ANY EMERGENCY...$65 charge will apply....” Complaint/Grievance Logs were requested for 2023 and 2024. The following grievances and complaints regarding medication-related issues were revealed: Quarter 1 2023 Complaint and CAHPS Log: Date recorded: 1/18/2023 Date of Complaint: 1/7/2023 Date of Resolution: 1/9/2023 “;...Meds ordered for 2 hour STAT delivery...Meds were not delivered (sic)/received for several hours resulting (sic) in patient high level agitation. Optum sates (sic) patient was not profled (sic) in system. Review on why auotmatic (sic) integration did not occur....” Date recorded: 2/21/2023 Date of Complaint: 10/23/2022 Date of Resolution: 2/22/2023 “;...Negative CAHPS survey comment BIGGEST COMPLAINT WAS PHARMACY. MISTAKES AND DELIVERY. MISLABELING OF MEDICATION, DIRECTIONS FOR DOSAGE....” Date recorded: 2/24/2023 Date of Complaint: 2/23/2023 Date of Resolution: 2/23/2023 “;...Admission nurse ordered 2-hour STAT medication during admission process. Records show medication ordered at 2053, left pharmacy at 2219, and “;delivery arrival” at 0100. Per DeliverCareRX, their delivery service reports they were not able to deliver because of no answer at door. No call from delivery service or DeliverCareRX to inform HOW of inability to deliver. HOW received call from facility staff to report medication not delivered....” Quarter 3 2023 Date Reported: August 8, 2023 Date of Occurrence June 27, 2023 “;...Employee Error...Medication error on behalf of HOW employee....” Quarter 4 2023 Date Recorded: November 13, 2023 Date of Complaint: November 13, 2024 Date of Resolution: Not recorded “;...Negative CAHPS response-with responded with all negative responses across the survey. Date Recorded: November 14, 2023 Date of Complaint: November 14, 2023 Date of Resolution: November 14, 2023 “;...Patient RX did not deliver. After a call to delivercare rx it was found that RX wason (sic) backorder and HOW was not notified....” Date Recorded: November 22, 2023 Date of Complaint: November 22, 2023 Date of Resolution: Not recorded “;...Patient RX did not deliver. After a call to delivercare rx it was found that RX was not delivered because the auth was for generic and on;y (sic) name brand was available....” Date Recorded: December 10, 2023. Date of Complaint: Not recorded. Date resolved: Not recorded. “;...Patient was prescribed morphine despite morphine allergy. Allergies did not flow to iPrescribe because they were entered in correctly (sic)....” Quarter 1 2024 Date Recorded: March 17, 2024 Date of Occurrence: March 17, 2024 “;...Patient missed 3 doses of medication. Pharmacy failed to notify HOW that medication was on back order....” Date Recorded: February 1, 2024 Date of Complaint: January 25, 2024 Date of resolution: January 23, 2024 “;...Pt family unhappy with lack of response during last hours of life. Lack of timely pain meds....” Date Recorded: April 3, 2024 Date of Complaint: March 20, 2024 Date of resolution: March 21, 2024 “;...Pharmacy did not complete delivery of medication because they had wrong address and did not notify HOW. HOW found out after patient called to complain that meds had not arrived and in pain....” Date Recorded: April 4, 2024 Date of Complaint: March 28, 2024 Date of resolution: March 28, 2024 “;...Pharmacy Compalint (sic) due to extreme delay in delivery....” Quarter 2 2024 Date Recorded: April 22, 2024 Date of Complaint: April 3, 2024 Date of resolution: April 5, 2024 “;...Medication was ordered on 4/1 for a 4/2 delivery. Meds not delivered until 4/3....” Date Recorded: April 22, 2024 Date of Complaint: April 18, 2024 Date of resolution: April 18, 2024 “;...Delay in comfort meds being delivered to patient....” Date Recorded: May 6, 2024 Date of Occurrence: May 4, 2024 “;...Pharmacy error...Prefilled syringes ordered, pharmacy filled one syringe to 20mg....” Date Recorded: June 4, 2024 Date of Complaint: June 4, 2024 Date of resolution: June 13, 2024 “;...Negative CAHPS response regarding pain management....” Governing Body minutes were requested for 2023 and 2024. “;...Hospice Care Holdings, L.P. Minutes of a meeting of the Compliance Committee....” were provided from the following dates: February 22, 2023, May 26, 2023, September 7, 2023, December 5, 2023 and February 13, 2024. These minutes indicated that, “;...compliance and quality metrics...” were discussed each quarter and, “;...an update on key compliance initiatives...” was presented each quarter; however, no detail was provided. Quality and Performance Improvement (QAPI) Committee meeting minutes were requested for 2023 and 2024. Minutes were provided for quarterly meetings held on May 2, 2023, August 2023 (date unknown), November 21, 2023, January 30, 2024 and April 2024 (date unknown). The minutes indicated some tracking of patient falls, patient infections and patient complaints as well as reference to PIPs (performance improvement plans) related to CAHPS (Consumer Assessment of Health Providers and Systems) scores. Copies of all PIPs related to the provision of patient care and pharmaceutical/medication services for 2023-2024 were requested. A live discharge rate PIP was created March 27, 2023 with the measurable goal, “;...20% or below by July 2023 [of live discharges] per Care Hospice....” Although data had been tracked quarter by quarter, the “;analyze” portion of the PIP, “;...list identified causes the QAPI team will focus on....” had not been completed. A CAHPS Overview PIP was initiated in January 2024 with a measurable goal that indicated, “;...Increase [composite score] to at least national average of 83.1% by May 2024...Would you recommend...Increase score to...86%...Timely Help...Increase score to...76%...Communication...Increase score to at least...83%...Family training...Increase score to at least...78%....” The “;Analyze” portion of the PIP does not identify any possible causes for why the CAHPS scores may be below goal; however, the “;Improve” portion of the PIP is robust and highly detailed. A “;One Point Pharmacy Transition” PIP was initiated on March 1, 2024 with the measurable goals of, “;...All patients successfully transitioned by 4.1.2024 (sic)...All concerns will be addressed by HOW PHX leadership within 24 hours iof (sic) receipt of complaint....” Quite a few areas of the PIP indicate, “;...See Attached OFI (opportunities for improvement) but the attachment referenced was not provided. Patient #1 Start of Care: March 19, 2024 End of Care: June 14, 2024 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Grievance Received...3/202/24 (sic)...Date/Time form completed if different than above...4/3/2024...interviews notes...3/20/24...Patient was transferred yesterday. Cg, Facility called last night looking for meds...called One Point and verified meds were being delivered tonight. I let them know. Called this am, did not get delivered. I called One Point, driver took to old address and returned without notifying us. I confirmed address and advised it needs to get there STAT....” There is no documentation of attempts to contact the family regarding the resolution of the complaint. There is no documentation regarding resolution of the complaint or date the investigation was concluded. “...Clinical notes....” revealed: “...03-19-2024 10:46p...Phone call...OnePoint confirmed orders for medications received, 4 of 5 are ready however one was delayed and is being filled now. Medications to still be delivered today...03-20-2024...signed 8:08a...0800 call to One point (sic) to obtain eta for medication delivery, told...that the delivery department just arrived...will have someone call once...aware. Explained this was a delay in care and HOW needed an ETA ASAP...3-20-2024...Patient is in bed, reports pain. This RN was told by OnePoint that medications are 30 minutes away that should have been delivered last night...Medications arrived approximately 0940...3-20-2024...apology and review of delayed medication delivery this am. assured family we have pin pointed the errors and are working to make corrections so this does not occur again....” Patient #2 Start of Care: September 29, 2023 End of Care: November 3, 2023 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Complaint Received...3/6/2024 8am via CAHPS survey...Negative CAHPS survey...Stated did not receive training or help for pain...did not receive liquid Morphine in timely manner on day of death, constipation not addressed....” There was no documentation of attempts to follow-up with the Complainant or attempts to reach the Complainant regarding the resolution of the Complaint. A chart review was conducted and the results attached to the complaint. No analysis of the review was provided. The chart review contained multiple references to the level of cleanliness of the patients home and pet ownership. The chart review indicated on multiple occasions the patients continued use of alcohol. No provided analysis indicated a link between these issues and the Complainants grievance of timely pain medication not being provided at the time of patients death or constipation not being adequately addressed. “;...Emergency Room Report....” dated September 28, 2023 revealed: “;...Alcohol...Use...Current...Type...Liquor...Frequency...Daily...Comments...vodka..2-3....” “;...Clinical Notes...” dated 09/29/2023 revealed: “;...Patient drinks moonshine every day, stating...takes about 3 shots per day....” “;...Team Care Plan...” revealed no goals related to alcohol use or alcohol dependence. No documentation of IDG concerns regarding medication interaction or moderation of medication regime for patient due to daily alcohol use could be found. “...Clinical Notes....” dated 11/2/2023 revealed: “...Pt c/o pain to bladder and lower back...asked if pt is still drinking Moonshine, [caregiver] says...has had no ETOH in almost 48 hours...will relay info to nurse over possible concern of ETOH withdrawals...asked if [caregiver] would be interested in having a bench (sic) come and remove clutter for an affordable price...seemed more interested in disassembling sofa and placing it outside...to make room for a hospital bed...informed that...must purchase sheets for the bed...it is worth noting that while [caregiver] was talking about concern for finances and buying things like bed sheets, a brand new 43 inch television was delivered with this writer present....” “;...Clinical Notes....” dated 11/3/2023 and signed at 4:14 p.m. revealed: “;...RN PHONE CALL...SPOUSE CALLED REGARDING INCREASED AGITATION AND RESTLESSNESS...DR...ORDERS MSIR AND CLONAZEPAM. PATIENT HAS PAIN THAT CURRENT OXYCODONE NOT EFFECTIVE. INCREASED AGITATION POSSIBLE DUE TO PATIENT RECENTLY STOPPING ALCOHOL....” “;...Clinical Notes....” dated 11/3/2023 revealed: “;Time of Call...1810...seizure trance for over an hour...[Caregiver] states the patient has had episodes before, but he has not responded for over an hour now...Breathing at a normal rate but heavy...Eyes are open, mouth is open...arms can be moved easily...Educated that clonazepam and morphine have been ordered and how this would be given even though he cannot swallow them. [Caregiver] states [caregiver] has not done this before...Accepts a nurse to assess and teach medication administration...Updated [Employee #9] who will make a visit....” “;...Clinical Notes....” dated 11/4/2024 and signed at 1:14 a.m. by Employee #8 revealed: “;...Death visit...Time of death...1932....” Patient #3 Start of Care: March 16, 2024 End of Care: June 24, 2024 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Complaint received...6/24/24...Patient transferred hospice services...[caregiver] states...The fact that there were no notes after our meeting with your nurse on wed about my mom about (sic) getting an order for lorazepam, my mom had to suffer last night with sundowning which brought my dad to tears...When my mom was having severe constipation, I guess they had a hard time getting an order for an enema. I hear that your company is slow to respond and that you prescribe only minimum low doses of comfort meds...on 6/22 a call came into triage from the [caregiver] with...concerns. This SN was AOC (administrator on call)...attempted to reconcile the active concerns. Triage was sent out and medication changes were made....” Interviews and a chart review were conducted. Counseling was provided to two staff persons in relation to the complaint. There was no documentation of follow-up contact to the caregiver regarding the resolution of the complaint. A CAHPS survey was attached to the Complaint/grievance “;...Clinical notes....” revealed: “;...06/20/2024...Multiple messages back-and-forth to ensure gho receives new orders for medications...06/22/2024...signed 8:05 p.m....GHO (group home owner) called, she reports pt has uncontrolled symptoms of pain/restlessness, pt family at bedside...obtained new orders for Lorazepam 0.5mg q4 PRN, increase MSIR to 5mg q4 PRN, order faxed to GH......6/22/24...triage call 1726...pt CG called...is asking for ETA on Lorazepam...pt is anxious/restless/hallucinating and does not have PRN available ...6/22/24...phone call from triage re: family concerned/upset about medications...[caregiver] stated multiple med changes were made on Wednesday (June 21)...family was told there would be a prn order for Lorazepam...This RN verified that triage...was ordering the new medications... [caregiver] shared concerns of pain management and that a nurse came out the other night and did not increased the MSIR dose as the CG was requesting due to continued pain despite the low dose of MSIR... This SN updated [caregiver] that triage RN is approx 20 min out to come check on [patient] and the orders for new medication are being faxed over to the facility....” Patient #4 Start of Care: March 28, 2024 End of Care: March 29, 2024 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Complaint Received...3/28/24 330pm...[Caregiver] called approx. 320 stating they are still awaiting the MSIR and Ativan to arrive...states [patient] is restless and they need the medication...This SN called One Point at 323pm and spoke with....the delivery department who stated the medications had not left yet...made calls to multiple CVS, Walgreens, and Walmart to see if any in the area of the family carried both liquid MSIR and liquid Ativan. None of the pharmacies carried both at the same location. One Point was called back by this SN at 353...pharmacy...gave an ETA of approx. 45 minutes to an hour...the [caregiver] called back approx. 450 stating the medication still had not arrived. This SN called One Point...was told driver was approx. 15 min. out...530 this SN phoned [caregiver] who was very upset the medication had still not been delivered...requested if...could go pick them up somewhere. This SN...updated that SN had called multiple pharmacies in the area and none had both medications in stock. Patient is heard in background very restless...541pm One Point called again by this SN...updated this SN that the driver was approx. 1 hours out from delivery. This SN requested to speak with Rover directly as the times do not match the prior calls...called...back at 604pm...647pm this SN called [caregiver] who states the medication had arrived...states HOW let them down and it was not fair [patient] had to suffer like that....” Interviews were conducted and a summary provided in the complaint which revealed: “;...I find a couple things transpired...Delay on previous stop along with traffic...Driver gave inaccurate ETA information to dispatch...I am actually showing two separate STAT orders/deliveries...three medications ordered at 10:21am...with delivery at 1:29pm, as well as the two medications you mentioned, with timeline below. Do we know if the controlled substances were originally intended to be ordered at the same as these first three, but had to wait for prescriber signature...Below is the timeline I am showing on the pharmacy side...1:06-1:07pm...2eRX received, one for each medication...I also do not see any indication of a phone call to notify us of the STAT, but the eRX do both state “;STAT” on them...1:40pm...eRX seen by one point, need clarification on DOB...2:05pm...Note added...2:18pm...Note added...2:54pm...Medications packaged and sent to delivery department...3:08pm...Delivery assigned to Rover...Jack, hopefully you can identify the timeline on your end for what occurred between 3:08pm and the delivery timestamp we show of 6:17pm....” There is no indication of an investigation into what occurred with the delivery after 3:08 p.m. There is no date for the conclusion of the investigation and no documentation of the family being contacted regarding the results of the investigation. There is no indication of corrective action to prevent recurrence. A morphine sulfate (concentrate) 20mg/ml 5mg prn every hour order was found entered into the electronic MAR dated March 27, 2024 at 5:51 p.m. The identity of the individual entering and/or authorizing the order is not known. A letter addressed to the patients primary physician revealed: “;...The team at Hospice of the West would like to extend our sympathy for the loss of your patient...who passed away on March 29, 2024...We first saw [patient] on March 28, 2024 and they received 35 days of Hospice care...Hospice of the West provided the following...All medications associated with the terminal diagnosis....” Patient #5 Start of Care: August 17, 2023 End of Care: August 21, 2023 “;...Complaint/Grievance report....” revealed: “;...Date/time complaint received...11/13/23...Description of complaint...0/10 rating...0 explain things...0 care...0 help w/pain...QAPI review...11/15/23....” There was no documentation of attempts to contact the Complainant to follow-up or to discuss resolution of the complaint. A chart review analysis was attached to the complaint/grievance form that revealed, “;...No documentation in chart of [caregiver] dissatisfaction or concerns....” “;...Clinical Notes....” dated August 20, 2023 revealed: “;...Time of call...08/20/23@1049...They are out of Morphine Injection....” Patient #6 Start of Care: July 1, 2022 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Complaint Received...11/22/2023 1031am (sic)...On 11/20/2023 and (sic) order was placed for oxycontin. Auth was provided in backline due to cost on 11/20 at 119pm (sic) ref#24799306. On 11/22 family reported the medication had still not arrived. Deliver care reported the auth was given for the generic and only the brand name was available. No call was ever made to HOW to report any back orders or delays in delivery...Follow up with family. Follow up with pharmacy rep...with delivery changed to a stat. Deliver Care manager...states issue with their new system was the basis of the error...This writer followed up with DON at facility, aware of error and steps taken to prevent going forward by switching to facility pharmacy. The writer also followed up with [caregiver] to explain...steps to prevent going forward...Meeting set up...to discuss pharmacy concerns...QAPI review 3/26/24....” A physician order for oxycontin placed in November 2023 could not be found in the medical record. A request was made for the order to be provided. A copy of a prescription was provided that was issued on November 22, 2022 at 4:33 p.m. that revealed: “...oxycodone 10mg tablet dispense 84...substitution permitted....” Patient #7 Start of Care: March 10, 2024 End of Care: March 20, 2024 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Complaint Received...3/20/24 12pm...This writer contacted POA...to check in for post-admit call...[POA] reported being dissatisfied...reported not receiving communication from staff, now (sic) knowing when Dr...had seen (patient) and not knowing what medications (patient) was receiving...This writer attempted to call facility DON without answer....” A chart review was conducted and notes from the chart review are provided. There is no documentation of attempts to contact the Complainant regarding the resolution of the complaint. Patient #8 Start of Care: August 18, 2023 End of Care: August 20, 2023 Hospice of the West “;...Complaint/Grievance Report....” dated September 26, 2023 revealed: “;...This RN placed a call to patient [caregiver] for routine condolence call after patient death...Patient was on service under GIP (General Inpatient Care) at Haven of Tucson...Upon initial call...[caregiver] reported that ...you are the first person from your agency to contact me since [the patient] died.”...spoke for 40 minutes...[caregiver] has filed 3 reports with governing bodies...AZDHS...AZ Board of Nursing...Actions at time of/or immediately after Complaint...Collaboration with HOW CL (Clinical Lead) to coordinate meeting with Haven of Tucson for educational opportunities...Referral sent to HOW Regional Bereavement Coordinator...for follow up...Date investigation concluded...9/28/2023....QAPI review...10/6/23....” The complaint/grievance report was completed by Employee #3. Documentation of education provided to Haven of Tucson staff was requested but could not be provided within the survey time frame. Documentation could not be found of follow-up contact made with the Complainant either by the Bereavement Coordinator or regarding the resolution of the complaint. Documentation of findings, analysis or resolution of the complaint could not be found. The Complainant was contacted on August 22, 2024 at 3:35 p.m. The Complainant remarked that the patient the Complaint was regarding died almost a year ago exactly. The Complainant stated that they had prior experiences due to family with three other hospices and were aware that hospices usually followed bereaved families for a year. “;I never heard anything from them [Hospice of the West]. Not one word. Then weirdly, I did get one just now, a letter. Im sure its all electronically generated,” stated the Complainant. The Complainant stated that a nurse came to the hospital from HOW. The Complainant stated that at no time was it explained to them that this was an outpatient hospice service until they went to Haven of Tucson where they were told the hospice “;rents rooms” at Haven. The Complainant stated they still have nightmares about an HOW nurse that tried to inject medication who was unable to do so without spilling medication out everywhere and nightmares of the patient reported in the complaint being in excruciating pain while on hospice. The Complainant reports they did try to talk with the nursing staff about the patients pain but was told over the phone by a nurse who had not been visiting the Complainants mother that HOW was medicating the patient as much as they could. The Complainant stated at some point there was a change in leadership and the Complainant was contacted by an individual identified as Employee #1 who reached out and expressed appreciation for the Complainants grievance. Employee #1 said there would be an investigation and that someone in compliance from HOW would be calling the Complainant. “;Nobody else ever called. And that tells me that they dont care.” Patient #9 Start of Care: December 13, 2023 End of Care: January 22, 2024 “;...Complaint/Grievance Report....” revealed: “;Date/Time Complaint Received...1/22/2024 2118...[caregiver] is dissatisfied with lack of education provided, lack of follow up visits, inability to speak to physician directly, delay in antibiotic arrival for UTI...QAPI review 2/1/24....” The date the investigation was concluded was not noted. Attempts to contact the Complainant to report the results of the investigation were not documented. A chart review was conducted and attached to the complaint. The chart review indicated, “;...antibiotic order placed 1/20/24 at 9:11 p.m., med delivered 1/21/24 at 11am....” “;...Clinical Notes....” dated January 20, 2024 signed 2:32 a.m. revealed: “;...Consulted with Dr...who ordered Bactrim DS to treat a UTI....” “;...Clinical Notes....” revealed: “;01/21/2024...triage call 0314...pt is yelling out in pain, pt has UTI and catheter was replaced yesterday, asking for nurse assessment...01/21/2024...triage call 7:30 a.m...[caregiver] called, states pt is still in a lot of pain...states pt did not received (sic) ABX that were ordered yesterday, this RN reviewed with Dr...and new order for Tramadol 50mg q6 PRN received, advised that would followup (sic) with pharmacy this a.m., explained that would have to reach on call pharmacy and would take a little time...This RN called DCRX and reached answering service, awaiting call back from on call pharmacist...01/21/2024...triage call 0830...return call from on call pharmacist Toni, it appears that yesterday medicine were ordered for next day delivery by mistake, toni (sic) will fill stat order on oxybutin (sic) and tramadol and send ABX with those medications stat, this RN updated [caregiver]...01/21/2024...triage call 1005...[A different caregiver] called, states pt was prescribed ABX and did not receive medication, this RN spoke to [caregiver] and updated on medication delivery....” Patient #10 Start of Care: June 13, 2023 End of Care: June 23, 2023 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Complaint Received...9/22/2023 CAHPS Survey...Received results 10/5/2023...Date/Time form completed if different than above...10/6/2023...[Caregiver] main complaint was that [patient] transitioned quickly and didnt have the necessary comfort meds on hand such as Morphine...The issue of timely meds has been resolved...We can place stat orders with DeliverCareRX Pharmacy and they deliver same day...Effective immediately, staff have been instructed to...Keep patients, Caregivers and POAs informed of appointment times and if you are running late or need to reschedule...Date investigation concluded...10/6...QAPI review...10/6/23....” The investigation conducted was noted to be a chart review. No analysis or findings were included. Documentation of follow-up with the Complainant was not included. “;...Supplemental Order....” dated September 22, 2023 06:59 p.m. revealed: “;...Morphine Sulfate (Concentrate) by Mouth Solution 20mg/mL 0.5mg PRN every 4 hours PO....” “...Clinical Notes....” dated September 22, 2023 at 7:13 p.m. revealed: “...Patient was lethargic and intermittently confused...Patient had begun to transition...Wife reported last night he was hallucinating...and then started to get agitated... agitated...Today patient is breathing labored...Doctor ordered Morphine 5 mg...as needed....” “...Clinical Notes....” dated September 22, 2023 signed at 7:00 p.m. revealed: “...Date/Time of call...6/22/23 @ 1841...Reason for call...reporting 2nd fall today...reports patient tried to get out of bed and fell...no visible injuries and no complaints of pain....” “...Clinical Notes....” dated September 23, 2023 signed 12:06 a.m. revealed: “...order to give 10mg MSIR....” “...Clinical Notes....” dated September 23, 2023 signed 7:13 p.m. revealed: “...patient seen for fall and change in condition...patient had a fall last night and has three more skin tears....” Patient #11 Start of Care: August 6, 2023 End of Care: August 13, 2023 “;...Complaint/Grievance Report....” revealed: “;...Date/time Complaint received...9/26/2023 9:20 a.m....This RN placed call to patient [name of Caregiver] for routine call after patient death on 8/13/2023. Patient was on service under Routine LOC (Level of Care) at Hven (sic) of Tucson...Upon initial call...[caregiver] said it was overall not a good experience...There was a lot of misunderstanding/miscommunication with the facility and the hospice team...The care at the Haven of Tucson was not good. She referenced patient developing a diaper rash due to incontinence...The HHA (home health aide) mistakenly gave [caregiver] a shower instead of the patient at first visit...action at time of/or immediately after Complaint...Collaboration with HOW CL to coordinate meeting with Haven of Tucson for educational opportunities...Education given to the HOW Tucson team during stand up...Hospice HHA spoken to...admitted...initially took [caregiver] into the shower but then once...checked the patient plan of care...realized it was not correct and did not shower [caregiver]...date investigation concluded...9/28/2023...QAPI review...10/9/2023....” Documentation of follow-up contact with the Complainant could not be found. A request was made for the training records regarding the staff of Haven of Tucson but the training records could not be provided in the time requested during the survey period. Patient #12 Start of Care: June 27, 2024 End of Care: July 26, 2024 The Complainant was contacted and interviewed on August 19, 2024 at 8:39 a.m. The Complainant stated that, “;Things happen, Ill give that to them,” but that the medication error of prescribing 200mg of Metoprolol to the patient reported in the complaint was not the first issue they experienced with the care provided by Hospice of the West. The Complainant stated that they, as the primary caregiver and surrogate decision-maker for the patient, met with a nurse, who reviewed the patients medications with the Complainant. The Complainant noted at the time that the patients medications had been “;pared down to the essentials” but otherwise no changes had been made. The Complainant stated that on July 4, 2024, Latanoprost was ordered for the patient but was not delivered for the patient until a stat order was placed and the medication received on July 12, 2024. The Complainant stated they reported this issue to Hospice of the West and stated the responsiveness on this issue was “;very appropriate.” On July 4, 2024, the patient began taking all other medications ordered, including Metoprolol. The Complainant reported that the Complainant was made aware by staff at the facility where the patient resided that the patient had been prescribed “;ten times the amount” of Metoprolol than the patient was intended to be prescribed. The Complainant reported this to the hospice nurse who came to see the patient and stated the hospice nurse told the Complainant this was “;not possible” and that what the Complainant read on the MAR (medication administration sheet) “;must be a typo.” The patient continued to receive 200mg of Metoprolol from July 4 to July 25, 2024 according to the Complainant. The Complainant reported to the nurse that the patient had a heart rate in the 40s, was shaking and had not been responsive for weeks. The Complainant stated the hospice nurse told the Complainant this was a normal part of the dying process. The Complainant stated that the nursing home sent the Complainant a photograph of the prescription bottle to provide the hospice and the hospice finally agreed there was a medication error. But the Complainant stated that the hospice was not apologetic and instead “;tried to deflect blame” onto the nursing home. The Complainant stated the Complainant contacted Hospice of the West. The Complainant stated, “;I wanted to know, what are you going to do?” The Complainant stated they were ignored by the first person they spoke to. The Complainant stated they continued to pursue the issue and were put in contact with a second staff person identified as Employee #1 who apologized to the Complainant for what had happened. The Complainant stated that Employee #1 called the Complainant daily to give updates regarding an investigation Employee #1 stated was being conducted by Hospice of the West; however, the Complainant stated that once the Complainant filed a complaint with Arizona Department of Health Services, Employee #1 ceased contact with the Complainant. “;...Belmont Village Scottsdale Physicians Orders....” month selected June 2024 revealed: “;...Metoprolol Succ [succinate] ER [extended release] 25mg [milligram] tab take 1 tablet by mouth once daily...morning...9/25/2023...ordered by provider...D/C [discontinued]...7/2/2024....” Hospice of the West medication order entry created June 27, 2024 at 3:58 p.m. revealed: “;...Metoprolol Succinate ER by mouth...200 milligram daily...Give 200 milligram daily by mouth for hypertension....” Hospice of the West physicians order signed by Employee #7 and by Employee #4 on July 2, 2024 at 2:43 p.m. revealed: “;...Metoprolol Succinate ER By Mouth Tablet Extended Release 24 Hour 200MG 200 Milligram daily PO Give 200mg by mouth daily for hypertension (HC)....” Hospice of the West physician order signed July 25, 2024 by Employee #5 and on August 6, 2024 by Employee #6 revealed: “;...Metoprolol Succinate ER by Mouth Tablet Extended Release 24 Hour 200MG 200 Milligram daily PO Give 200mg by mouth daily for hypertension (HC) ended on 07-25-24....” Physician Order modification details entered into the electronic MAR (Medication Administration Record) indicated the “;Start Physician” for the initial order was Employee #4. “;...Team Care Plan....” signed by Employee #4 and Employee #7 on July 2, 2024 revealed: “;...Primary diagnosis...Alzheimers disease, unspecified...Medications...Metoprolol Succinate by mouth 200mg Extended Release...200mg daily...for hypertension....” June 28, 2024 Pulse: 82bpm BP [blood pressure]: 138/81 Orientation: Person, Place, mental status intermittently confused, cooperative, forgetful July 3, 2024 “;...Clinical Notes....” revealed: “;...Triage 529PM: Call from...Belmont Village...needs an updated list of medications due to a lot of changes were made...Needs Imodium and Metoprolol ordered...Med list faxed...with confirmation...This list included all discontinued meds...Imodium and metoprolol ordered....” July 11, 2024 Pulse: 83bpm BP: 143/73 Orientation: Person, mental status: Continuously confused “;...Clinical Notes....” revealed: “;...Pt. just finished with breakfast and states...stomach hurts...Per [surrogate decision-maker] pts primary caregiver that has been with pt for last several days was just diagnosed with strep throat...requesting pt be swabbed....Discussed with supervisor...and we do not swab only watch for symptoms and treat from there....” July 18, 2024 Pulse: 45bpm BP: 107/53 Orientation: Person, mental status: Intermittently confused, cooperative July 25, 2024 “;...Clinical Notes....” revealed: “;...Received messages from [surrogate decision-maker] regarding Covid (sic) being in facility. Per charge RN at facility there are no cases in the memory care unity. Discussed with [surrogate decision-maker] that we do not test we only treat if symptomatic...Upset that facility wouldnt test...said...heard the medtech that was on unit yesterday morning was positive for covid (sic)...Received a call from patients daughter, informing that metoprolol bottle received on 7/16 was 200mg once daily, which differs from patients original dose of 25mg. Metoprolol dose corrected to 25mg QD, pharmacy updated and medication sent for delivery, Dr...updated on medication error and orders received to hold metoprolol until HR above 60, then resume 25mg once daily....” July 26, 2024 Pulse: 66bpm BP: 132/84 Orientation: Person, Place, intermittently confused, cooperative “;...Clinical Notes....” revealed: “;...Triage 742AM: Call from [surrogate decision-maker] Request a call back from director. Message relayed...9:23 a.m....This nurse spoke with...pharmacy to request medication list. Medical records will take information and review before sending...4:49 p.m....Called OPPC to confirm medication will be delivered STAT this morning after delay due to authorization of medication the previous evening. Medication will arrive at facility by 11am per pharmacy staff...6:46 p.m....Vitals stable...Medication clarification on metoprolol reviewed and rectified. Orders were faxed to facility yesterday. Facility still awaiting arrival of medications....” “;...Incident/Unusual Occurrence/Adverse Event Report....” dated July 30, 2024 and completed by Employee #5 revealed: “;...Received call from [patients surrogate decision-maker] on 07/26/2024 stating that metoprolol bottle received by facility on 7/16 was 200mg once daily, which differs from patients original dose of 25mg...New medication orders faxed...Patients [surrogate decision-maker] updated by phone...also reports concerns regarding COVID in...facility and asks for COVID testing. This nurse confirmed that HOW (Hospice of the West) does not provide routine COVID testing and our physician declines to treat asymptomatic patients who have not tested positive....[Surrogate decision-maker] called office...would like to terminate hospice care stating the medication error made...feel...cannot trust hospice...Revocation sent...and pt d/c on 7/26/2024...Vital signs before...7/18/24...107/53...45...Vital signs after...7/26...132/84...66....” Documentation of two handouts reviewed in a nurses call conducted on August 14, 2024 by pharmacy staff were provided. One handout was titled, “;...Look Alike/Sound Alike Medications...” and the other handout was titled, “;...Medication Safety Corner: Avoiding E-Prescribing Errors....” An email was sent to Hospice of the West staff on August 14, 2024 reminding staff to send copies of medical records such as medication lists, H&Ps (history & physicals), labs and advanced directives along with consents at the time of admission. “;...Disciplinary Action Form....” dated August 12, 2024 revealed a verbal warning issued to Employee #8 for a transcription error during admission of Patient #12 for entering Metoprolol 200mg by mouth once daily instead of 25 mg by mouth once daily. The form indicated, “;...Patient did not suffer ill effects from incorrect dosage. The expectation when admitting a patient is that a medication list is obtained from current facility/care setting and meds are reviewed with physician from that list, and then transcribed/ordered according to physician approval and/or changes. If a medication list is unavailable, medication bottles or pill cards may be used as a reference...will obtain and send in medication lists with admission consents on all patients...going forward....” “;...Agency Discharge Summary....” revealed: “;...Summary of stay...Daughter elected to revoke hospice benefit on 7/26/2024 to seek aggressive treatment not within the hospice plan of care....” Interviews were conducted with Employees #1 and #3 on August 21 and August 22. Employee #3 stated that patients who are unhappy with the medication service provided by the hospice can instead pick up their medications at the pharmacy of their choice at no additional cost. But when asked how this right is communicated to patients, Employee #3 could not direct Compliance Officers to specific information provided to patients. This right did not appear to be clearly communicated in the admission materials provided by Hospice of the West to patients. Both Employees #1 and #3 acknowledged and agreed that adverse trends affecting patient care should be identified, a root cause analysis performed and actions to improve agency performance should be taken in accordance with policies and procedures; howev er, Employee #1 was asked to provide all performance improvement plans initiated by HOW in 2023 and 2024 related to the provision of patient care and related to pharmaceutical services. The two PIPs initiated, one initiated in March 27, 2023 regarding live discharge rates, and the other initiated March 1, 2024 regarding the transition to OnePoint Pharmacy as a subcontracted provider, did not appear to address the complaints and grievances reported by patients.”

“Based on interview, review of facility policies and procedures and review of facility documents, the Department has determined that Hospice has failed to ensure that the Governing Body failed to ensure the QAPI (Quality Assessment and Performance Improvement) program was reviewed and evaluated for effectiveness at least every 12 (twelve) months with documentation maintained of governing body oversight and that a quality improvement plan was implemented that included, at minimum, a method to make changes or take action as a result of identifying concerns about the delivery of a service relating to patient care. Failure to implement methods to make changes or take action stemming from the identification of concerns regarding the delivery of service relating to patient care can result in negative trends in patient care continuing unabated, resulting in entrenched substandard patient care. Findings include: Facility policy titled, “;...Governing Body....” updated April 23, 2023 revealed: “;...Duties of the Governing Body will include the following...Ensuring that hospice-wide performance improvement plan (QAPI)...Is defined, implemented, maintained and evaluated annually...Addresses priorities for improved quality care and patient safety...Takes actions to demonstrate improvement in hospice performance...Improvement actions are evaluated for effectiveness...Approving frequency and specific plan for performance improvement data collection....” Facility policy titled, “;...Regulatory Compliance—Auditing and Monitoring....” revealed: “;...Care Hospice conducts regular audits...in accordance with an audit protocol established by the QAPI Committee...that...may include, but are not limited to...Program statistics...Patient outcomes...Contracts...Patient/Caregiver satisfaction surveys...Code of Conduct...Reporting mechanisms...Disciplinary actions...Response and corrective actions, and Auditing and monitoring functions...Components of the compliance program that are regularly audited and monitored include...Standards of conduct...Compliance policies and procedures...Disciplinary actions...Response and corrective actions, and...Auditing and monitoring functions...Findings from the audits of hospice programs and the compliance program are used to identify and resolve problems...The Administrator (Program Director) compiles a summary of audit findings for the regular reports to the Governing Body and for inclusion in the Annual Evaluation Report...The Compliance Officer provides the Governing Body with a summary of audit findings....” Facility policy titled, “;...Incident and Adverse Events....” revealed: “;...Adverse Event...any event that deviates from accepted practice, is potentially harmful, and/or has resulted in harm to a patient, family member, employee, volunteer, visitor or their property. It includes any happening that is not consistent with the routine operation of Hospice or the routine care of a particular patient/client. Adverse events...include...Medication and treatment errors...Patient/client dissatisfaction...Client/patient/family injury, including falls...Incident...An unusual circumstance that may result or did result in personal injury of an employee...Serious incident/adverse event...An adverse event is considered “;serious” if, in the view of the investigator, it results in any of the following outcomes...Death...a life-threatening adverse event...Inpatient hospitalization or prolongation of existing hospitalization...A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions...All incidents/adverse events are reported to and investigated by the Chief Clinical Officer or designee to determine the appropriate corrective action and response....A root cause analysis is conducted when there is a sentinel event...The Clinical Director, in collaboration with the QAPI Committee, tracks and trends all reports of incident/adverse events in order to analyze their causes, implement preventative actions/performance improvement and mechanisms that include feedback and learning throughout the hospice and evaluate the effectiveness of preventative/corrective actions...The Clinical Director prepares a quarterly incident/adverse events report to submit to the hospice Administrator...And Governing Body, as applicable....” Complaint/Grievance Logs were requested for 2023 and 2024. The following grievances and complaints regarding medication-related issues were revealed: Quarter 1 2023 Complaint and CAHPS Log: Date recorded: 1/18/2023 Date of Complaint: 1/7/2023 Date of Resolution: 1/9/2023 “;...Meds ordered for 2 hour STAT delivery...Meds were not delivered (sic)/received for several hours resulting (sic) in patient high level agitation. Optum sates (sic) patient was not profled (sic) in system. Review on why auotmatic (sic) integration did not occur....” Date recorded: 2/21/2023 Date of Complaint: 10/23/2022 Date of Resolution: 2/22/2023 “;...Negative CAHPS survey comment BIGGEST COMPLAINT WAS PHARMACY. MISTAKES AND DELIVERY. MISLABELING OF MEDICATION, DIRECTIONS FOR DOSAGE....” Date recorded: 2/24/2023 Date of Complaint: 2/23/2023 Date of Resolution: 2/23/2023 “;...Admission nurse ordered 2-hour STAT medication during admission process. Records show medication ordered at 2053, left pharmacy at 2219, and “;delivery arrival” at 0100. Per DeliverCareRX, their delivery service reports they were not able to deliver because of no answer at door. No call from delivery service or DeliverCareRX to inform HOW of inability to deliver. HOW received call from facility staff to report medication not delivered....” Quarter 3 2023 Date Reported: August 8, 2023 Date of Occurrence June 27, 2023 “;...Employee Error...Medication error on behalf of HOW employee....” Quarter 4 2023 Date Recorded: November 13, 2023 Date of Complaint: November 13, 2024 Date of Resolution: Not recorded “;...Negative CAHPS response-with responded with all negative responses across the survey. Date Recorded: November 14, 2023 Date of Complaint: November 14, 2023 Date of Resolution: November 14, 2023 “;...Patient RX did not deliver. After a call to delivercare rx it was found that RX wason (sic) backorder and HOW was not notified....” Date Recorded: November 22, 2023 Date of Complaint: November 22, 2023 Date of Resolution: Not recorded “;...Patient RX did not deliver. After a call to delivercare rx it was found that RX was not delivered because the auth was for generic and on;y (sic) name brand was available....” Date Recorded: December 10, 2023. Date of Complaint: Not recorded. Date resolved: Not recorded. “;...Patient was prescribed morphine despite morphine allergy. Allergies did not flow to iPrescribe because they were entered in correctly (sic)....” Quarter 1 2024 Date Recorded: March 17, 2024 Date of Occurrence: March 17, 2024 “;...Patient missed 3 doses of medication. Pharmacy failed to notify HOW that medication was on back order....” Date Recorded: February 1, 2024 Date of Complaint: January 25, 2024 Date of resolution: January 23, 2024 “;...Pt family unhappy with lack of response during last hours of life. Lack of timely pain meds....” Date Recorded: April 3, 2024 Date of Complaint: March 20, 2024 Date of resolution: March 21, 2024 “;...Pharmacy did not complete delivery of medication because they had wrong address and did not notify HOW. HOW found out after patient called to complain that meds had not arrived and in pain....” Date Recorded: April 4, 2024 Date of Complaint: March 28, 2024 Date of resolution: March 28, 2024 “;...Pharmacy Compalint (sic) due to extreme delay in delivery....” Quarter 2 2024 Date Recorded: April 22, 2024 Date of Complaint: April 3, 2024 Date of resolution: April 5, 2024 “;...Medication was ordered on 4/1 for a 4/2 delivery. Meds not delivered until 4/3....” Date Recorded: April 22, 2024 Date of Complaint: April 18, 2024 Date of resolution: April 18, 2024 “;...Delay in comfort meds being delivered to patient....” Date Recorded: May 6, 2024 Date of Occurrence: May 4, 2024 “;...Pharmacy error...Prefilled syringes ordered, pharmacy filled one syringe to 20mg....” Date Recorded: June 4, 2024 Date of Complaint: June 4, 2024 Date of resolution: June 13, 2024 “;...Negative CAHPS response regarding pain management....” Quality and Performance Improvement (QAPI) Committee meeting minutes were requested for 2023 and 2024. Minutes were provided for quarterly meetings held on May 2, 2023, August 2023 (date unknown), November 21, 2023, January 30, 2024 and April 2024 (date unknown). The minutes indicated some tracking of patient falls, patient infections and patient complaints as well as reference to PIPs (performance improvement plans) related to CAHPS (Consumer Assessment of Health Providers and Systems) scores. Copies of all PIPs related to the provision of patient care and pharmaceutical/medication services for 2023-2024 were requested. A live discharge rate PIP was created March 27, 2023 with the measurable goal, “;...20% or below by July 2023 [of live discharges] per Care Hospice....” Although data had been tracked quarter by quarter, the “;analyze” portion of the PIP, “;...list identified causes the QAPI team will focus on....” had not been completed. A CAHPS Overview PIP was initiated in January 2024 with a measurable goal that indicated, “;...Increase [composite score] to at least national average of 83.1% by May 2024...Would you recommend...Increase score to...86%...Timely Help...Increase score to...76%...Communication...Increase score to at least...83%...Family training...Increase score to at least...78%....” The “;Analyze” portion of the PIP does not identify any possible causes for why the CAHPS scores may be below goal; however, the “;Improve” portion of the PIP is robust and highly detailed. A “;One Point Pharmacy Transition” PIP was initiated on March 1, 2024 with the measurable goals of, “;...All patients successfully transitioned by 4.1.2024 (sic)...All concerns will be addressed by HOW PHX leadership within 24 hours iof (sic) receipt of complaint....” Quite a few areas of the PIP indicate, “;...See Attached OFI (opportunities for improvement) but the attachment referenced was not provided. In an interview conducted with Employee #1 on August 21, 2024, Employee #1 confirmed that adverse trends in patient outcomes should be addressed according to facility policies and procedures and are generally tracked and addressed through the QAPI program. Governing Body minutes were requested for calendar year 2023 and for calendar year 2024 until the present survey date. “...Hospice Care Holdings, L.P. Minutes of a Meeting of the Compliance Committee....” from the following dates: February 22, 2023, May 26, 2023, September 7, 2023, December 5, 2023 and February 13, 2024 were provided. The minutes dated February 13, 2024 revealed: “...Mr. Moore and Ms. Rich reviewed compliance and quality metrics for the fourth quarter of 2023 and provided an update on key compliance initiatives. Mr. Moore highlighted key items from the materials shared with the Committee prior to the meeting....” The minutes dated December 5, 2023 revealed: “...Mr. Moore and Ms. Rich reviewed compliance and quality metrics for the third quarter of 2023 and provided an update on key compliance initiatives. Mr. Moore highlighted key items from the materials shared with the Committee prior to the meeting....” The minutes dated September 7, 2023 revealed: “...Mr. Moore and Ms. Rich reviewed compliance and quality metrics for the second quarter of 2023 and provided an update on key compliance initiatives. Mr. Moore highlighted key items from the materials shared with the Committee prior to the meeting....” The minutes dated May 26, 2023 revealed: “...Mr. Shea gave opening remarks before Mr. Moore and Ms. Rich reviewed compliance and quality metrics for the first quarter of 2023 and provided an update on key compliance initiatives....” No further documentation or detail regarding governing body evaluation or participation in QAPI or performance improvement was provided. In an interview conducted with Employees #1 and #2 on August 19, 2024, Employees #1 and #2 confirmed that the minutes for 2023 and 2024 governing body meetings had been provided as requested.”

“Based on review of documents, records, and interviews, it was determined that the Governing Body and Administrator failed to provide hospice care and services necessary for the palliation and management of the terminal illness and related conditions. This deficient practice poses a risk to the health and safety of patients if quality services are not provided to meet the needs of patients. Findings include: The condition in not met as evidenced by: Based on review of documents, observations and interviews, it was determined the Governing Body and Administrator failed to ensure hospice care and services for patients on service. This deficient practice poses a risk to the health and safety of patients if hospices are not organized appropriately according to state and federal requirements. The Condition of Participation deficiency is the result of the standard deficiencies found under the Conditions of Participation of Organizational Environment in the following tags: Cross reference: L0500, L0559, L0686, L0759 L0500: Failed to protect and promote the exercise of patients’ rights. a. failed to protect and promote the exercise of patient rights as detailed in Hospice’s policies and procedures for 12 (twelve) out of 12 (twelve) patients reviewed for the right to have grievances investigated according to policies and procedures b. failed to protect and promote the exercise of patient rights to receive effective pain management and symptom control for conditions related to terminal illness c. failed to protect and promote the exercise of patient rights to express concern and/or dissatisfaction with treatment or care and not be subject to discrimination or reprisal d. failed to protect and promote the exercise of patient right for the provision of care and services as specified in the patient plan of care e, failed to protect and promote the exercise of patient rights to have the patient and/or caregivers to participate actively in treatment with his or her feedback being treated with respect Interviews were conducted with Employees #1 and #3 on August 21 and August 22. Employee #3 stated that patients who are unhappy with the medication service provided by the hospice can instead pick up their medications at the pharmacy of their choice at no additional cost. But when asked how this right is communicated to patients, Employee #3 could not direct Compliance Officers to specific information provided to patients. This right did not appear to be clearly communicated in the admission materials provided by Hospice of the West to patients. Both Employees #1 and #3 acknowledged and agreed that adverse trends affecting patient care should be identified, a root cause analysis performed and actions to improve agency performance should be taken in accordance with policies and procedures; however, Employee #1 was asked to provide all performance improvement plans initiated by HOW in 2023 and 2024 related to the provision of patient care and related to pharmaceutical services. The two PIPs initiated, one initiated in March 27, 2023 regarding live discharge rates, and the other initiated March 1, 2024 regarding the transition to OnePoint Pharmacy as a subcontracted provider, did not appear to address the complaints and grievances reported by patients. L0559: Failed to ensure that the Governing Body reviewed and implemented the QAPI program: Failure to implement methods to make changes or take action stemming from the identification of concerns regarding the delivery of services relating to patient care. a. Governing Body failed to ensure the Governing Body reviewed and evaluated for effectiveness at least every 12 months with documentation maintained of governing body oversight and that a quality improvement plan was implemented that included at a minimum: 1. Governing Body failed to implement a method to make changes or take action as a result of identifying concerns about the delivery of service relating to patient care. 2. Governing Body failed to ensure the QAPI (Quality Assessment and Performance Improvement) plan included PIP (Performance Improvement Plans) stemming from identification of concerns. b. Request made for Governing Body minutes documenting implementation of actions taken in response to patient complaints stemming from identification of concerns the delivery of services relating to patient care. No documentation was received. No further documentation or detail regarding governing body evaluation or participation in QAPI or performance improvement was provided. In an interview conducted with Employees #1 and #2 on August 19, 2024, Employees #1 and #2 confirmed that the minutes for 2023 and 2024 governing body meetings had been provided as requested. L0581: Failed to engage in and document actions taken to prevent infections and communicable diseases according to facility policies and procedures a. Hospice failed to implement the appropriate actions that are expected to result in improvement and disease prevention. b. Patient #12 filed a complaint involving COVID precautions, no documentation of review of clinical guidelines or infection control action was documented. . Interview with Employee #1 confirmed that no documentation of review on infection control action was documented after complaint was received L0686: Hospice failed to provide medications to terminal patients as ordered according to the plan of care which can result in needless suffering for patients who are terminally ill. a. Failed to ensure the contractual agreement with hospice pharmacy to assure that medications are readily available based on the facility policy titled, “...Availability 24/7...” b. Failed to ensure the facility policy titled, “...Pain and Symptom Management...” was developed and implemented for 12 (twelve) patients Information was requested regarding the delivery practices and procedures for the previous subcontractor but this information was not provided. Interview with Employee #1 and #2 confirmed that multiple pain medication orders were complained about by patients. L0759: Failed to ensure the hospice has provided adequate training to SNF/NF or ICF/IID staff, and that coordination of services and communication with the facilities is clearly defined. . a. Records of training documentation for the staff who provided services on behalf of Hospice of the West in SNF/NF/ ICD/IID facilities were requested but not received. b. Hospice failed to provide written agreements in accordance with the facility policy titled, “...Hospice Care for Nursing Residents-Written Agreements...”, copies of all contracts for services provided under arrangement including SNF/NF/ICD/IID agreements were requested, not received. Records of training provided to staff who provide services on behalf of Hospice of the West in nursing homes/SNF/ICF facilities were requested but were not provided. In interview with Employee #1 and #2 a request was made for copies of all contracts for services under arrangement including SNF/NF agreements but these agreements were not provided. The cumulative effect of these systemic deficiencies has resulted in the facility’s failure to meet the requirement for Condition of Participation for Organization and Administration of Services.”

“Based on interviews, facility policies and procedures, review of facility documents and review of patient medical records, the Department has determined that Hospice failed to provide drugs and biologicals related to the palliation and management of the terminal illness according to physician’s orders and the patient plan of care. Failure to provide medications to terminal patients as ordered according to the plan of care can result in needless suffering for patients who are terminally ill. Findings include: Facility policy titled, “;...Availability 24/7....” revealed: “;...Contractual agreements are maintained with pharmacies in the hospices service area to assure that medications are readily available....” be effective...The RN Case Manager or designee notifies the patients attending physician....” Facility policy titled, “;...Plan of Care....” revealed: “;...The plan is established by the attending physician, the medical director or physician designee and 2 members of the IDG in collaboration with the patient/representative/primary caregiver at the start of care...The comprehensive Plan of Care is developed within 5 days of admission...The written plan is reviewed every 15 days...Review of the patient plan of care is documented...The Hospice...plan of care...reflects...the following...Treatments, drugs, biologicals and interventions to manage pain and symptoms of the terminal illness: including dosage/frequency/route....” Facility policy titled, “;...Physician Orders....” revealed: “;...The nurse receiving the order documents its receipt and a verbal order confirmation is sent to the attending physician for signature...Some of the reasons orders are obtained from physicians include...New medication, change in medication...Documentation of receipt of verbal orders and of written orders sent to the physician for signature is maintained in the patients clinical record...When the signed order is returned, it is filed in the patients clinical record....” Facility policy titled, “;...Pharmacy Services....” revealed: “;...Pharmaceutical services are provided in accordance with accepted professional standards...and services are available on a 24 hour basis...In addition to ordering, administration, storage, disposal and record keeping of drugs...responsibilities include...Providing information regarding the safe and appropriate use of drugs to other health professionals...Providing a pharmacist comprehensive medication review based on information from the RNs initial assessment within 5 days of admission and no longer than every 15 days thereafter...Appropriateness of the dose, frequency and route of administration....” Facility policy titled, “;...Pain and Symptom Management....” revealed: “;...The Care Hospice nurse assesses every patients pain and other symptoms as part of the initial assessment...The patients pain and other symptoms related to the terminal condition are thoroughly assessed during the comprehensive assessment of the patient by the RN case manager or designee...The patients preferences for pain management are reflected in the pain control measures selected...Procedures and protocols for pain assessment and management are developed and implemented using a numerical or other rating scale for pain assessment...If a patients pain score is above their acceptable rating or a patient states their pain level is not acceptable...If appropriate...the...medical director will be notified and the nurse will carry out the recommended action...as ordered by the physician...Pain will be reassessed within 24 hours...Pain is re-assessed during every home visit, any time a patient states his/her pain level has changed, and whenever pain medications or dosages have changed....” “;...Optum Hospice Pharmacy Services, LLC Pharmacy Services Agreement....” signed May 5, 2023 by representative of Optum Hospice Pharmacy Services, LLC and signed April 25, 2023 by representative of Care Hospice & its Affiliates revealed: “;...Client agrees to utilize only Optum to provide it with any of the prescription benefit management services comparable to those described herein during the term of this agreement...Optum may provide services under this Agreement through subcontractors....” A PowerPoint was attached to the service agreement regarding a change of subcontractors that occurred on March 4, 2024. Information was requested regarding the delivery practices and procedures for the previous subcontractor but this information was not provided. The subcontractor as of March 4, 2024 was OnePoint. “;...OnePoint Patient Care Quick Reference Guide....” revealed: “;...After Hours Support is available 24 hours a day, 365 days a year, for urgent new admissions...Weekdays...Morning...Departure time...10:00 a.m....Delivered by...3:00 p.m....Evening...Cut Off time...1:30 p.m...Departure time...2:30 p.m...Delivered by...8:00 p.m...Late Night (In Town Only)...Cut Off Time...6:00 p.m...Departure time...7:00 p.m...Delivered by...12:00 a.m...Weekends/Holidays...Morning...Departure time...10:00 a.m....Delivered by...6:00 p.m...Evening...Departure time...2:30 p.m....Delivered by...8:00 p.m....Late Night...Departure time...6:00 p.m...Delivered by..11:00 p.m...STAT—in town...During Standard Business Hours ONLY...STAT...Within 5 Hours of ordering...After Hours/On Call...Outside Standard Business Hours...Departure Time...First Come, First Served...Delivered By...Urgent Delivery (2-5 hours)...Delivery Windows...All NEW ORDERS will be delivered the SAME DAY unless otherwise specified...All REFILLS will be delivered the NEXT BUSINESS DAY unless otherwise specified...Refills placed Friday, Saturday, or Sunday are delivered the following Monday...order by Thursday if needed over the weekend...STAT service is available with a 3 HOUR DELIVERY when and where traffic and weather allow...$25 service charge will apply...ON-CALL service will be provided AFTER BUSINESS HOURS FOR ANY EMERGENCY...$65 charge will apply....” Complaint/Grievance Logs were requested for 2023 and 2024. The following grievances and complaints regarding medication-related issues were revealed: Quarter 1 2023 Complaint and CAHPS Log: Date recorded: 1/18/2023 Date of Complaint: 1/7/2023 Date of Resolution: 1/9/2023 “;...Meds ordered for 2 hour STAT delivery...Meds were not delivered (sic)/received for several hours resulting (sic) in patient high level agitation. Optum sates (sic) patient was not profled (sic) in system. Review on why auotmatic (sic) integration did not occur....” Date recorded: 2/21/2023 Date of Complaint: 10/23/2022 Date of Resolution: 2/22/2023 “;...Negative CAHPS survey comment BIGGEST COMPLAINT WAS PHARMACY. MISTAKES AND DELIVERY. MISLABELING OF MEDICATION, DIRECTIONS FOR DOSAGE....” Date recorded: 2/24/2023 Date of Complaint: 2/23/2023 Date of Resolution: 2/23/2023 “;...Admission nurse ordered 2-hour STAT medication during admission process. Records show medication ordered at 2053, left pharmacy at 2219, and “;delivery arrival” at 0100. Per DeliverCareRX, their delivery service reports they were not able to deliver because of no answer at door. No call from delivery service or DeliverCareRX to inform HOW of inability to deliver. HOW received call from facility staff to report medication not delivered....” Quarter 3 2023 Date Reported: August 8, 2023 Date of Occurrence June 27, 2023 “;...Employee Error...Medication error on behalf of HOW employee....” Quarter 4 2023 Date Recorded: November 13, 2023 Date of Complaint: November 13, 2024 Date of Resolution: Not recorded “;...Negative CAHPS response-with responded with all negative responses across the survey. Date Recorded: November 14, 2023 Date of Complaint: November 14, 2023 Date of Resolution: November 14, 2023 “;...Patient RX did not deliver. After a call to delivercare rx it was found that RX wason (sic) backorder and HOW was not notified....” Date Recorded: November 22, 2023 Date of Complaint: November 22, 2023 Date of Resolution: Not recorded “;...Patient RX did not deliver. After a call to delivercare rx it was found that RX was not delivered because the auth was for generic and on;y (sic) name brand was available....” Date Recorded: December 10, 2023. Date of Complaint: Not recorded. Date resolved: Not recorded. “;...Patient was prescribed morphine despite morphine allergy. Allergies did not flow to iPrescribe because they were entered in correctly (sic)....” Quarter 1 2024 Date Recorded: March 17, 2024 Date of Occurrence: March 17, 2024 “;...Patient missed 3 doses of medication. Pharmacy failed to notify HOW that medication was on back order....” Date Recorded: February 1, 2024 Date of Complaint: January 25, 2024 Date of resolution: January 23, 2024 “;...Pt family unhappy with lack of response during last hours of life. Lack of timely pain meds....” Date Recorded: April 3, 2024 Date of Complaint: March 20, 2024 Date of resolution: March 21, 2024 “;...Pharmacy did not complete delivery of medication because they had wrong address and did not notify HOW. HOW found out after patient called to complain that meds had not arrived and in pain....” Date Recorded: April 4, 2024 Date of Complaint: March 28, 2024 Date of resolution: March 28, 2024 “;...Pharmacy Compalint (sic) due to extreme delay in delivery....” Quarter 2 2024 Date Recorded: April 22, 2024 Date of Complaint: April 3, 2024 Date of resolution: April 5, 2024 “;...Medication was ordered on 4/1 for a 4/2 delivery. Meds not delivered until 4/3....” Date Recorded: April 22, 2024 Date of Complaint: April 18, 2024 Date of resolution: April 18, 2024 “;...Delay in comfort meds being delivered to patient....” Date Recorded: May 6, 2024 Date of Occurrence: May 4, 2024 “;...Pharmacy error...Prefilled syringes ordered, pharmacy filled one syringe to 20mg....” Date Recorded: June 4, 2024 Date of Complaint: June 4, 2024 Date of resolution: June 13, 2024 “;...Negative CAHPS response regarding pain management....” Governing Body minutes were requested for 2023 and 2024. “;...Hospice Care Holdings, L.P. Minutes of a meeting of the Compliance Committee....” were provided from the following dates: February 22, 2023, May 26, 2023, September 7, 2023, December 5, 2023 and February 13, 2024. These minutes indicated that, “;...compliance and quality metrics...” were discussed each quarter and, “;...an update on key compliance initiatives...” was presented each quarter; however, no detail was provided. Quality and Performance Improvement (QAPI) Committee meeting minutes were requested for 2023 and 2024. Minutes were provided for quarterly meetings held on May 2, 2023, August 2023 (date unknown), November 21, 2023, January 30, 2024 and April 2024 (date unknown). The minutes indicated some tracking of patient falls, patient infections and patient complaints as well as reference to PIPs (performance improvement plans) related to CAHPS (Consumer Assessment of Health Providers and Systems) scores. Copies of all PIPs related to the provision of patient care and pharmaceutical/medication services for 2023-2024 were requested. A live discharge rate PIP was created March 27, 2023 with the measurable goal, “;...20% or below by July 2023 [of live discharges] per Care Hospice....” Although data had been tracked quarter by quarter, the “;analyze” portion of the PIP, “;...list identified causes the QAPI team will focus on....” had not been completed. A CAHPS Overview PIP was initiated in January 2024 with a measurable goal that indicated, “;...Increase [composite score] to at least national average of 83.1% by May 2024...Would you recommend...Increase score to...86%...Timely Help...Increase score to...76%...Communication...Increase score to at least...83%...Family training...Increase score to at least...78%....” The “;Analyze” portion of the PIP does not identify any possible causes for why the CAHPS scores may be below goal; however, the “;Improve” portion of the PIP is robust and highly detailed. A “;One Point Pharmacy Transition” PIP was initiated on March 1, 2024 with the measurable goals of, “;...All patients successfully transitioned by 4.1.2024 (sic)...All concerns will be addressed by HOW PHX leadership within 24 hours iof (sic) receipt of complaint....” Quite a few areas of the PIP indicate, “;...See Attached OFI (opportunities for improvement) but the attachment referenced was not provided. Patient #1 Start of Care: March 19, 2024 End of Care: June 14, 2024 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Grievance Received...3/202/24 (sic)...Date/Time form completed if different than above...4/3/2024...interviews notes...3/20/24...Patient was transferred yesterday. Cg, Facility called last night looking for meds...called One Point and verified meds were being delivered tonight. I let them know. Called this am, did not get delivered. I called One Point, driver took to old address and returned without notifying us. I confirmed address and advised it needs to get there STAT....” There is no documentation of attempts to contact the family regarding the resolution of the complaint. There is not documentation regarding resolution of the complaint or date the investigation was concluded. Patient #2 Start of Care: September 29, 2023 End of Care: November 3, 2023 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Complaint Received...3/6/2024 8am via CAHPS survey...Negative CAHPS survey...Stated did not receive training or help for pain...did not receive liquid Morphine in timely manner on day of death, constipation not addressed....” There was no documentation of attempts to follow-up with the Complainant or attempts to reach the Complainant regarding the resolution of the Complaint. A chart review was conducted and the results attached to the complaint. No analysis of the review was provided. The chart review contained multiple references to the level of cleanliness of the patients home and pet ownership. The chart review indicated on multiple occasions the patients continued use of alcohol. No provided analysis indicated a link between these issues and the Complainants grievance of timely pain medication not being provided at the time of patients death or constipation not being adequately addressed. “;...Emergency Room Report....” dated September 28, 2023 revealed: “;...Alcohol...Use...Current...Type...Liquor...Frequency...Daily...Comments...vodka..2-3....” “;...Clinical Notes...” dated 09/29/2023 revealed: “;...Patient drinks moonshine every day, stating he takes about 3 shots per day....” “;...Team Care Plan...” revealed no goals related to alcohol use or alcohol dependence. No documentation of IDG concerns regarding medication interaction or moderation of medication regime for patient due to daily alcohol use could be found. “;...Clinical Notes....” dated 11/3/2023 and signed at 4:14 p.m. revealed: “;...RN PHONE CALL...SPOUSE CALLED REGARDING INCREASED AGITATION AND RESTLESSNESS...DR...ORDERS MSIR AND CLONAZEPAM. PATIENT HAS PAIN THAT CURRENT OXYCODONE NOT EFFECTIVE. INCREASED AGITATION POSSIBLE DUE TO PATIENT RECENTLY STOPPING ALCOHOL....” “;...Clinical Notes....” dated 11/3/2023 revealed: “;Time of Call...1810...seizure trance for over an hour...[Caregiver] states the patient has had episodes before, but he has not responded for over an hour now...Breathing at a normal rate but heavy...Eyes are open, mouth is open...arms can be moved easily...Educated that clonazepam and morphine have been ordered and how this would be given even though he cannot swallow them. [Caregiver] states [caregiver] has not done this before...Accepts a nurse to assess and teach medication administration...Updated [Employee #9] who will make a visit....” “;...Clinical Notes....” dated 11/4/2024 and signed at 1:14 a.m. by Employee #8 revealed: “;...Death visit...Time of death...1932....” Patient #3 Start of Care: March 16, 2024 End of Care: June 24, 2024 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Complaint received...6/24/24...Patient transferred hospice services...[caregiver] states...The fact that there were no notes after our meeting with your nurse on wed about my mom about (sic) getting an order for lorazepam, my mom had to suffer last night with sundowning which brought my dad to tears...When my mom was having severe constipation, I guess they had a hard time getting an order for an enema. I hear that your company is slow to respond and that you prescribe only minimum low doses of comfort meds...on 6/22 a call came into triage from the [caregiver] with...concerns. This SN was AOC (administrator on call)...attempted to reconcile the active concerns. Triage was sent out and medication changes were made....” Interviews and a chart review were conducted. Counseling was provided to two staff persons in relation to the complaint. There was no documentation of follow-up contact to the caregiver regarding the resolution of the complaint. A CAHPS survey was attached to the Complaint/grievance “;...Clinical notes....” revealed: “;...06/20/2024...Multiple messages back-and-forth to ensure gho receives new orders for medications...06/22/2024...signed 8:05 p.m....GHO (group home owner) called, she reports pt has uncontrolled symptoms of pain/restlessness, pt family at bedside...obtained new orders for Lorazepam 0.5mg q4 PRN, increase MSIR to 5mg q4 PRN, order faxed to GH......6/22/24...triage call 1726...pt CG called...is asking for ETA on Lorazepam...pt is anxious/restless/hallucinating and does not have PRN available ...6/22/24...phone call from triage re: family concerned/upset about medications...[caregiver] stated multiple med changes were made on Wednesday (June 21)...family was told there would be a prn order for Lorazepam...This RN verified that triage...was ordering the new medications... [caregiver] shared concerns of pain management and that a nurse came out the other night and did not increased the MSIR dose as the CG was requesting due to continued pain despite the low dose of MSIR... This SN updated [caregiver] that triage RN is approx 20 min out to come check on [patient] and the orders for new medication are being faxed over to the facility.. Patient #4 Start of Care: March 28, 2024 End of Care: March 29, 2024 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Complaint Received...3/28/24 330pm...[Caregiver] called approx. 320 stating they are still awaiting the MSIR and Ativan to arrive...states [patient] is restless and they need the medication...This SN called One Point at 323pm and spoke with....the delivery department who stated the medications had not left yet...made calls to multiple CVS, Walgreens, and Walmart to see if any in the area of the family carried both liquid MSIR and liquid Ativan. None of the pharmacies carried both at the same location. One Point was called back by this SN at 353...pharmacy...gave an ETA of approx. 45 minutes to an hour...the [caregiver] called back approx. 450 stating the medication still had not arrived. This SN called One Point...was told driver was approx. 15 min. out...530 this SN phoned [caregiver] who was very upset the medication had still not been delivered...requested if...could go pick them up somewhere. This SN...updated that SN had called multiple pharmacies in the area and none had both medications in stock. Patient is heard in background very restless...541pm One Point called again by this SN...updated this SN that the driver was approx. 1 hours out from delivery. This SN requested to speak with Rover directly as the times do not match the prior calls...called...back at 604pm...647pm this SN called [caregiver] who states the medication had arrived...states HOW let them down and it was not fair [patient] had to suffer like that....” Interviews were conducted and a summary provided in the complaint which revealed: “;...I find a couple things transpired...Delay on previous stop along with traffic...Driver gave inaccurate ETA information to dispatch...I am actually showing two separate STAT orders/deliveries...three medications ordered at 10:21am...with delivery at 1:29pm, as well as the two medications you mentioned, with timeline below. Do we know if the controlled substances were originally intended to be ordered at the same as these first three, but had to wait for prescriber signature...Below is the timeline I am showing on the pharmacy side...1:06-1:07pm...2eRX received, one for each medication...I also do not see any indication of a phone call to notify us of the STAT, but the eRX do both state “;STAT” on them...1:40pm...eRX seen by one point, need clarification on DOB...2:05pm...Note added...2:18pm...Note added...2:54pm...Medications packaged and sent to delivery department...3:08pm...Delivery assigned to Rover...Jack, hopefully you can identify the timeline on your end for what occurred between 3:08pm and the delivery timestamp we show of 6:17pm....” There is no indication of an investigation into what occurred with the delivery after 3:08 p.m. There is no date for the conclusion of the investigation and no documentation of the family being contacted regarding the results of the investigation. There is no indication of corrective action to prevent recurrence. A morphine sulfate (concentrate) 20mg/ml 5mg prn every hour order was found entered into the electronic MAR dated March 27, 2024 at 5:51 p.m. The identity of the individual entering and/or authorizing the order is not known. A letter addressed to the patients primary physician revealed: “;...The team at Hospice of the West would like to extend our sympathy for the loss of your patient...who passed away on March 29, 2024...We first saw [patient] on March 28, 2024 and they received 35 days of Hospice care...Hospice of the West provided the following...All medications associated with the terminal diagnosis....” Patient #5 Start of Care: August 17, 2023 End of Care: August 21, 2023 “;...Complaint/Grievance report....” revealed: “;...Date/time complaint received...11/13/23...Description of complaint...0/10 rating...0 explain things...0 care...0 help w/pain...QAPI review...11/15/23....” There was no documentation of attempts to contact the Complainant to follow-up or to discuss resolution of the complaint. A chart review analysis was attached to the complaint/grievance form that revealed, “;...No documentation in chart of [caregiver] dissatisfaction or concerns....” “;...Clinical Notes....” dated August 20, 2023 revealed: “;...Time of call...08/20/23@1049...They are out of Morphine Injection....” Patient #6 Start of Care: July 1, 2022 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Complaint Received...11/22/2023 1031am (sic)...On 11/20/2023 and (sic) order was placed for oxycontin. Auth was provided in backline due to cost on 11/20 at 119pm (sic) ref#24799306. On 11/22 family reported the medication had still not arrived. Deliver care reported the auth was given for the generic and only the brand name was available. No call was ever made to HOW to report any back orders or delays in delivery...Follow up with family. Follow up with pharmacy rep...with delivery changed to a stat. Deliver Care manager...states issue with their new system was the basis of the error...This writer followed up with DON at facility, aware of error and steps taken to prevent going forward by switching to facility pharmacy. The writer also followed up with [caregiver] to explain...steps to prevent going forward...Meeting set up...to discuss pharmacy concerns...QAPI review 3/26/24....” Patient #7 Start of Care: March 10, 2024 End of Care: March 20, 2024 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Complaint Received...3/20/24 12pm...This writer contacted POA...to check in for post-admit call...[POA] reported being dissatisfied...reported not receiving communication from staff, now (sic) knowing when Dr...had seen (patient) and not knowing what medications (patient) was receiving...This writer attempted to call facility DON without answer....” A chart review was conducted and notes from the chart review are provided. There is no documentation of attempts to contact the Complainant regarding the resolution of the complaint. Patient #9 Start of Care: December 13, 2023 End of Care: January 22, 2024 “;...Complaint/Grievance Report....” revealed: “;Date/Time Complaint Received...1/22/2024 2118...[caregiver] is dissatisfied with lack of education provided, lack of follow up visits, inability to speak to physician directly, delay in antibiotic arrival for UTI...QAPI review 2/1/24....” The date the investigation was concluded was not noted. Attempts to contact the Complainant to report the results of the investigation were not documented. A chart review was conducted and attached to the complaint. The chart review indicated, “;...antibiotic order placed 1/20/24 at 9:11 p.m., med delivered 1/21/24 at 11am....” “;...Clinical Notes....” dated January 20, 2024 signed 2:32 a.m. revealed: “;...Consulted with Dr...who ordered Bactrim DS to treat a UTI....” “;...Clinical Notes....” revealed: “;01/21/2024...triage call 0314...pt is yelling out in pain, pt has UTI and catheter was replaced yesterday, asking for nurse assessment...01/21/2024...triage call 7:30 a.m...[caregiver] called, states pt is still in a lot of pain...states pt did not received (sic) ABX that were ordered yesterday, this RN reviewed with Dr...and new order for Tramadol 50mg q6 PRN received, advised that would followup (sic) with pharmacy this a.m., explained that would have to reach on call pharmacy and would take a little time...This RN called DCRX and reached answering service, awaiting call back from on call pharmacist...01/21/2024...triage call 0830...return call from on call pharmacist Toni, it appears that yesterday medicine were ordered for next day delivery by mistake, toni (sic) will fill stat order on oxybutin (sic) and tramadol and send ABX with those medications stat, this RN updated [caregiver]...01/21/2024...triage call 1005...[A different caregiver] called, states pt was prescribed ABX and did not receive medication, this RN spoke to [caregiver] and updated on medication delivery....” Patient #10 Start of Care: June 13, 2023 End of Care: June 23, 2023 “;...Complaint/Grievance Report....” revealed: “;...Date/Time Complaint Received...9/22/2023 CAHPS Survey...Received results 10/5/2023...Date/Time form completed if different than above...10/6/2023...[Caregiver] main complaint was that [patient] transitioned quickly and didnt have the necessary comfort meds on hand such as Morphine...The issue of timely meds has been resolved...We can place stat orders with DeliverCareRX Pharmacy and they deliver same day...Effective immediately, staff have been instructed to...Keep patients, Caregivers and POAs informed of appointment times and if you are running late or need to reschedule...Date investigation concluded...10/6...QAPI review...10/6/23....” The investigation conducted was noted to be a chart review. No analysis or findings were included. Documentation of follow-up with the Complainant was not included. “;...Supplemental Order....” dated September 22, 2023 06:59 p.m. revealed: “;...Morphine Sulfate (Concentrate) by Mouth Solution 20mg/mL 0.5mg PRN every 4 hours PO....” “...Clinical Notes....” dated September 22, 2023 at 7:13 p.m. revealed: “...Patient was lethargic and intermittently confused...Patient had begun to transition...Wife reported last night he was hallucinating...and then started to get agitated... agitated...Today patient is breathing labored...Doctor ordered Morphine 5 mg...as needed....” “...Clinical Notes....” dated September 22, 2023 signed at 7:00 p.m. revealed: “...Date/Time of call...6/22/23 @ 1841...Reason for call...reporting 2nd fall today...reports patient tried to get out of bed and fell...no visible injuries and no complaints of pain....” “...Clinical Notes....” dated September 23, 2023 signed 12:06 a.m. revealed: “...order to give 10mg MSIR....” “...Clinical Notes....” dated September 23, 2023 signed 7:13 p.m. revealed: “...patient seen for fall and change in condition...patient had a fall last night and has three more skin tears....” Patient #11 Start of Care: August 6, 2023 End of Care: August 13, 2023 “;...Complaint/Grievance Report....” revealed: “;...Date/time Complaint received...9/26/2023 9:20 a.m....This RN placed call to patient [name of Caregiver] for routine call after patient death on 8/13/2023. Patient was on service under Routine LOC (Level of Care) at Hven (sic) of Tucson...Upon initial call...[caregiver] said it was overall not a good experience...There was a lot of misunderstanding/miscommunication with the facility and the hospice team...The care at the Haven of Tucson was not good. She referenced patient developing a diaper rash due to incontinence...The HHA (home health aide) mistakenly gave [caregiver] a shower instead of the patient at first visit...action at time of/or immediately after Complaint...Collaboration with HOW CL to coordinate meeting with Haven of Tucson for educational opportunities...Education given to the HOW Tucson team during stand up...Hospice HHA spoken to...admitted...initially took [caregiver] into the shower but then once...checked the patient plan of care...realized it was not correct and did not shower [caregiver]...date investigation concluded...9/28/2023...QAPI review...10/9/2023....” Documentation of follow-up contact with the Complainant could not be found. A request was made for the training records regarding the staff of Haven of Tucson but the training records could not be provided in the time requested during the survey period. Patient #12 Start of Care: June 27, 2024 End of Care: July 26, 2024 “;...Belmont Village Scottsdale Physicians Orders....” month selected June 2024 revealed: “;...Metoprolol Succ [succinate] ER [extended release] 25mg [milligram] tab take 1 tablet by mouth once daily...morning...9/25/2023...ordered by provider...D/C [discontinued]...7/2/2024....” Hospice of the West medication order entry created June 27, 2024 at 3:58 p.m. revealed: “;...Metoprolol Succinate ER by mouth...200 milligram daily...Give 200 milligram daily by mouth for hypertension....” Hospice of the West physicians order signed by Employee #7 and by Employee #4 on July 2, 2024 at 2:43 p.m. revealed: “;...Metoprolol Succinate ER By Mouth Tablet Extended Release 24 Hour 200MG 200 Milligram daily PO Give 200mg by mouth daily for hypertension (HC)....” Hospice of the West physician order signed July 25, 2024 by Employee #5 and on August 6, 2024 by Employee #6 revealed: “;...Metoprolol Succinate ER by Mouth Tablet Extended Release 24 Hour 200MG 200 Milligram daily PO Give 200mg by mouth daily for hypertension (HC) ended on 07-25-24....” Physician Order modification details entered into the electronic MAR (Medication Administration Record) indicated the “;Start Physician” for the initial order was Employee #4. “;...Team Care Plan....” signed by Employee #4 and Employee #7 on July 2, 2024 revealed: “;...Primary diagnosis...Alzheimers disease, unspecified...Medications...Metoprolol Succinate by mouth 200mg Extended Release...200mg daily...for hypertension....” June 28, 2024 Pulse: 82bpm BP [blood pressure]: 138/81 Orientation: Person, Place, mental status intermittently confused, cooperative, forgetful July 3, 2024 “;...Clinical Notes....” revealed: “;...Triage 529PM: Call from...Belmont Village...needs an updated list of medications due to a lot of changes were made...Needs Imodium and Metoprolol ordered...Med list faxed...with confirmation...This list included all discontinued meds...Imodium and metoprolol ordered....” July 11, 2024 Pulse: 83bpm BP: 143/73 Orientation: Person, mental status: Continuously confused “;...Clinical Notes....” revealed: “;...Pt. just finished with breakfast and states...stomach hurts...Per [surrogate decision-maker] pts primary caregiver that has been with pt for last several days was just diagnosed with strep throat...requesting pt be swabbed....Discussed with supervisor...and we do not swab only watch for symptoms and treat from there....” July 18, 2024 Pulse: 45bpm BP: 107/53 Orientation: Person, mental status: Intermittently confused, cooperative July 25, 2024 “;...Clinical Notes....” revealed: “;...Received messages from [surrogate decision-maker] regarding Covid (sic) being in facility. Per charge RN at facility there are no cases in the memory care unity. Discussed with [surrogate decision-maker] that we do not test we only treat if symptomatic...Upset that facility wouldnt test...said...heard the medtech that was on unit yesterday morning was positive for covid (sic)...Received a call from patients daughter, informing that metoprolol bottle received on 7/16 was 200mg once daily, which differs from patients original dose of 25mg. Metoprolol dose corrected to 25mg QD, pharmacy updated and medication sent for delivery, Dr...updated on medication error and orders received to hold metoprolol until HR above 60, then resume 25mg once daily....” July 26, 2024 Pulse: 66bpm BP: 132/84 Orientation: Person, Place, intermittently confused, cooperative “;...Clinical Notes....” revealed: “;...Triage 742AM: Call from [surrogate decision-maker] Request a call back from director. Message relayed...9:23 a.m....This nurse spoke with...pharmacy to request medication list. Medical records will take information and review before sending...4:49 p.m....Called OPPC to confirm medication will be delivered STAT this morning after delay due to authorization of medication the previous evening. Medication will arrive at facility by 11am per pharmacy staff...6:46 p.m....Vitals stable...Medication clarification on metoprolol reviewed and rectified. Orders were faxed to facility yesterday. Facility still awaiting arrival of medications....” “;...Incident/Unusual Occurrence/Adverse Event Report....” dated July 30, 2024 and completed by Employee #5 revealed: “;...Received call from [patients surrogate decision-maker] on 07/26/2024 stating that metoprolol bottle received by facility on 7/16 was 200mg once daily, which differs from patients original dose of 25mg...New medication orders faxed...Patients [surrogate decision-maker] updated by phone...also reports concerns regarding COVID in...facility and asks for COVID testing. This nurse confirmed that HOW (Hospice of the West) does not provide routine COVID testing and our physician declines to treat asymptomatic patients who have not tested positive....[Surrogate decision-maker] called office...would like to terminate hospice care stating the medication error made...feel...cannot trust hospice...Revocation sent...and pt d/c on 7/26/2024...Vital signs before...7/18/24...107/53...45...Vital signs after...7/26...132/84...66....””

“Based on interview, review of facility policies and procedures and review of facility documentation, the Department has determined that Hospice failed to ensure that Hospice provide hospice care to residents of a SNF/NF or ICF/IID, including, but not necessarily limited to, ensuring that professional management of the resident’s hospice services was provided according to the patient’s plan of care for patients #1, 3, 4, 6, 7, 8, 11 or 12, that hospice provides adequate training to SNF/NF or ICF/IID staff who provide hospice services to patients, that there is clear delineation and understanding of the responsibilities of the hospice and facility staff, and that coordination of services and communication with the facilities is clearly defined. Failure to ensure the hospice has provided quality hospice care to residents of SNF/NF/ICF/IID facilities can result in patients who are in facilities not receiving the same level of care as patients who are in the community. Findings include: Facility policy titled, “;...Hospice Care for Nursing Facility Residents-Written Agreements....” revealed: “;...Hospice care in a SNF is provided in accordance with the provisions stated in the written agreement between Care Hospice and the facility...Care Hospice does not provide care in facilities with which it does not have a written agreement...The written agreement must include at least the following...An agreement that it is Care Hospices responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF resident were in his or her own home...A delineation of Care Hospices responsibilities, which include, but are not limited, to...Providing medical direction and management to the patient...Nursing...Counseling...Provision of medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness...All other hospice services that are necessary...A provision that Care Hospice may use the SNF nursing personnel where permitted by State Law....” Facility policy titled, “;...Hospice Care for Nursing Facility Residents....” revealed: “;...Care Hospice Staff assures that facility staff providing care to Care Hospice patients are oriented to the Hospice philosophy of care, pain control, symptom management, principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements....” Records of training provided to staff who provide services on behalf of Hospice of the West in nursing homes/SNF/ICF facilities were requested but were not provided. A request was made for copies of all contracts for services under arrangement including SNF/NF agreements but these agreements were not provided.”

“Based on review of facility policy and procedure and interview, the Department has determined the Administrator failed to ensure that the hospice Interdisciplinary Group or IDG included a social worker, marriage and family therapist, or a mental health counselor as well as a pastoral counselor for 12 (twelve) out of 12 (twelve) patients reviewed, Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 & 12. Failure to ensure the IDG includes a social worker or other mental health counselor as well as a pastoral counselor within the IDG can result in a patient’s psychosocial and spiritual needs being neglected, resulting in poor outcomes for the patient. Findings include: Facility policy titled, “...Interdisciplinary Group Meeting....” revealed: “...The clinical record or minutes of the IDG document that the plan of care was reviewed and update and that effective interchange, reporting and coordination of patient/family care occurs...IDG Sign In Sheet....” Facility policy titled, “...Interdisciplinary Group....” revealed: “...The IDG includes...A medical social worker; and...A spiritual or other counselor....” A review of IDG sign-in sheets for 12 (twelve) out of 12 (twelve) patients reviewed indicated signatures for the Medical Director and/or physican and nurse only.”

“Based on review of facility documents, review of patient medical records and review of facility policies and procedures, the Department has determined that Hospice failed to implement appropriate actions to reduce exposure and improve prevention of infections and communicable diseases according to facility policies and procedures for Patient #12. Failure to engage in and document actions taken to prevent infections and communicable diseases according to facility policies and procedures can result in patients and staff being needlessly exposed to infectious and communicable diseases. Findings include: Facility policy titled, “;...Infection Control Program and Exposure Control Plan....” revealed: “;...Care Hospice follows CDC guidelines which are amended and supplemented from time to time...Care Hospice shall provide infection control education to colleagues and contracted providers...at the time of orientation and at least annually thereafter....” Facility policy titled, “;...Addendum: CDC and other Infection Control Guidelines....” revealed: “;...CDC Infection Control Guidance: CDC guidance for COVID-19 and Healthcare Workers: Information on COVID-19...The Guideline for Infection Control in Healthcare Personnel, American Journal of Infection Control, 1998, Volume 26, 289-354....” CDC (Centers for Disease Control) webpage titled, “;...Infection Control Guidance: SARS CoV-2....” most recently updated May 8, 2023 revealed: “;...Perform SARS-CoV-2 Viral Testing...anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible...asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately....” CDC webpage titled, “;...Infection Control Guidance: Streptococcus A....” most recently updated March 25, 2024 revealed: “;...Prevention of transmission of GAS in healthcare settings involves...rapidly diagnosing and treating patients with clinical infection...GAS (Group A streptococcus) infections can have a wide variety of clinical presentations...because clinical signs and symptoms of viral pharyngitis can mimic those of GAS pharyngitis, laboratory testing...is necessary to make an accurate...diagnosis... Even one case of postpartum or postsurgical GAS infection typically prompts an epidemiological investigation because of the potential for prevention of additional cases....” Patient #12 Start of Care: June 27, 2024 End of Care: July 26, 2024 July 11, 2024 Pulse: 83bpm BP: 143/73 Orientation: Person, mental status: Continuously confused “;...Clinical Notes....” revealed: “;...Pt. just finished with breakfast and states...stomach hurts...Per [surrogate decision-maker] pts primary caregiver that has been with pt for last several days was just diagnosed with strep throat...requesting pt be swabbed....Discussed with supervisor...and we do not swab only watch for symptoms and treat from there....” July 25, 2024 “;...Clinical Notes....” revealed: “;...Received messages from [surrogate decision-maker] regarding Covid (sic) being in facility. Per charge RN at facility there are no cases in the memory care unity. Discussed with [surrogate decision-maker] that we do not test we only treat if symptomatic...Upset that facility wouldnt test...said...heard the medtech that was on unit yesterday morning was positive for covid (sic)...Received a call from patients daughter, informing that metoprolol bottle received on 7/16 was 200mg once daily, which differs from patients original dose of 25mg. Metoprolol dose corrected to 25mg QD, pharmacy updated and medication sent for delivery, Dr...updated on medication error and orders received to hold metoprolol until HR above 60, then resume 25mg once daily....” “;...Incident/Unusual Occurrence/Adverse Event Report....” dated July 30, 2024 and completed by Employee #5 revealed: “;...Received call from [patients surrogate decision-maker] on 07/26/2024 stating that metoprolol bottle received by facility on 7/16 was 200mg once daily, which differs from patients original dose of 25mg...New medication orders faxed...Patients [surrogate decision-maker] updated by phone...also reports concerns regarding COVID in...facility and asks for COVID testing. This nurse confirmed that HOW (Hospice of the West) does not provide routine COVID testing and our physician declines to treat asymptomatic patients who have not tested positive....[Surrogate decision-maker] called office...would like to terminate hospice care stating the medication error made...feel...cannot trust hospice...Revocation sent...and pt d/c on 7/26/2024...Vital signs before...7/18/24...107/53...45...Vital signs after...7/26...132/84...66....” Facility policy titled, “;...Infection Control Program and Exposure Control Plan....” revealed: “;...Care Hospice follows CDC guidelines which are amended and supplemented from time to time...Care Hospice shall provide infection control education to colleagues and contracted providers...at the time of orientation and at least annually thereafter....” Facility policy titled, “;...Addendum: CDC and other Infection Control Guidelines....” revealed: “;...CDC Infection Control Guidance: CDC guidance for COVID-19 and Healthcare Workers: Information on COVID-19...The Guideline for Infection Control in Healthcare Personnel, American Journal of Infection Control, 1998, Volume 26, 289-354....” CDC (Centers for Disease Control) webpage titled, “;...Infection Control Guidance: SARS CoV-2....” most recently updated May 8, 2023 revealed: “;...Perform SARS-CoV-2 Viral Testing...anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible...asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately....” CDC webpage titled, “;...Infection Control Guidance: Streptococcus A....” most recently updated March 25, 2024 revealed: “;...Prevention of transmission of GAS in healthcare settings involves...rapidly diagnosing and treating patients with clinical infection...GAS (Group A streptococcus) infections can have a wide variety of clinical presentations...because clinical signs and symptoms of viral pharyngitis can mimic those of GAS pharyngitis, laboratory testing...is necessary to make an accurate...diagnosis... Even one case of postpartum or postsurgical GAS infection typically prompts an epidemiological investigation because of the potential for prevention of additional cases....” Patient #12 Start of Care: June 27, 2024 End of Care: July 26, 2024 July 11, 2024 Pulse: 83bpm BP: 143/73 Orientation: Person, mental status: Continuously confused “;...Clinical Notes....” revealed: “;...Pt. just finished with breakfast and states...stomach hurts...Per [surrogate decision-maker] pts primary caregiver that has been with pt for last several days was just diagnosed with strep throat...requesting pt be swabbed....Discussed with supervisor...and we do not swab only watch for symptoms and treat from there....” July 25, 2024 “;...Clinical Notes....” revealed: “;...Received messages from [surrogate decision-maker] regarding Covid (sic) being in facility. Per charge RN at facility there are no cases in the memory care unity. Discussed with [surrogate decision-maker] that we do not test we only treat if symptomatic...Upset that facility wouldnt test...said...heard the medtech that was on unit yesterday morning was positive for covid (sic)...Received a call from patients daughter, informing that metoprolol bottle received on 7/16 was 200mg once daily, which differs from patients original dose of 25mg. Metoprolol dose corrected to 25mg QD, pharmacy updated and medication sent for delivery, Dr...updated on medication error and orders received to hold metoprolol until HR above 60, then resume 25mg once daily....” “;...Incident/Unusual Occurrence/Adverse Event Report....” dated July 30, 2024 and completed by Employee #5 revealed: “;...Received call from [patients surrogate decision-maker] on 07/26/2024 stating that metoprolol bottle received by facility on 7/16 was 200mg once daily, which differs from patients original dose of 25mg...New medication orders faxed...Patients [surrogate decision-maker] updated by phone...also reports concerns regarding COVID in...facility and asks for COVID testing. This nurse confirmed that HOW (Hospice of the West) does not provide routine COVID testing and our physician declines to treat asymptomatic patients who have not tested positive....[Surrogate decision-maker] called office...would like to terminate hospice care stating the medication error made...feel...cannot trust hospice...Revocation sent...and pt d/c on 7/26/2024...Vital signs before...7/18/24...107/53...45...Vital signs after...7/26...132/84...66....” Interview with Employee #1 confirmed that no documentation of review on infection control action was documented after complaint was received”