Hospice of Amador & Calaveras

“Based on interview and record review, the Hospice Agency (HA) failed to ensure the Plan of Care (POC) was followed for five of 19 sampled patients (Patient 3, Patient 10, Patient 11, Patient 17, and Patient 18) when home visits were missed and were not rescheduled within the work week.These failures had the potential to affect patients’ overall health and well-being. A review of Patient 11’s clinical record indicated a POC with SOC of 3/12/25. Patient 11’s diagnoses included dementia (memory issues) and chronic kidney disease. A review of Patient 11’s POC for certification period 3/12/25 through 5/10/25 included the order for hospice aide visits one time a week for the first week and 2 times a week for 8 weeks, starting the week of 3/16/25.A review of Patient 11’s visit calendar, indicated there was one visit made by hospice aide the week of 3/16/25 instead of two visits scheduled. Patient 11’s clinical records did not contain missed visit notes and there were no communication notes explaining why the visits were missed. The clinical record did not contain any notes that the agency attempted to reschedule the visits the same week.In a concurrent interview and record review on 4/1/25, at 4:30 p.m., the DPCS acknowledged that Patient 11’s visits for hospice aide were not completed as ordered the week of 3/16/25. The DPCS was unable to find missed visit note or other documentation to notify Patient 11’s physician of missed hospice aide visit. The DPCS was unable to answer if the agency attempted to reschedule hospice aide visit the same week.During a review of the agency’s policy and procedure (P&P) titled “Missed Visits,” undated, the P&P indicated, “PURPOSE…To ensure that missed visits are documented and does not affect the quality of patient care…POLICY…A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record…PROCEDURE: 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit…4. The clinical supervisor or designee will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits…” 1a. Patient 10 had a SOC date of 1/21/25 and diagnoses included senile degeneration of brain (decline in cognitive function and memory) and dementia (loss of memory and thinking abilities that interfere with daily life).A review of Patient 10’s POC, dated 1/30/25 for the recertification period 1/21/25-4/20/25 indicated, “Skilled…SN [Skilled Nursing]:…2W13W [two times per week for 13 weeks] (01/26-04/20/25)…”During a review of Patient 10’s visit calendar for February 2025 for the recertification period 1/21/25-4/20/25, the calendar indicated two SN visits were scheduled for the week of 2/23/25. The calendar further indicated the SN visit on 2/28/25 was cancelled which indicated only one visit was completed for the week of 2/23/25 instead of two as ordered.During a review of Patient 10’s “Patient Activity” notes, dated 2/28/25, the notes indicated, “RN [registered nurse] writer called and spoke to [Patient 10’s family member]…to confirm planned visit for today. CG [caregiver] reported the pt’s [patient’s] needs are met at this time, denied need for any refills or any questions/concerns, and refused RN visit today…” The notes did not indicate the cancelled visit was rescheduled to a later date.During a concurrent interview and record review on 4/3/25 at 12:22 p.m. with the DPCS, the DPCS confirmed Patient 10 had two planned visits on the week of 2/23/25 and one of them was cancelled. The DPCS stated, “…that was a Friday, it wasn’t rescheduled, expectation is to reschedule and if family didn’t want it, they should document.” The DPCS confirmed there was no documentation of the effort to reschedule the cancelled visit.1b. Patient 17 had a SOC date of 1/17/25 and diagnoses included Nonrheumatic aortic (valve) stenosis (heart valve narrowing or obstruction) and atherosclerotic heart disease (damage or disease in the heart’s major blood vessels).A review of Patient 17’s POC, dated 1/30/25 for the recertification period 1/17/25-4/16/25 indicated, “Skilled…SN [Skilled Nursing]: 2W2W [twice a week for two weeks] (01/17-01/25/25)…”During a review of Patient 17’s visit calendar for January 2025 for the recertification period 1/17/25-4/16/25, the calendar indicated one SN visit was completed for the week of 1/12/25. The calendar further indicated there were two SN visits scheduled on the week of 1/19/25 and the SN visit on 1/21/25 was cancelled which indicated only one visit was completed for the week of 1/19/25 instead of two as ordered.During a review of Patient 17’s “Patient Activity” notes, dated 1/21/25, the notes indicated, “[Patient 17’s family member] reports that she does not want a SN visit this evening. She reports that HHA and MSW [Medical Social Worker] were already there and that [Patient 17] and family want to rest. IDT [interdisciplinary team] updated…” The notes did not indicate the cancelled visit was rescheduled to a later date.During a concurrent interview and record review on 4/2/25 at 4:14 p.m. with the DPCS, the DPCS confirmed Patient 17’s order indicated two visits per week for two weeks. The DPCS confirmed only one visit was scheduled on the first week (week of 1/12/25) and stated, “The admission nurse must have accidentally put two visits on a Friday…it should have been 1W1W [one visit for one week].” The DPCS also confirmed one visit was cancelled for the week of 1/19/25 and stated, “…one visit was cancelled, that’s why there’s only one visit.” The DPCS confirmed the cancelled visits were not rescheduled and there were no attempts done to reschedule the cancelled visit. The DPCS stated, “Expectation is to try to reschedule it.”1c. Patient 18 had a SOC date of 1/31/25 and diagnoses included Multiple sclerosis (causes breakdown of the protective covering of nerves) and neuromuscular dysfunction of bladder (the nerves and muscles involved in bladder control do not work correctly).A review of Patient 18’s “Patient Summary”, for the recertification period 1/31/25-4/30/25, indicated, “AIDE…Effective date 3/9/25…1W for 7W [once per week for seven weeks]…”During a review of Patient 18’s visit calendar for March 2025 for the recertification period 1/31/25-4/30/25, the calendar indicated there was no HHA visits scheduled for the week of 3/9/25. The calendar further indicated there was one cancelled HHA visit for the week of 3/16/25 and one HHA visit was cancelled for the week of 3/23/25. The calendar indicated there were no HHA visits completed for Patient 18.During a review of Patient 18’s “Patient Activity” notes, dated 3/27/25, the notes indicated, “[Patient 18] no longer is accepting HHA visits. CM [clinical manager] notified.” The notes did not indicate the cancelled visits were rescheduled.During a concurrent interview and record review on 4/3/25 at 12:36 p.m. with the DPCS, the DPCS confirmed there were no visits scheduled for Patient 18 for the week of 3/9/25. The DPCS confirmed the cancelled visits on the week of 3/16/25 and 3/23/25, and there was no documentation on the cancelled visits and stated, “For the cancelled visit on 3/16/25, she went there, and patient refused, no rescheduling done…Expectation was the nurse should have reassessed having aide visits.” A review of Patient 3’s clinical record indicated a POC with a start of care date (SOC) of 10/14/24 for certification period 10/14/24 through 1/11/25 and a second certification period from 1/12/25 to 4/11/25. Patient 3’s diagnoses included secondary malignant neoplasm of brain (abnormal growth of cells started somewhere in the body and has spread to the brain) and ataxia (lack of muscle coordination and control). The hospice aide orders indicated frequency of 2 times a week for 13 weeks from 10/14/24 through 1/1/25 and 2 times a week for 13 weeks from 1/12/25 through 4/11/25.A review of Patient 3’s home visit schedule from October 2024 to April 2025 indicated 2 missed visits from the hospice aide on 11/28/24 and 2/17/25. In a concurrent interview and record review on 4/3/25 starting at 1:18 p.m., the Director of Patient Care Services (DPCS) confirmed the following:-Patient 3’s hospice aide visit on 11/28/24 was cancelled and there was no documentation on why it was cancelled and if the missed visit was reported to the Registered Nurse Case Manager (RNCM) or DPCS. -Patient 3’s hospice aide visit on 2/17/25 was cancelled and there was no documented evidence the visit was rescheduled. The DPCS further confirmed the hospice aide visit was done once instead of twice for this week.”

“Based on observation, interview, and record review, the agency failed to reconcile and update the Plan of Care (POC) for one of 19 sampled patients (Patient 1) to accurately reflect the patent’s medication list.This failure resulted in current changes of medications not communicated in a timely manner among the care team members. A review of Patient 1’s clinical record indicated admission to the agency in late 2024 with a primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).A review of Patient 1’s ‘Patient Summary’ which contained patient’s POC for the certification period from 3/16/25 to 6/16/25 indicated the skilled nursing (SN) was to visit the patient three times a week for ongoing comprehensive assessment.On 4/2/25, at 10 a.m., a joint home visit with Licensed Nurse (LN 2) was conducted at the assisted living facility where Patient 1 resided. Facility Staff (FS 1) explained that the facility had a designated ‘Hospice Binder’ for communication with agency which contained physician orders, POC, and short visit notes for every visit. A review of the skilled nursing (SN) note dated 3/31/25, indicated, “Wound care done. No new orders, no change in medications.” A review of 3/28/25 SN visit note, indicated, “No medications change. Wound care [sic], looks better.” FS 1 printed and provided a three pages document titled, “PHYSICIAN’S ORDERS; Current Orders as 2-Apr-2025 12:00 AM” and explained that this was a list of medications that Patient 1 was currently taking. The list of medications contained a note on a last page, “Please, make sure our medications match yours.” Upon reviewing the document and comparing it with agency’s medications profile, absent from the profile was Cephalexin 500 milligram (antibiotic), with the order date of 12/24/24.During an interview with FS 1 on 4/2/25, at 10:20 a.m., FS 1 stated she administered Patient 1’s medications. FS 1 explained that Patient 1 no longer received Cephalexin, and added, “He took it in the past, stopped a month or two ago.”During a continued observation and interview on 4/2/25, at approximately 11:10 a.m., LN 2 was observed providing wound care to Patient 1’s right buttock and applying metronidazole powder (medications to treat infections). The medication was not listed as active on Patient 1’s POC, medication profile, and medications list provided by the FS 1. LN 2 reviewed the metronidazole’s label and stated it was ordered on 3/18/25. LN 2 explained that apparently there was a physician order placed on 3/18/25, otherwise the pharmacy would not dispense the medication without physician’s order. LN 2 stated that metronidazole powder was on his wound care treatment list but was unable to explain why the metronidazole powder was not on patient’s medication profile and POC.During a follow up interview with FS 1 on 4/2/25, at 12:30 p.m., FS 1 explained that one of the nurses brought metronidazole powder to the facility and were using it each time the wound care was done. FS 1 stated, “We were never provided the order …we need the order.” FS 1 requested LN 2 to bring a physician’s order for metronidazole powder so the facility will have it on file.During an interview and record review on 4/2/25 at 12:45 p.m., with the Executive Director (ED) and Director of Patient Care Services (DPCS), Patient 1’s clinical record was reviewed. The DPCS and ED confirmed that Patient 1’s POC contained all current medications the patient was taking. The DPCS and ED were not able to find an active physician’s order for Cephalexin. The DPCS explained that the medication had been discontinued a while ago and was unable to explain why patient’s medication list and POC were not updated when the medication was discontinued. During a further interview and record review on 4/2/25, at 12:45 p.m., the DPCS and ED acknowledged that metronidazole powder was not included in Patient 1’s POC, medication profile, and medication list provided by assisted living staff. The DPCS provided physician order dated 3/21/25 for right buttock wound care using metronidazole powder which was located in paper chart and stated it was not transcribed into the patient’s electronic record. A review of SN visit note dated 3/18/25, at 11:10 a.m., indicated, “Visit to provide wound care to right buttock abscess/wound. Moderate amount of …drainage noted, with foul odor… [Doctor’s name] called…discussed wound and foul odor. No new orders for antibiotics received, though he did order Metronidazole powder to apply during wound care.” A review of nursing visits notes dated 3/20, 3/21, 3/22, 3/24, 3/26, 3/28, and 3/31/25 contained wound treatment notes and indicated that metronidazole powder was applied to the wound during wound care.During a follow up interview and record review on 4/2/25, at 4:55 p.m., the DPCS acknowledged that nurses were using metronidazole powder starting 3/18/25 and the order was entered on 3/21/25. The DPCS and ED acknowledged that Patient 1’s POC and medication profile were not accurate. The DPCS stated the agency interdisciplinary team was expected to update POC with every change of medications and that medication list was updated to contain all active medications.A review of the agency’s policy titled, “Coordination of Care,” with the revision date of 11/23, indicated, “Purpose: To ensure the coordination of services for each patient…Hospice will utilize a case management system to guide an interdisciplinary team to provide comprehensive, coordinated health care to patients…The interdisciplinary team…will conduct assessments, develop and update the plan of care…a minimum of every 15 calendar days…Hospice… will communicate changes in a timely manner…Written evidence of care coordination will be found in the plan of care.” A review of the agency’s policy titled “Medication Profile,” with the revision date of 11/23, indicated, “Patients receiving medications…will have a current, accurate medication profile…The medication profiles will be updated for each change to reflect current medications.””

“Based on interview and record review, the agency failed to ensure information were shared between all disciplines providing care and services for 1 of 19 sampled patients (Patient 8) when there was no documented evidence that Patient 8’s death was pronounced by the physician, and the physician was not notified by the Licensed Vocational Nurse (LVN) upon Patient 8’s death.This failure had the potential to result in delays in communication about the circumstances of Patient 8’s death. During a review of Patient 8’s Plan of Care (POC), the POC indicated Patient 8 had a Start of Care (SOC) of 1/16/25 with diagnoses that included neurocognitive disorder with Lewy bodies (a progressive brain disorder characterized by abnormal protein deposits that disrupt brain function, leading to cognitive decline, movement issues, and behavioral changes).During a review of Patient 8’s document “Visit Details,” dated 1/25/25, the document indicated Patient 8 died on 1/25/25 and the death visit was provided by Licensed Nurse 1 (LN 1). The document did not indicate that the physician was notified of Patient 8’s death. The document also did not indicate that Patient 8’s death was pronounced by the physician.During an interview on 4/3/25 at 12:45 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated, “…if LVN is at the death, they call the doctor, give assessment, and doctor pronounces death.” The DPCS confirmed she was not able to find documentation that the physician was notified of Patient 8’s death.During a review of the agency’s policy and procedure (P&P) titled “DEATH AT HOME,” undated, the P&P indicated, “2. The nurse will assist the family/caregiver at the home with notification of the attending physician…4. The nurse will notify the attending physician of the patient’s death. It will be the attending physician’s responsibility to pronounce death…The physician will routinely accept hospice’s description or report of the absence of vital signs when assuming this responsibility.””

“Based on observation, interview, and record review, the agency failed to ensure the Plan of Care (POC) contained documentation that one of 19 sampled patients (Patient 1) had a chair and bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff).This failure resulted in clinical information not being recorded to ensure the patient received continuity of care from all disciplines. A review of Patient 1’s clinical record indicated admission to the agency in late 2024 with a primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).A review of Patient 1’s ‘Patient Summary’ which contained patient’s POC for the certification period from 3/16/25 to 6/16/25 indicated the skilled nursing (SN) was to visit the patient three times a week for ongoing comprehensive assessment. The Patient Summary and POC did not indicate that Patient 1 had bed pad alarm.On 4/2/25, at 10 a.m., a joint home visit with Licensed Nurse (LN 2) was conducted at the assisted living facility where Patient 1 resided. Patient 1 was observed sitting in a wheelchair in a lobby dressed in street clothes. A tab alarm was observed attached to the left top part of the wheelchair.At approximately 11:10 a.m., Patient 1 was brought to his room and LN 2 assisted facility staff (FS 2) to transfer the patient to the bed. After Patient 1 was positioned in bed, FS 2 transferred bed pad alarm and placed it on the bed next to Patient 1. FS 2 stated Patient 1 was identified at high risk for falls and one of the interventions to alert the staff when he was attempting to get up, was to place bed pad alarm on his bed and wheelchair. FS 2 stated Patient 1 had been on bed pad alarm for a while. LN 2 was unable to explain when the fall preventative intervention with bed pad alarm was implemented and why it was not reflected on the patient’s POC.During an interview and record review on 4/2/25 at 12:45 p.m., with the Executive Director (ED) and Director of Patient Care Services (DPCS), Patient 1’s clinical record was reviewed. The ED stated that in order for Patient 1 to have a bed pad alarm, agency physician should have written an order, and the order had to be communicated to the assisted living staff where the patient resided. The ED stated Patient 1’s POC should reflect the bed pad alarm and validated that the POC did not indicate the bed pad alarm had been used. The DPCS and ED reviewed Patient 1’s clinical record from the start of care until present and were not able to find a physician order for bed pad alarm. The ED and DPCS were unable to find any documentation in nursing visit notes that the bed pad alarm was utilized as one of the interventions for Patient 1.A review of the agency’s policy titled, “Coordination of Care,” with the revision date of 11/23, indicated, “Purpose: To ensure the coordination of services for each patient…Hospice will utilize a case management system to guide an interdisciplinary team [IDT] to provide comprehensive, coordinated health care to patients…The type and scope of services …will be based upon comprehensive and ongoing assessments regarding the needs of the patient…It will be responsibility of the Case Manager to facilitate communication about changes in the patient’s status… Hospice… will communicate changes in a timely manner.””

“Based on interview and record review, the Hospice Agency (HA) failed to provide care consistent with patient and family wishes for one of three sampled patients (Patient 1), when Patient 1 received double the amount of opioid (narcotic drugs that produce morphine-like effects, used for pain relief) that family requested. This failure had the potential to result in Patient 1 experiencing adverse effects and caused Patient 1’s family to experience distress and anxiety. Findings: A review of Patient 1’s “Plan of Care (POC),” for certification period 5/9/23 to 8/6/23, indicated Patient 1 had a Start of Care date with the HA on 5/9/23 for diagnoses including congestive heart failure (heart does not pump blood as well as it should) and chronic kidney disease (kidneys cannot filter blood as well as they should). Patient 1’s POC indicated orders for 5/9/23: “HYDROcodone [pain medication containing opioid] 10 mg [milligrams]- acetaminophen [pain and fever reducer] 325 mg [brand name Norco 10/325] ...Schedule: [1 tab [tablet]...]; three times daily; ..ROUTINE...Reason: pain...” “morphine concentrate [morphine sulfate-pain medication containing the opioid morphine] 100 mg / 5 ml [milliliters] (20 mg/ml) oral solution...Schedule: [0.25 ml...PRN [as needed]]; every 3hr [hour]...Reason: pain or SOB [Shortness of Breath] ...” A review of Patient 1’s “Physician CII [Schedule II controlled drugs due to potential abuse] Orders,” dated 6/29/23, indicated “...Clinical Findings/Problems/Request for Orders...Pain...Telephone/Verbal//Written Orders by Physican...Norco 10/325 mg tablet, take 1.5 tablets by mouth 3 times daily...” A review of Patient 1’s “Physican CII Orders,” dated 7/17/23, “...Clinical Findings/Problems/Request for Orders...Pain...Telephone/Verbal//Written Orders by Physican...MS Contin [brand name for pain medication containing the opioid morphine in a controlled release pill formulation] 30 mg tablet, take 1 tablet by mouth every 12 hours for pain, to be taken with MS Contin 15 mg tablet equaling 45 mg ...Dispense 30 tablets...” A review of Patient 1’s “Physican CII Orders,” dated 7/17/23, “...Clinical Findings/Problems/Request for Orders...Pain...Telephone/Verbal//Written Orders by Physican...MS Contin 15 mg tablet, take 1 tablet by mouth every 12 hours for pain, to be taken with MS Contin 30 mg tablet equaling 45 mg ...Dispense 30 tablets...” A review of Patient 1’s “Patient/Caregiver Instructions,” dated 7/18/23, indicated “...Discontinue Norco 10/325 mg tablet...” A review of Patient 1’s medication administration record from Assisted Living Facility, indicated administration of one dose of MS Contin on 7/18/23, two doses on 7/19/23 and 7/20/23, and one dose on 7/21/23. A review of Patient 1’s “Care Conference Record,” dated 6/21/23, indicated “...Purpose of Meeting: review Plan of Care...Discussion/Conclusion: ...Please offer morphine by name...Please contact family prior to administering new medications...” A review of Patient 1’s “Care Conference Record,” dated 7/13/23, indicated “...Purpose of Meeting: review Plan of Care...Discussion/Conclusion: ...Family to discuss use of MS Contin instead of Norco & notify Hospice of outcome. Family has decided to switch to MS Contin ... [name of HA] to notify [Family Member (FM)] when MS Contin is ordered...” A review of Patient 1’s “HN Visit #17” note, dated 7/7/23, indicated “...Patient Pain Goal...teaching on Morphine Sulfate use for pain management. was afraid that by using this medication that she would die...” A review of Patient 1’s “HN Visit #20” note, dated 7/13/23, indicated “...Visit Narrative Summary...pain controlled with Norco 10/325mg 1 1/2 tabs times a day. will change to MSContin 30 mg d/t [due to] swallowing difficulties...Addendum [charted 7/27/23]- MS Contin dose will be 45mg bid [two times a day]. (not Mscontin 30mg) ...” A review of Patient 1’s “HN Visit #22” note, dated 7/17/23, indicated “...Current Pain Status - Level: 2/10 Scale Used: numbers [numerical scale used to rate pain on scale of 0 to 10, mild to severe] ...Level After Medications: 2/10 Scale Used: numbers...Visit Narrative Summary: ...is satisfied with current pain regiment of Norco 10/325mg 1 1/2 tabs 3 times a day. MS Contin 45 mg BID to arrive to facility on 7/18/23...” A review of Patient 1’s “HN Visit #24” note, dated 7/21/23, indicated “...change from Norco to MS Contin was d/t swallowing difficulty and decrease PO [oral] intake / GI [Gastrointestinal] upset. Was taking Norco 10/325 1 1/2 tabs three times a day. Medication change was discussed in IDT [Interdisciplinary Team] on 7/13/23. Then followed up with family on 7/13/23 at a care conference at [Assisted Living Facility} that afternoon ...Family agreeable to medication change from Norco to MS Contin...” A review of Patient 1’s “Patient Activity” note, dated 7/13/23, indicated “IDT...Increase of Norco 10/325 1/1/2 tabs 3 times a day for more effective pain control...” During a telephone interview on 2/14/24 at 12:38 p.m. with Patient 1’s FM, the FM stated Patient 1 was admitted to the HA for congestive heart failure. Patient 1’s FM stated Patient 1 was taking 1 1/2 tablets of Norco 10/325 three times a day, total of 4 1/2 pills a day. FM stated this was 45 milligrams of the opioid hydrocodone. The Director of Patient Care Services (DPCS) talked to family about changing to MS Contin because it would only be two pills a day, it was longer acting, and were smaller pills that were easier to swallow. The FM stated she notified the HA that she wanted the MS Contin dose to be opioid equivalent (equal potency to morphine-one milligram of hydrocodone is equivalent to one milligram of morphine, per US Department of Health and Human Services, “Opioid Oral Morphine Milligrams Equivalent (MME) Conversion Factors, 8/25/20) to the Norco 10/325 dosage of 45 milligrams that she had been receiving. The FM stated the MS Contin was started on 7/18/23. The FM stated that Patient 1 had immediate reaction including increased grogginess, difficulty getting words out, fidgeting, and fingers turning blue. The FM stated Patient 1 died on 7/22/23. The FM stated Patient 1 was receiving 2 doses of 2 pills per day of 45 milligrams for a total of 90 milligrams opioid per day, which was twice the dose when taking Norco 10/325. The FM stated Patient 1’s pain medication did not need to be increased. The FM stated the DPCS called the day after Patient 1 expired and stated that a clerical error had been made and Patient 1 received a double dose of opioid. During an interview on 2/15/24 at 11:01 a.m. with the Director of Patient Clinical Services (DPCS), the DPCS stated that Patent 1’s family was fully aware of medications Patient 1 was receiving. The DPCS stated that during Patient 1’s initial care conference on 6/21/23, the family expressed that Patient 1 was not comfortable with morphine. The DPCS stated that FM was uneasy about changing to MS Contin. The DPCS stated, “I mistakenly, not looking at her chart, told [FM], we had mistakenly doubled the dose.” During a subsequent interview on 2/15/24 at 1:00 p.m. with the DPCS, the DPCS stated an investigation was done after Patient 1 expired to determine if Patient 1 had received incorrect dose of opioids. The DPCS called the FM the next day and stated thought there had been a clerical error and Patient 1 may have received extra doses of MS Contin than what the HMD ordered. The DPCS stated, “Did not do my due diligence before calling [FM].” The DPCS stated that the dosages that Patient 1 received of MS Contin were correct per the HMD orders. The DPCS acknowledged there was no documentation in either the care conference notes or IDT notes that family had agreed to increase dose of opioids. During an interview on 2/15/24 at 12:39 p.m. with the Nursing Supervisor (NS), the NS stated that Patient 1’s pain medication was increased for pain control from 45 milligrams of hydrocodone per day to 90 milligrams of morphine per day by the HMD (hospice medical director). The NS stated they were made aware by the family during the care conference that family wanted equivalent dose of opioids. Reviewed the “HN Visit #20” note, dated 7/13/23, that indicated swallowing difficulties with the size of the Norco pills. The NS acknowledged that the Visit Notes did not reflect that medication was changed due to need for pain control. The NS stated the nurse Case Manager did not question doubling the dose, but it was the Case Manager (CM)’s position to contact HMD to question doubling dose of opioids. During an interview on 2/15/24 at 1:49 p.m. with Registered Nurse Case Manager (RNCM), RNCM stated Patient 1 did not eat well, had edema (swelling caused by fluid in the tissues), respiratory problems, sores, and pain in legs, shoulder, and during wound care. RNCM stated Patient 1’s pain was managed by Norco 10/325 1 tablet 3 times a day and then was increased to 1 1/2 tablets 3 times a day. The RNCM also stated Patient 1 received a dose of morphine sulfate 5 milligrams prior to wound care three times a week. RNCM stated Patient 1’s pain medication was changed to MS Contin due to swallowing difficulties. RNCM acknowledged that the order for MS Contin contained 90 milligrams of opioid, double the opioid dose of the prior pain medication Norco 10/325. The RNCM stated, “Didn’t think that was a big change in the dose.” Reviewed with RNCM “HN Visit #22,” dated 7/17/23, that indicated, “is satisfied with current pain regiment of Norco 10/325mg 1 1/2 tabs 3 times a day.” RNCM stated the family did not know that Patient 1 needed more pain medication, because patient did not let family know. RNCM stated the family had notified the HA that they wanted an equivalent dose of opioid for MS Contin. The RNCM stated she spoke with another family member in the parking lot after care conference on 7/13/23 and this family member agreed to increasing the pain medication, but RNCM acknowledged she did not document conversation. RNCM stated if she has questions about equivalent dosages will contact the pharmacy. When asked if she questioned the MS Contin dosage, RNCM stated, “Did not question this medication dosage.” During an interview on 2/15/24 at 2:41 p.m. with Hospice Medical Director (HMD), HMD stated he had visited Patient 1 at Assisted Living Facility one or two times early in her admission. HMD stated Patient 1 was taking Norco 10/325, 1 1/2 pills, 3 times a day for a total of 45 milligrams of opioid equivalent then MS Contin, 45 milligrams, 2 times a day for 90 milligrams of opioid equivalent was ordered for pain that was not controlled. The HMD stated he was not aware that family had requested an equivalent opioid dose of MS Contin to Norco 10/325. HMD stated, “If I knew they wanted equivalent dose would have started with 60 milligrams a day, split into two 30 milligrams pills.” HMD further stated, “Almost always try to go with family’ s wishes.” A review of the HA Policy and Procedure (P&P) titled “Pain Management,” revised 11/18, indicated “...The patient’s right to pain management is respected and supported. Hospice clinicians plan, support, and coordinate activities and resources to ensure that the pain of all patients is recognized and addressed appropriately...Clinicians will consider the patient’s personal, cultural, spiritual, and ethnic beliefs when communicating that pain management is an important part of care ... [HA} will educate patients and families, when appropriate, about their roles in managing pain and the potential limitations and side effects of pain treatment...” A review of the HA P&P titled “Verification of Physician Orders,” revised 11/20, indicated “...an order or prescription will be verified when...There is a question or discrepancy in the order or prescription...” A review of the HA P&P titled “Administration and Documentation of Medications,” revised 11/23, indicated “...As part of the assessment process, a drug history will be taken and a comparison made between the physician’s...orders and the current medication the patient is taking. Any discrepancies or contradictions will be reported to the physician for resolution...” A review of the HA P& P titled “Identification, Prevention, and Treatment of Secondary Symptoms,” revised 11/18, indicated “...Supporting and educating the patient and family/caregiver is an essential part of symptom control. Care will directed to optimize the patient’s comfort and dignity through appropriate treatment of secondary symptoms, as well as through aggressively managing these symptoms...Interdisciplinary group members will report to the Case Manager symptoms they may observe that are changes or are new from the patient’s initial assessment...” A review of a website from the US Dept of Health & Human Services at https://www.hhs.gov, dated 8/25/20, indicated “Opioid Oral Morphine Equivalent (MME) Conversion Factors...Type of Opioid (strength units)...Hydrocodone (mg)...MME Conversion Factor 1...””