Mercy Hospice

“Upon patient record review, 1 of 19 (Patient #7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #7: Patient with buttocks, coccyx and sacral wounds- described as excoriation at times and 5/15/26 as Stage II sacrum. Policy presented by staff requires weekly wound measurements with no documented evidence of weekly measurements.”

“Upon client record review, 2 of 19 (Patient #2, 7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: 4/16/26 order to implement volunteer. Upon initial record review, there was no documented evidence of visit provided. Patient #7: 5/8/26 PRN SN visit related to leaking catheter. Catheter replaced with 18 Fr. 10cc balloon. The 5/5/26 physician order is for 16 Fr. 10cc balloon, with no update for 18 Fr. 4/20/26 On 5/15/26 SN note states “daughter called – foley not draining and leaking, white sediment. Attempted to irrigate – unable. Discontinued 18 Fr. 10 cc catheter and replaced with 18 Fr. 10 cc”. There is no order for 18 Fr. 10 cc size catheter.”

“Upon patient record review, 3 of 19 (Patient #1, 4, 12) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1, 4, 12: Patients have Oxygen prescribed with no Oxygen precautions included on the hospice aide care plan.”

“Upon patient client record review, 1 of 19 (Patient #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 #7: 5/5/26 PRN visit for Foley Catheter insertion. Family would like a foley catheter due to increased weakness. Foley inserted. Patient tolerated procedure with minimal discomfort. No specifics of procedure documented to include catheter size. (16 Fr 10 ml in supplies but not specified in notes). In addition, on 5/13/26 SN note states catheter new/changed/in place/patent 18 Fr. 30 cc balloon. Unclear of which intervention was performed as it was not chosen in prompt.”

“Based on interview and record review, the hospice agency failed to ensure spiritual services were explained in full and were offered and provided for four of 19 sampled patients (Patient 17, Patient 5, Patient 6, and Patient 9) when: 1.Chaplain (a member of the clergy who provides spiritual and emotional support) services were not offered to Patient 17;2. Chaplain services were not provided to Patient 5;3. Chaplain services were not offered to Patient 6; and4. Chaplain services were not offered to Patient 9. These failures placed Patient 17, Patient 5, Patient 6, Patient 9, and their families at risk for not being fully evaluated and not receiving the support for their spiritual needs. 2. 2. Patient 5 had a start of care (SOC) date of 7/18/25 and diagnoses included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic kidney disease (a long-term condition where the kidneys are damaged and cannot filter blood as they should), and anxiety disorder (persistent and excessive feelings of worry, fear, or panic).A review of Patient 5’s Medical Social Worker (MSW) Visit Note Report, dated 7/25/25, indicated, “PATIENT IS CATHOLIC…WHEN CHAPLAIN AVAILABLE, PATIENT WOULD BE INTERESTED IN SERVICES…”During a review of Patient 5’s Interdisciplinary Group (IDG) Comprehensive Assessment, dated 7/29/25, the assessment indicated, “CHAPLAIN…SERVICES DECLINED…THIS DISCIPLINE’S SERVICES HAVE BEEN OFFERED BUT HAVE BEEN DECLINED AT THIS TIME BY THE PATIENT/CAREGIVER…REGISTERED NURSE…NEW REFERRALS:…CHAPLAIN REQUESTED WHEN AVAILABLE…”A review of Patient 5’s Plan of Care (POC) for certification period 7/18/25 to 10/15/25 indicated Patient 5 did not have orders for chaplain visits.During a concurrent interview and record review on 11/20/25 at 2:04 p.m. with the Manager of Clinical Services (MCS), the MCS verified that Patient 5 had a SOC of 7/18/25 and confirmed that the agency did not have a Chaplain from 5/31/25 to 9/29/25, and during Patient 5’s SOC. The MCS further confirmed the MSW’s initial assessment and the IDG assessment indicated Patient 5 was interested in having chaplain services. The MCS confirmed the chaplain services were not provided, and Patient 5 was not referred to any community spiritual resources and stated, “…I don’t see anything on the social work notes…”During a review of the facility’s policy and procedure (P&P) titled “82.09, Spiritual Care Services,” revised 12/29/2022, the P&P indicated, “…1. Hospice provides spiritual support, in keeping with the patient’s belief system and practice and as developed by the Interdisciplinary Groups’ (IDG) Plan of Care (POC)…2. The Medical Social Services Professional or chaplain completes a Spiritual Support Needs Assessment, as part of the electronic Patient Medical Record…3. The chaplain provides spiritual services or coordinates a referral to appropriate resources when requested by the patient, family and/or caregiver…”3. Patient 6 had a SOC date of 6/10/25 and diagnoses included cerebral infarction (reduce blood flow to the brain), vascular dementia (changes in thinking and memory due to reduced blood flow in the brain), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).Patient 6’s POC for certification period of 6/10/25 to 9/7/25, indicated Patient 6 did not have orders for chaplain services.During a review of Patient 6’s Start of Care Visit Note, dated 6/10/25, the note indicated, “…NEW REFERRALS: HHA [hospice aide], MSW…” The note did not indicate that chaplain services were offered to Patient 6.During a concurrent interview and record review on 11/19/25 at 3:22 p.m. with the MCS, the MCS confirmed Patient 6 had an SOC of 6/10/25 and there was no documentation that chaplain services were offered to Patient 6.4. Patient 9 had a SOC date of 8/20/25 and diagnoses included malignant neoplasm of left and right lungs (abnormal cell growth affecting both lungs), anxiety disorder, and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).Patient 9’s Plan of Care (POC) for certification period of 8/20/25 to 10/18/25, indicated Patient 9 did not have orders for chaplain services.During a review of Patient 9’s Start of Care Visit Note, dated 8/20/25, the note indicated, “…NEW REFERRALS: NONE…” The note did not indicate that chaplain services were offered to Patient 6.During a concurrent interview and record review on 11/19/25 at 1:01 p.m. with the MCS, the MCS confirmed Patient 9 had an SOC of 8/20/25 and there was no documentation that chaplain services were offered to Patient 9 at the start of care. The MCS stated chaplain services are offered at the start of care and important to verify what support the patient needs. The MCS further stated the chaplain services should have been offered to Patient 9 at the beginning of care.During a review of the agency’s P&P titled “33.03, Bill of Rights and Responsibilities,” revised 9/10/25, the P&P indicated, “…4. Patient Rights – Decision Making…Participate in, consent to, or refuse care in advance of and during treatment and be fully informed in advance about the care/service, where appropriate, including:…The services the agency offers…”During a review of the agency’s P&P titled “82.9, Spiritual Care Services,” revised 12/29/2022, the P&P indicated, “…5. The refusal of spiritual care by the patient, family and/or caregiver will be documented in the Patient Medical Record…” Findings: A review of Patient 17’s clinical record indicated the agency admitted the patient on 9/4/25 with multiple diagnoses, which included autoimmune hemolytic anemia (a condition where the body’s immune system mistakenly attacks and destroys its own red blood cells, which can cause fatigue, weakness, shortness of breath, and other symptoms). A review of Patient 17’s Hospice Certification and Plan of Care (POC, a document which contains patient’s pertinent medical history, physician’s orders for medications and treatments, clinical interventions and direction to clinicians providing direct patient care) for certification period from 9/4/25 to 11/2/25 contained physician orders for Skilled Nursing (SN) and Medical Social Worker (MSW) services. A review of the IDG (interdisciplinary group, a team of professionals who work together to create, implement, and update the POC for patients) and POC Update reports indicated that chaplain was not involved in any of the meetings for Patient 17. During a concurrent interview and record review on 11/19/25 at 1:50 p.m., the Manager of Clinical Services (MCS) explained that chaplain/spiritual services were to be fully explained to the patient and caregiver and offered during the initial MSW evaluation. The MCS reviewed Patient 17’s initial MSW visit notes dated 9/6/25 and was not able to find evidence that patient 17 and or her family were offered chaplain services. Upon reviewing MSW’s phone visit notes dated 9/17/25 and 9/23/25 the MCS was not able to provide documented evidence the chaplain/spiritual services were offered to Patient 17 and the patient or family declined. The MCS stated that the agency was required to provide all core services (essential), including chaplain services on a routine basis. The MCS explained that it was the expectation for MSW to document in patient’s clinical records if the patient and family declined the chaplain/spiritual services. The MCS acknowledged that Patient 17’s records did not indicate that chaplain services were offered, and the services were declined. A review of the agency’s policy and procedure (P & P) titled, “Spiritual Care Services,” with the revision date of 12/29/22 indicated, “Hospice provides spiritual support, in keeping with the patient’s belief system and practice…Spiritual services will support the dignity of the dying patient. Spiritual services can include religious rituals, assisting with funeral and memorial services…The Hospice chaplain provides direct support and coordinates spiritual care…coordinates a referral to appropriate resources.” The P & P indicated that “The refusal of spiritual care by the patient, family and/or caregiver will be documented in the Patient Medical Record.””

“Based on interview and record review, the agency failed to ensure volunteer services were offered and provided according to patients’ needs and preferences for two of 19 sampled patients (Patient 6 and Patient 18), whenPatient 6’s interest for volunteers for music was not provided, and Patient 18 was not offered volunteer services.These failures had the potential to result in Patient 6’s preferences not being honored and had the potential to affect Patient 6’s well-being and placed Patient 18 and her family at risk for not receiving the support they might needed. Findings: A review of Patient 18’s clinical record indicated the agency admitted the patient on 8/19/25 with multiple diagnoses, which included chronic lung disease, stroke and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), aphasia (difficulties with communication and hearing loss. A review of Patient 18’s Hospice Certification and Plan of Care (POC, a document which contains patient’s pertinent medical history, physician’s orders for medications and treatments, clinical interventions and direction to clinicians providing direct patient care) for certification period from 8/19/25 to 10/17/25 contained physician orders for Skilled Nursing (SN) and Medical Social Worker (MSW) services. A review of the Patient 18’s clinical record did not indicate a documentation and/or communication that volunteer services was offered during initial SN assessment. A review of MSW initial evaluation visit note dated 8/21/25 indicated Patient 18 had limited family members and/or friends available. A further review of MSW assessment indicated that the patient was single, with no children and her closest family was her brother. The MSW documented that brother was not available during the 8/21/25 visit and was not reachable after MSW left him several messages. The MSW documented,” This worker to make a more detail assessment on future visits…Should also assess for volunteer on next visit.” A review of MSW follow up visit notes dated 8/30/25 and 9/20/25 did not contain documented evidence that MSW followed up and offered volunteer services to Patient 18 as documented during 8/21/25 visit. During a concurrent interview and record review on 11/19/25 at 2:35 p.m., the Manager of Clinical Services (MCS) acknowledged that there was no follow up on 8/30/25 and 9/20/25 MSW visits regarding volunteer services. The MCS reviewed coordination notes and was not able to find any documentation that volunteer services were offered and the patient/family declined. The MCS stated that Patient 18 could have benefited from a volunteer to spend time with the patient talking, reading books, praying with the patient, or just sitting there. A review of the facility’s policy and procedure (P&P) titled, “Volunteer Services,” with the revision date of 10/31/25, indicated,” Purpose: To provide qualified volunteers to help meet the patient’s needs…The Hospice will use volunteers to provide…Direct patient care services, household chores…companionship…errands.” The P&P indicated further, “Volunteers may work in a variety of capacities, including…Providing emotional support and practical assistance to enhance the comfort and quality of life for patients, caregivers and family. These services include…providing companionship, listening, and simply “being there.” Findings:1.Patient 6 had a start of care (SOC) date of 6/10/25 and diagnoses included cerebral infarction (reduce blood flow to the brain), vascular dementia (changes in thinking and memory due to reduced blood flow in the brain), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Patient 6’s Medical Social Worker (MSW) Visit Note, dated 6/13/25, the note indicated, “…PATIENT HAS NO RELIGIOUS AFFILIATION…INTERESTED IN VOLUNTEER FOR MUSIC…”During a review of Patient 6’s Interdisciplinary Group (IDG) Comprehensive Assessment, dated 6/24/25, the assessment indicated, “…SERVICE NEEDS (VETERAN, VOLUNTEER, SOCIALIZATION, CULTURE, COMMUNITY, COMFORT THERAPY): NONE…”During a review of Patient 6’s Volunteer Referral Form, dated 7/3/25, the form indicated, “VOLUNTEER ACTIVITIES REQUESTED: [name of animal-assisted therapy program] FOR FACILITY VISIT…” The note further indicated that pet therapy was marked under the comments section of the form.During a review of Patient 6’s “Volunteer Plan,” dated 7/8/25, the plan indicated, “…ASSIGNED [name of volunteer] and [name of animal organization] FOR VISITS…”During a concurrent interview and record review on 11/19/25 at 3:22 p.m. with the Manager of Clinical Services (MCS), the MCS confirmed Patient 6 was interested in volunteers for music. The MCS stated the MSW sends the volunteer referral form on the next IDG meeting after the start of care and confirmed there was no referral form sent for Patient 6 related to Patient 6’s interest in volunteers for music. The MCS further confirmed that a volunteer referral form was sent for Patient 6 on 7/13/25 for pet therapy. The MCS confirmed there was no documented evidence on why the interest in volunteer for music was not provided and why the pet therapy was provided instead. The MCS stated the expectation was to try to meet Patient 6’s needs and to match Patient 6 with music and stated, “…if not possible [to accommodate the needs], we will communicate if needs cannot be met and it should be documented…”During a review of the agency’s policy and procedure (P&P) titled “82.11, Volunteer Services,” revised 10/31/25, the P&P indicated, “…Purpose: To provide qualified volunteers to help meet the patient’s needs and to follow the Interdisciplinary Group (IDG) Plan of Care (POC)…3. Volunteers may work in a variety of capacities, including: Patient care providing emotional support and practical assistance to enhance comfort and quality of life for patients, caregivers, and family…4. The selection of volunteers is based on initial screening and/or interview…””

“Based on interview and record review, the agency failed to effectively coordinate the provision of care and support the objectives outlined in the plan of care for one of 19 sampled patients (Patient 3), to ensure continuity of communication between the agency and skilled nursing facility (SNF), when:1. Patient 3’s physician order for discontinuation of Eliquis (blood thinner medication, placing the person at increased risk for bleeding) and starting Aspirin was not implemented for two months; and2. Patient 3’s record did not contain six (6) other medications that Patient 3 was prescribed since admission to the agency on 9/9/25.This failure placed Patient 3 at risk for bleeding and other adverse reactions from medication that was discontinued by physician. In addition, not receiving prescribed medications placed Patient 3 at risk for increased shortness of breath, uncontrolled pain, and other symptoms that could affect the patient’s quality of life. Findings:A review of the Plan of Care (POC, a document which contains patient’s pertinent medical history, physician’s orders for medications and treatments, clinical interventions and direction to clinicians providing direct patient care) indicated Patient 3 was admitted to the agency for end-of-life care in the fall of 2025. Patient 3’s diagnoses included dementia with anxiety (a progressive decline in mental abilities), irregular heart rhythm, lung disease, osteoarthritis (a degenerative joint disease that causes pain and stiffness), fracture of right hip, and insomnia (inability to sleep). Patient 3’s clinical record indicated that the patient resided at the skilled nursing facility.A review of the POC for certification period from 9/9/25 through 12/7/25 contained a physician order for skilled nursing (SN) which directed agency’s nurses to develop a nursing POC. The physician documented that Patient 3’s medications were to “be safely administered by SNF nurses.” The POC contained Patient 3’s medications list, which included Eliquis 2.5 mg (milligram, a unit of measurement) to be administered orally twice a day for the patient’s irregular heart rhythm, Budesonide (a medication used to treat shortness of breath by inhaling it), Hydroxyzine (a medication for agitation), melatonin (a medication to help with insomnia), Cranberry tablet (a supplement), Lidocaine patch (an adhesive medicated patch to control pain), and Voltaren gel (a numbing medication to control pain). The POC indicated further, “Hospice nurse to coordinate plan of care with facility staff…Hospice/facility [SNF] staff to coordinate for any changes…or care plan needs.”A review of Patient 3’s clinical record contained a physician order dated 9/18/25 to discontinue Eliquis and to start Aspirin (a common over-the-counter medication which also can be used as blood thinner) 81 mg chewable tablet once a day.A review of Patient 3’s IDG (interdisciplinary group, a team of professionals who work together to create, implement, and update the POC for patients) Comprehensive (a thorough evaluation of patient’s care needs and medications) Assessment and Plan of Care Update Report (CAPOCR), reviewed and completed by agency’s medical director (MD), nurse, and social worker during 9/23/25 IDG meeting was requested by the Department on 11/18/25. The POC Report indicated that Patient 3 was taking Aspirin 81 mg once a day, Budesonide inhalation (breathing) daily in the afternoon, Cranberry supplement once a day, Hydroxyzine 1 tablet every 6 hours as needed for agitation or verbal aggression, Melatonin 2 tablets every day at bedtime, Lidocaine patch that needed to be applied to patient’s hip in the morning and removed 12 hours later to control hip pain, and Voltaren gel for lower back pain to be applied twice a day. The POC Report dated 9/23/25 did not indicate that Patient 3 was taking Eliquis.On 11/19/25, at 10 a.m., an agency’s skilled nurse (SN) accompanied by Department, conducted a routine visit to the SNF, where Patient 3 resided. The facility’s nurse provided a document titled “Order Summary Report [OSR]” which contained Patient 3’s active orders for treatments and medications. Upon reviewing Patient 3’s medications listed on CAPOCR dated 9/23/25 and comparing with OSR provided by facility, the facility’s medication profile did not match the medications identified as active medications on Patient 3’s updated POC. SN 1 acknowledged that Patient 3 should not be taking Eliquis because the medication was discontinued by Patient 3’s physician two months ago. SN 1 validated that Patient 3’s medication profile had multiple discrepancies with medications and did not contain Aspirin, Budesonide, Cranberry, Hydroxyzine, Melatonin, Lidocaine patch, and Voltaren. SN 1 stated that nurses should review and verify that Patient 3’s medication list was accurate and updated with IDG POC every time they visited the patient. During a concurrent interview and review of Patient 3’s medications profile on 11/19/25, at 10:30 a.m., facility’s Unit Manager (UM) stated that the patient had been taking Eliquis 2.5 mg tablet every day in the morning and evening since her admission. The UM stated the facility nurses were not aware that Patient 3 Eliquis was discontinued by physician. The UM acknowledged that Patient 3 was not taking Aspirin, Budesonide, Cranberry, Hydroxyzine, Melatonin, Lidocaine patch, and Voltaren because the facility’s staff did not have physician orders for these medications.During a concurrent interview and record review on 11/19/25, at 12:35 p.m., the Manager of Clinical Services (MCS) stated the new physician’s order was to be communicated by agency’s nurses to facility and implemented timely. The MCS stated the expectation was that the new order was communicated verbally or over the phone, the new order signed by physician was faxed over to facility and nurse was to follow up with the facility to make sure the order was received and implemented. The MCS added, “Every visit SN should be pulling facility’s orders and compare with our orders and patient’s POC. Patient’s orders should be accurate and updated.” The MCS stated that the facility was aware that Eliquis was discontinued on 9/18/25 and Aspirin started because it was discussed during Patient 1’s care conference on 9/18/25. The MCS confirmed that Patient 3’s medication list was not updated on 9/18/25 when the patient’s physician discontinued Eliquis and prescribed Aspirin and the medication list was not accurate. The MCS reviewed SN visit notes dated 9/25/25, 10/2, 10/15, 10/22, 11/5, and 11/12/25 and validated that medication discrepancy was not noted during the above visits and Patient 1 continued receiving Eliquis for another two months. The MCS stated, “If the nurses compared the facility’s list of Patient 1’s medications with agency’s POC, they would catch the discrepancy, but it was not done.” The MCS validated that Eliquis and Aspirin discrepancy was not identified during IDG’s meetings dated 10/7, 10/21, 11/4 and 11/18/25.During a continued interview with MCS on 11/19/25, commencing at 12:35 p.m., the MCS was unable to explain why Patient 3 was not taking Budesonide inhaler, Cranberry supplement, Hydroxyzine and Melatonin tablets, Lidocaine patch, and Voltaren gel as prescribed. The MCS explained that Patient 3 was taking these 6 medications at the start of care and had no explanation why they were not found on Patient 3’s profile at the facility. The MCS added that the expectation was that each SN visit the hospice nurses should ensure that patient’s orders are updated, and the medication list is accurate.A review of the agency’s policy and procedure (P & P) titled, “Hospice Care for Nursing Facility Residents – Coordination of Care,” with last revision date of 3/17/24 indicated, ”Hospice ensures that mechanisms are in place to provide for coordination of all Hospice services provided to patients residing in nursing facilities…The Hospice…is responsible for a patient who is a resident of a nursing facility…The Hospice ensures that the IDG communicates with nursing facility…in the provision of care to the patient.” The policy further explained that the agency was to provide to the nursing facility the most recent plan of care specific to each patient, hospice medication information, and hospice physician orders specific to each patient.A review of the agency’s P & P titled, “Hospice Care for Nursing Facility Residents – Hospice Plan of Care,” revised 1/2/25, indicated, “A written Plan of Care is established and maintained for each facility patient…All care provided to the facility patient must be in accordance with the written Plan of Care…Any changes to the Plan of Care are discussed among all caregivers…Documentation of Coordination of Care is provided to the facility for each Hospice visit.””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the amount of narcotics (medications used for pain control, known to be addictive with risks for being abused/misused) medication dispensed to one of three sampled patients (Patient 1) were monitored accurately, when the amount of narcotics dispensed did not match what was in the home. This failure had the potential for pain medications to not be accounted for and, for Patient 1 to have ineffective pain management. Findings: A review of Patient 1’s “Hospice Certification and Plan of Care (POC),” for certification period 12/9/23 to 3/7/24, indicated Patient 1 had a Start of Care date of 12/9/23 for a terminal diagnosis of cervical cancer. The POC indicated “...Orders of Discipline and Treatments...Hospice Nurse to provide safe administration of medication, medication response and instruct on schedule actions, purpose, side effects, compliance... Goals...Medications will be managed appropriately as evidenced by patient/caregiver ability to safely administer, ability to verbalize/demonstrate compliance with medication regimen, and patient exhibiting steady stream symptom control throughout episode of care...” A review of Patient 1’s POC, indicated SN (Skilled Nurse) visit frequency was 1 time a week for 1 week, then 3 times a week for 1 week, and then 2 times a week for 12 weeks. A review of Patient 1’s physician order, dated 12/18/23, indicated “...Order Description: ...Daily Visits and [name of doctor] needs calls from CM [case manager] with photo record of the med counts daily. Not to exceed pain meds doses as prescribed by MD [medical doctor] ...SN Effective 12/17/2023...” A review of Patient 1’s physician’s order, dated 12/21/23, indicated “...Order Description: Reduce SNV (Skilled Nursing Visit) to 2x[times]week on Mon/Thurs...SN Effective 12/17/2023... “ A review of Patient 1’s physician’s order, dated 12/27/23, indicated “...Order Description: Daily SNV...SN Effective 12/24/2024...” A review of Patient 1’s physician’s order, dated 1/3/24, indicated “...Order Description: SNV decreased to 3xweek...SN Effective 12/31/2023...” A review of Patient 1’s physician’s order, dated 1/18/24, indicated “...Order Description: Reduce skilled nursing visits to two times a week, responding well to hospice plan of care...SN Effective 01/14/2024...” A review of Patient 1’s “Client Medication Report,” indicated: “Start Date...1/1/2024...MS Contin [extended release formulation of morphine sulfate for management of pain] 60 mg [milligrams] tablet...Instructions: Take 3 tabs [tablets] (180 mg) by mouth every 8 hours for pain...” “Start Date...12/18/2023...Oxycodone [narcotic pain medication]10 mg tablet...Instructions: 3tabs=30mg...every 4 hours...” A review of Patient 1’s “Client Episode Coordination Notes,” dated 2/15/24, indicated “...Late entry for 2/9/24...Phone call from [Director of Patient Care Services] to [Patient 1’s family member (FM)] regarding concerns over diversion. [FM] and patient very upset on phone call and a lot of cursing was done by patient throughout the conversation... After phone conversation [DPCS] and MCS [NS-Nursing Supervisor] did deep audit on each recorded med [medication] count and it was apparent that starting with RNCM [Registered Nurse Case Manager 2] visit medications were unaccounted for at each visit after 1/8...” A review of Patient 1’s “Client Episode Coordination Notes,” dated 2/14/24, indicated “...Late entry for 2/9/24...called [Patient 1’s FM] to discuss discrepancies in medication counts and dispense...[DPCS] notified [FM] and the patient that there were many tablets of MS Contin unaccounted for based on what was dispensed in the last 34 days and what the order said...that according to the pharmacy records 686 MS Contin 60 mg were dispensed and per the orders should have taken 306 tablets in that timeframe. [DPCS] let them know that per the nurse’s count at the visit yesterday the patient had 137 tablets of MS Contin which means there are still tablets unaccounted for...[FM] said they had been writing all the pills down that the patient has been taking...Let [FM] and the patient know that there were also some oxycodone unaccounted for and [FM] reports they gave her extra sometimes...Discussed the importance of notifying the nurse of the extra doses they gave...[FM] reports they did find more MS Contin and have 152 today not 137 and that the patient had 75 oxycodone left today. Yesterday per the nurses count she had 114 oxycodone left which means she used 39 since yesterday but should have used about 18...” A review of Patient 1’s “Client Episode Coordination Notes,” dated 2/8/24, indicated “...During a pharmacy call with [name of pharmacy] pharmacist on 2.8.24 it was noted that the patient had received delivery of 72 days worth of MS Contin ER in a 34 day period. [DPCS] and [name of Nursing Supervisor- NS] performed an audit on the dispense and delivery of MS Contin ER, Oxycodone...discovered that refills were performed early based on the current medication orders...Patient has used about 46 days worth of oxycodone in 37 days without notifying RNCM or hospice of need for increase in medication...[RNCM 2] performed a visit today and did a medication count...Patient currently has...114 tablets of oxycodone, 137 tablets of MS Contin ER...left as of today...” A review of Patient 1’s “Client Episode Coordination Notes,” dated 12/20/23, indicated “...I have concerns over the difficulty this patient and caregivers have in detailing how patient is taking meds and the inconstancy [sic] in med management. Last visit instructions were given both verbally and in writing and caregiver continues to have difficulties in giving appropriate medsications [sic] ...family does not seem to understand the gravity of giving the appropriate meds at the appropriate times - as all these meds have the potential of being abused we are now doing daily pill counts...” A review of Patient 1’s “Visit Note Report,” dated 2/8/24, indicated “...Patient and caregiver report that patient pain has been increasing at this time, instruction provided on utilization of PRN [as needed] medications and to utilize as per MD orders. Patient and caregiver verbalize understanding stating that at times patient is experiencing an increase in pain so they may give a few more pills than prescribed. This was inappropriate and was described as such to patient and caregiver...” A review of Patient 1’s “Visit Note Report,” dated 1/8/24, indicated “...Plan for next visit...Reassess pain management, constipation and narcotic counts for accuracy...” A review of Patient 1’s “Visit Note Report,” dated 12/18/23, indicated “...Extensive teaching done on pain mgt [management] and to follow DR. orders, not to take meds whenever they want, keep log for PRN [as needed] meds. Demonstrated to [FM] how to make log for med count...verbalized understanding...Patient and [FM] is non compliance with all narcotics administration and not using pain meds as directed by MD...Reinforced medication count logs and daily SNV for safety... Daily calls from CM with a photo record of the med counts. Not to exceed pain meds doses as prescribed by MD...” A review of Patient 1’s “Hospice Controlled Substance Agreement,” signed 2/9/23 by FM, indicated “...Because these medications have the chance for abuse and misuse, it is expected these medications are protected and be taken exactly as prescribed, for this reason, this agreement will be put into place...Do not share, sell, or allow others to have access to these medications...These medications have the chance for abuse and misuse. Keep these medications protected, in a safe and secure place...I agree to keep a log of medications I am taking and allow my provider to count the medications as needed upon request...In the event this plan is not effective in safely controlling the medications, additional plans may be put in place such as...Discussion of alternate care settings...Potential for discharge from hospice services...” During an interview on 2/29/24 at 2:11 p.m. with the Nurse Supervisor {NS), NS stated Patient 1 was admitted to HA for cervical cancer and began requesting refills for pain medication earlier than ordered. The NS stated the nurses determined that the medication count in the home did not correspond to what was dispensed. The HA began daily nursing visits for narcotic medication counts. The NS stated after a few weeks the counts were matching so visits went to two to three times week. The NS stated that medication administration in a controlled environment for patient safety, including patient going to skilled nursing facility or care facility, was discussed with patient and family. The family declined. Patient 1 was discharged from services due to concern of diversion of narcotic medications. During an interview on 2/29/24 at 2:22 p/m. with the Director of Patient Care Services (DPCS), the DPCS stated Patient 1 was discharged from hospice services on 2/10/24 for “cause” due to concern with medication diversion. Patient 1 and family declined placement in facility where medication administration would be monitored. Patient 1 received visits two times a week from 12/9/23 to 12/27/23. Medications were reconciled once a week. The DPCS stated that nurses identified discrepancies of medication in the home and began daily visits to perform narcotic counts from 12/27/23 to 1/2/24 and during that time the counts matched and visits were decreased to two times a week on 1/2/24 with narcotic counts to be done at each visit. A different RNCM began visits to Patient 1 on 1/8/24. RNCM 2 reconciled the medications but did not notice the counts did not match. The DPCS stated that during a meeting on 2/8/24 with the hospice pharmacy she was notified of the pharmacy concern that too much medication had been dispensed. From 1/2/24 to 2/5/24, MS Contin 60 mg was filled for a total of 686 tablets. Patient 1 should have taken 306 tablets in that time frame per MD orders. From 1/1/24 to 2/6/24 Oxycodone 10 mg was filled for a total of 948 tablets dispensed. If taking the maximum dosage of 18 tablets per day Patient 1 would have taken 612 tablets per MD order. The DPCS stated, “The medications were reconciled but the new RNCM did not notice the discrepancies.” The DPCS further stated, “Should have been checking every time. Was checking, but not appropriately. Not going back and seeing what was given. [RNCM 2] did not follow the plan in place.” During a telephone interview on 3/5/24 at 9:48 a.m. with RNCM 1, RNCM 1 stated she was Patient 1’s RNCM for the first couple of weeks and family was instructed to keep log on what medications were given and to follow MD orders. Narcotic counts were done. Patient 1 always seemed to be running low, so MD was notified to order more. RNCM 1 stated, initially, family was not logging medications and could not determine what was given, how much or how often. RNCM 1 stated daily visits were done because narcotic counts were off. RNCM 1 stated family was upset about daily visits for medication counts. During a telephone interview on 3/5/24 at 10:06 a.m. with the HA Pharmacist (PHM), the PHM stated that the hospice pharmacy dispensed to Patient 1 from 1/2/24 to 2/5/24 650 pills of MS Contin 60 mg and Patient 1 should have used 306 pills in 34 days if taking 9 pills per day. The hospice pharmacy dispensed to Patient 1 from 1/2/24 to 2/5/24 738 pills of Oxycodone 10 mg and Patient 1 could have used 612 pills in 34 days if taking18 pills per day the maximum PRN dosage. The PHM stated that there should have been 344 MS Contin 60 mg pills and 126 Oxycodone 10 mg pills in the home. PHM stated he contacted the hospice agency and the DPCS was made aware of the issue. The PHM stated the DPCS was concerned and was going to research with the nurse to see if the nurse was aware of discrepancy. The PHM stated, “Could have monitored more closely. Nurses need to do the counts and need to recognize when something is off, if they are using more meds than they need.” During a telephone interview on 3/5/24 at 11:40 a.m. with RNCM 2, RNCM 2 stated he became Patient 1’s RNCM in January 2024. Patient 1 was taking lots of narcotics every day and counts were done at every visit. Family was keeping a log of what was given and the counts were done each time and matched with the log. RNCM 2 stated he did not see any discrepancies. RNCM 2 stated, in mid to late January, “By accident sent more medications, but was never put in log and was flagged by the pharmacy for being sent too soon.” RNCM 2 stated the family would say Patient 1 was running low, count would show there was less than a week left and would refill the medication. RNCM 2 stated he was not able to make every visit and Patient 1 and family would refuse visit if RNCM 2 was not able to make the visit. RNCM 2 stated he did not notice the discrepancy until notified by the DPCS on 2/8/24. RNCM 2 stated, “No, I did not notice the discrepancy before that, unfortunately, and unsure what happened to the pills.” A review of the HA Policy and Procedure (P&P) titled “Medication Management for Hospice,” revised 9/14/21, indicated “...The Hospice monitors the medications dispensed to and used by the patient...The Registered Nurse (RN) Case Manager provides instruction to the patient and/or caregiver on the following...Evaluated the patient and/or caregiver’s ability to safely administer medications...” A review of the HA P&P titled “Medication Administration and Management.” revised 9/28/23, indicated “...The qualifying clinician assesses all the current medications a patient is taking as part of the comprehensive assessment at start of care, resumption of care, recertification of services, and anytime a change or update is made to the medication profile. Assessments include an evaluation to identify any potential adverse effects and drug reactions, including...Noncompliance with drug therapy...As part of the initial assessment at the start of care, and throughout the episode of care, the patient and/or caregivers are assessed for the ability to safely administer medications...As indicated, all controlled substances are to be counted at specific time intervals which could include daily...All reports of missing medication must be reported to and reviewed by the clinical manager. The clinical manager will review the report and ensure that appropriate follow-up interventions are implemented...The qualifying clinician may instruct the patient and/or caregiver to administer selected medications per the physician or allowed practitioners orders...Monitoring activities are part of a collaborative process that may involve the patient, nurse, physician, allowed practitioner, pharmacist and other team members....” A review of the HA P&P titled “Skills: Medication Reconciliation,” not dated, indicated, “...Medication reconciliation is the best tool the hospice nurse can use...to identify discrepancies and reduce harmful medication errors...the hospice nurse must perform a methodic and careful reconciliation of all medications to prevent medication errors...” A review of the HA P&P titled “Comprehensive Drug Regimen Review, Adverse Drug Reactions and Medication Errors Response,” revised 9/11/22, indicated “...To identify and report medication errors any potential adverse effects and drug reactions, including...noncompliance with drug therapy...A Registered Nurse (RN)...reviews all medications that the patient is currently using...and are accountable for evaluation of the following, which includes...Non-compliance with drug therapy...Drug Regimen Review...The review will identify discrepancies,...and noncompliance with drug therapy...””