Maxcare Hospice

“Based on interview, record review, and hospice P&P review, the hospice failed to include all the current medication side effects and actual or potential drug interactions in the comprehensive assessments and ensure the medication profile was reviewed and updated to reflect the current medications including the specific parameters for its use for two of two sampled patients (Patients 1 and 2). This failure had the potential for patients to not receive the appropriate care and necessary services and negatively affect the patients’ well-being. Findings: 1. Review of Patient 1’s closed clinical record was initiated on 4/30/25. The clinical record showed the SOC was 6/10/24. The patient was certified for hospice services during the certification period from 6/10/24 to 8/30/24 and 8/31/24 to 11/28/24. The patient revoked hospice service on 9/15/24.Review of the Current Treatment/Medication/DME list, showed the medication included morphine sulfate (opioid) 10 mg 0.5 ml SL Q2H PRN for moderate pain and or respiratory distress and 20 mg 1ml SL Q2H PRN for severe pain and or respiratory distress. The medication list also includes lorazepam (antianxiety) 1 mg one tablet PO Q4H PRN for anxiety manifested by restlessness and agitation. According to lorazepam’s prescribing information, the concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death.Review of the POC/IDG dated 6/12, 6/26, 7/10, 7/24, 8/7, 8/21, 8/28, 9/4 and 9/18/24, showed a care plan for pain and respiratory issues. The interventions included instruct patient/PCG regarding new medication/treatment order and side effects.However, there was no documented evidence the POC/IDG identified the potential side effects or drug interactions between the lorazepam and morphine sulfate to address the patients pain and respiratory issues.In addition, review of the POC Summary failed to show documented evidence the IDG identified the potential drug interactions specific for the use of lorazepam and morphine sulfate medications.On 5/1/25 at 1118 hours, an interview and concurrent closed clinical record review was conducted with the RN 1. The RN 1 was asked if they needed to document the potential side effects or interactions of morphine and lorazepam to address pain and respiratory issues. The RN 1 replied, yes, it should have been discussed in the POC/IDG. The RN 1 was informed and acknowledged the findings. On 5/1/25 at 1436 hours, the findings were shared with the DPCS/Administrator Designee. The DPCS/Administrator Designee reviewed the clinical record and acknowledged the findings. 2.a. Review of the agency’s P&P titled Medication Profile revised 4/2017, showed a drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with addition of new medication. The review will identify: effectiveness, actual or potential side-effects, , actual and potential drug interactions, duplicate drug therapy, and changes in the patient’s condition that contraindicates continued administration of the medication.Review of Patient 2’s closed clinical record was initiated on 4/30/25. The closed clinical record showed the SOC was 4/24/24. The patient was certified of hospice services during the certification periods from 4/24/24 to 7/22/24 and 7/23/24 to 10/20/24. The patient was discharged from the hospice on 8/10/24.The POC Summary dated 4/30/24, showed the patient’s medication included morphine sulfate (opioid pain medication) 20 mg/ml give 10 mg (0.5 ml) sublingually every two hours as needed for moderate pain and/or respiration distress, included morphine sulfate 20 mg/ml give 20 mg (1 ml) sublingually every two hours as needed for moderate pain and/or respiration distress, and lorazepam (antianxiety drug) 1 mg one tablet by mouth every four hours as needed for anxiety manifested by restlessness and agitation.According to lorazepam’s prescribing information, the concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death*Further review of the POC Summary showed there was no documented evidence the IDG identified the potential drug interactions between the lorazepam and morphine sulfate medications.On 5/1/25 at 1058 hours, an interview and concurrent closed clinical record review was conducted with RN 1. RN 1 was informed and verified the above findings. b. The physician’s order dated 4/24/24, showed to administer the patient Jardiance (helps lower the blood sugar level in the blood) 10 mg one tablet by mouth once in the morning. Hold if blood sugar level is less than 100 mg/dL. The family will do blood test at home and as needed. They will report to hospice staff for abnormal results.*However, further review of the physician’s orders showed no documented evidence to indicate parameters for abnormal high levels of blood sugar.On 5/1/25 at 1103 hours, an interview and concurrent closed clinical record review was conducted with RN 1. RN 1 was asked what she considered abnormal results for blood sugar levels. RN 1 stated abnormal blood sugar levels are for less than 70 mg/dL or greater than 110 mg/dL. RN 1 stated the instruction for Jardiance’s parameters for abnormal blood sugar levels was incomplete. RN 1 was informed and acknowledged the above finding.”

“Based on interview, record review, and hospice P&P review, the hospice failed to ensure the individualized care plans were developed for two of two sampled patients (Patients 1 and 2). This failure had the potential to cause inconsistent delivery of care which could result in the decline or lack of improvement of the patients’ health conditions. Findings: 2. Review of the agency’s P&P titled Plan of Care revised 4/2017, showed the plan of care will identify the patient’s needs and services to meet those needs, including the management of plan and discomfort and symptom relief. It must state in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals, and outcome achievement. The written plan of care will contain, but not limited to safety measures to protect against infection or communicable disease.Review of Patient 2’s closed clinical record was initiated on 4/30/25. The closed clinical record showed the SOC was 4/24/24. The patient was certified of hospice services during the certification periods from 4/24/24 to 7/22/24 and 7/23/24 to 10/20/24.The SN notes dated 6/2/24 for an on call triage, showed the patient’s family member reported the patient slid off from the wheelchair to the floor. The patient was noted to sustain a small abrasion and bruises to right eye lid.The SN notes dated 6/4/24, showed the patient had big bruises to both eyes status post fall three days ago.Review of the POC/IDG dated 6/5/24, showed a nursing notes which state per the patient’s family member the patient fell on 6/1/24.*However, there was no documented evidence showing an individualized POC was developed to address the patient’s episode of fall and bruises on both eyes.On 5/1/25 at 1100 hours, an interview and concurrent closed clinical record review was conducted with RN 1. RN 1 was informed and verified the above finding. RN 1 stated she should had included a care plan for safety and skin integrity to address the fall and eye bruises.On 5/1/25 at 1450 hours, an interview and concurrent closed clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee was informed and acknowledged the above finding. 1. Review of Patient 1’s closed clinical record was initiated on 4/30/25. The clinical record showed the SOC was 6/10/24. The patient was certified for hospice services during the certification period from 6/10/24 to 8/30/24 and 8/31/24 to 11/28/24. The patient revoked hospice service on 9/15/24.Review of the Communication Log dated 8/5/24 at 0854 hours, showed the PCG reported patient was COVID positive.Review of the SN notes dated 8/7/24 on the section of narrative showed, the patient got COVID positive on 8/3/24, in isolation room.Review of the POC/IDG dated 8/7/24 on the section of IDG Discussion/Updated Comprehensive Assessment Review, showed the PCG reported patient was COVID positive.However, the IDG failed to show documented evidence of an individualized care plan was developed to address the patients COVID positive results. On 5/1/25 at 1036 hours, an interview and concurrent closed clinical record review was conducted with the RN 1. The RN 1 was asked if a care plan was developed for the report of patients COVID positive result. The RN 1 reviewed the closed clinical record and replied no. The RN 1 was informed and acknowledged the finding. On 5/1/25 at 1436 hours, the findings were shared with the DPCS/Administrator Designee. The DPCS/Administrator Designee reviewed the closed clinical record and acknowledged the findings.”

“Based on interview, record review, and hospice P&P review, the hospice failed to ensure the POCs included the measurable outcomes for two of two sampled patients (Patients 1 and 2). This failure had the potential for POCs to not be evaluated and provide the appropriate care and services to the patients. Findings: The review of the hospice’s P&P titled The Plan of Care revised 4/2017 showed the procedure includes the written plan of care may contain but will not be limited to individualized interventions to assist with end-of-life care and statement of treatment goals that are measurable. 1. Review of Patient 1’s closed clinical record was initiated on 4/30/25. The clinical record showed the SOC was 6/10/24. The patient was certified for hospice services during the certification period from 6/10/24 to 8/30/24 and 8/31/24 to 11/28/24. The patient revoked hospice service on 9/15/24.The POC/IDG Review dated 9/4 and 9/18/24, showed the patient’s identified problems with the established goal and interventions. The POC failed to include a measurable outcomes for the patient’s identified problems. The POC showed the following problems and goals:- for Endocrine: issues with NIDDM. the goal was for blood sugar management for patient comfort. The interventions included to monitor/assess effectiveness of current and new medication/treatment.- for Gastrointestinal: potential for altered bowel elimination related to poor intake, anorexia with severe dysphagia and constipation. The goal included patient/family/PCG will verbalize having elimination needs met at an acceptable level.- for Respiratory: potential for altered respiratory status related to currently hospitalized with aspiration pneumonia and oxygen therapy. The goal was to have an optimum level of oxygen.In addition, the POC/IDG Review dated 6/12, 6/26, 7/10, 7/24, 8/7, 8/21 and 8/28/24, showed the patient’s identified problems with the established goal and interventions. The POC failed to include a measurable outcomes for the patient’s identified problems. The POC showed the following problems and goals:- for Endocrine: issues with NIDDM. the goal was for blood sugar management for patient comfort. The interventions included to monitor/assess effectiveness of current and new medication/treatment.- for Gastrointestinal: potential for altered bowel elimination related to poor intake, anorexia with severe dysphagia and constipation. The goal included patient/family/PCG will verbalize having elimination needs met at an acceptable level.- for Respiratory: potential for altered respiratory status related to currently hospitalized with aspiration pneumonia and oxygen therapy. The goal was to have an optimum level of oxygen.However, the POC failed to show the measurable levels/parameters of the patient’s blood sugar comfort level, acceptable level of elimination and optimum level of oxygen.On 5/1/25 at 1118 hours, an interview and concurrent closed clinical record review was conducted with the RN 1. The RN 1 was asked if the goals were measurable. The RN 1 reviewed the closed clinical record and replied no. The RN 1 was informed and acknowledged the findings. On 5/1/25 at 1436 hours, findings were shared with the DPCS/Administrator Designee. The DPCS/Administrator Designee reviewed the closed clinical record and acknowledged the findings. 2. Review of Patient 2’s closed clinical record was initiated on 4/30/25. The closed clinical record showed the SOC was 4/24/24. The patient was certified of hospice services during the certification periods from 4/24/24 to 7/22/24 and 7/23/24 to 10/20/24. The patient was discharged from the hospice on 8/10/24.Review of the POC/IDG dated 5/1, 5/8, 5/22, 6/5, 6/19, 7/3, 7/17, and 7/31/24, showed the patient’s identified problems with the established goal and interventions. The POC failed to include a measurable outcome for the patient’s identified problems. The POC showed the following problems and goals:- For endocrine: issues with NIDDM, the goal was for blood sugar management for patient comfort. The interventions included to monitor/assess effectiveness of current and new medication/treatment.- For respiratory: issue with potential for altered respiratory status related to currently hospitalized with aspiration pneumonia and oxygen therapy. The goal was to have an optimum level of oxygen. The intervention included to check oxygen saturation as needed during SN visits.On 5/1/25 at 1110 hours, an interview and concurrent closed clinical record review was conducted with RN 1. The RN was asked if the care plan problems addressing endocrine and respiratory goals were measurable. RN 1 stated “no.” RN 1 further stated she should have revised the care plans to include specific ranges of blood sugar levels or oxygen saturation levels that were acceptable to the patient. RN 1 was informed and verified the above findings. On 5/1/25 at 1450 hours, an interview and concurrent closed clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee was informed and acknowledged the above finding.”

“Based on interview, record review, and agency P&P review, the hospice failed to ensure the IDG had revised the patients’ POCs as frequently as the patient’s condition required for two of two sampled patients (Patients 1 and 2). This failure had the potential for not providing appropriate, consistent, and quality care to the patients.Findings: 2.a. Review of the agency’s P&P titled Interdisciplinary Group Meeting revised 4/2017, showed the patient’s plan of care will be updated no less than every 15 days or more frequently if the patient’s condition requires; social, cultural, and physical environments presenting obstacles to effective intervention; integration of alternative therapies into medical regime to assist in effectiveness; and any special needs of the patient.Review of Patient 2’s closed clinical record was initiated on 4/30/25. The closed clinical record showed the SOC was 4/24/24. The patient was certified of hospice services during the certification periods from 4/24/24 to 7/22/24 and 7/23/24 to 10/20/24. The patient was discharged from the hospice on 8/10/24.The physician’s order dated 4/24/24, showed the patient was on a puree diet as tolerated.Review of the POC/IDG dated 5/1, 5/8, 5/22, 6/5, 6/19, 7/3, 7/17, and 7/31/24, showed under the gastrointestinal current goal was to be able to tolerate present tube feeding order.*However, the patient did not have a physician’s order for tube feeding. In addition, there was no documented evidence that the care plan current goal for gastrointestinal was revised as frequently as the patient’s condition required when the patient did not have tube feeding order. The care plan current goal addressing the patient’s tube feeding had a start date of 5/1/24.b. Review of SN notes dated 6/4, 6/11, 6/25, and 7/3/24, showed the patient’s lung sounds were mildly diminished, had increased shortness of breath with mild exertion, and required oxygen therapy at 2-3 L/min via nasal cannula to maintain an oxygen saturation of greater than 90%.Review of the physician’s order dated 4/24/24, showed to administer oxygen inhalation at 2 L/min via nasal cannula as needed and may titrate up to 5 L/min for severe shortness of breath and/or to maintain an oxygen saturation of 90% and above. SN may check the oxygen saturation every visit as needed.Review of the POC/IDG dated 6/5, 6/19, and 7/3/24, showed a care plan problem for respiratory with intervention of, “Oxygen as ordered via _ at _L/min.”However, there was no documented evidence that the care plan problem for respiratory was revised under the intervention of oxygen therapy to specify the physician’s order for oxygen administration as frequently as the patient’s condition when the patient had episodes of shortness of breath. The care plan problem addressing the patient potential for altered respiratory status related to high risk of aspiration and pneumonia had a start date of 5/1/24.On 5/1/25 at 1110 hours, an interview and concurrent closed clinical record review was conducted with RN 1. RN 1 was informed and verified the above findings. 1. Review of Patient 1’s closed clinical record was initiated on 4/30/25. The clinical record showed the SOC was 6/10/24. The patient was certified for hospice services during the certification period from 6/10/24 to 8/30/24 and 8/31/24 to 11/28/24. The patient revoked hospice service on 9/15/24.The POC/IDG Review dated 6/12, 6/26, 7/10, 7/24, 8/7, 8/21, 8/28, 9/4 and 9/18/24, showed the patient’s identified problems with the established goal and interventions. The POC/ IDG included the following:-Environment/Safety: The goal included no fall episode and will remain free from injury. The intervention showed a referral to physical therapy.However, review of the clinical record failed to show documented evidenced of a physicians order for the physical therapy. -Gastrointestinal: The goal includes potential for altered bowel elimination related to poor intake, anorexia with severe dysphagia and constipation. The intervention showed to instruct and teach patient/family/PCG on proper colostomy care and maintenance. However, review of the clinical record failed to show documented evidenced of the patient has colostomy tube. In addition, the POC/IDG failed to be revised as frequently as the condition requires when the patient does not have physical therapy order and colostomy tube. On 5/1/25 at 1036 hours, an interview and closed clinical record review was conducted with RN 1. RN 1 was asked if the patient has PT order. The RN replied, the patient does not have physical therapy. The RN 1 was also asked if the patient has colostomy tube. The RN replied no, the POC should be revised as it’s not needed. The RN 1 was informed and acknowledged the findings.On 5/1/25 at 1436 hours, an an interview and closed clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee was informed and acknowledged the findings.”

“Based on interview and record review, the hospice failed to maintain a system of communication and integration in accordance with their P&P to ensure the IDG had maintained responsibility for directing, coordinating, and supervising the care and services provided for two of two sampled patients (Patient 1 and 2). This failure had the potential of not addressing the care needs for these patients. Findings: The hospice’s P&P titled Care/Service Coordination revised 4/2017, showed a timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The procedure includes a written evidence of care coordination maybe found in the plan of care/service, case conference summary forms, clinical notes in the patient’s clinical record or interdisciplinary group meeting notes. 1. Review of Patient 1’s closed clinical record was initiated on 4/30/25. The clinical record showed the SOC was 6/10/24. The patient was certified for hospice services during the certification period from 6/10/24 to 8/30/24 and 8/31/24 to 11/28/24. The patient revoked hospice service on 9/15/24.a. Review of the Communication Log dated 8/5/24 at 0854 hours, showed the PCG reported patient was COVID positive. 1However, review of the closed clinical record failed to show documented evidenced of the physician was notified timely of the patients COVID positive results as per P&P. b. Review of the Current Treatment/ Medication/DME list showed an order dated 6/10/24 for Januvia (antidiabetic) 100 mg tablet one tablet oral daily. The special instructions include the last blood test for HgbA1C was in acceptable range for DM 2 patients and may need to have the HgbA1C for the next couple months.However, review of the closed clinical record failed to show documented evidenced of the blood test for HgbA1C was followed up/coordinated with the physician. On 5/1/25 at 1436 hours, an interview and concurrent closed clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee was asked if the plan for the HgbA1C blood test was coordinated with the physician. The DPCS reviewed the closed clinical record and replied, no documentation. The DPCS/Administrator Designee was informed and acknowledged the findings. c. Review of the Volunteer Notes dated 8/7/24, showed the volunteer assigned task. The Volunteer documented a checked mark on the completed task for companionship (reading /letter/writing, music, caring touch) and socialization. However, on the section of Volunteer Comments showed the volunteer did not see the patient due to the patient being tested positive for COVID.On 5/1/25 at 1420 hours, an interview and concurrent closed clinical record review was conducted with the DPCS/Administrator Designee and the Volunteer Coordinator. They were asked if the patient was seen by the volunteer on 8/7/24. The Volunteer Coordinator replied, no, it was inaccurate, I supervised the volunteer and was missed when I reviewed the notes. They were informed and acknowledged the findings. 2. Review of Patient 2’s closed clinical record was initiated on 4/30/25. The closed clinical record showed the SOC was 4/24/24. The patient was certified of hospice services during the certification periods from 4/24/24 to 7/22/24 and 7/23/24 to 10/20/24. The patient was discharged from the hospice on 8/10/24.The SN notes dated 6/4, 6/11, 6/25, and 7/3/24, showed the patient had increased shortness of breath with mild exertion, and required oxygen therapy at 2-3 L/min via nasal cannula to maintain an oxygen saturation of greater than 90%. However, there were documentation of oxygen saturations of the following: on 6/3 and 6/25/24, the oxygen saturation was 98 % in room air and on 6/11 and 7/3/24, the oxygen saturation was 97 % in room air.*However, there was no documented evidence the oxygen saturation was assessed or what the patient’s oxygen saturation level was prior to administering the oxygen therapy to the patient in the nursing narrative notes.*In addition, there was no documented evidence the IDG had maintained supervision for the care and services of the oxygen therapy for the patient.On 5/1/25 at 1450 hours, an interview and concurrent closed clinical record review was conducted with the DPCS/Administrator Designee. The DPCS/Administrator Designee was informed and acknowledged the above finding.”

“Upon patient record review, 2 of 14 (Patient #1,2) 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 has orders written 10/21/23 for Triamcinolone cream to be applied TID PRN without indication of specific location to apply cream on the medication profile. Patient #2 has orders on 9/3/24 and 9/24/24 for Cipro x7 days, on 11/30/24 for Keflex x7 days and the medications remain active on the medication profile. Orders on 11/8/24 for Nystatin ointment to be applied BID PRN for rash, without indication of location to apply ointment on the medication profile.”

“Upon patient record review, 6 of 14 (Patient #1,2,5,9,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1 Orders written 10/21/23 for Triamcinolone cream to be applied TID PRN without indication of specific location to apply cream. Patient #2 Orders on 11/8/24 for Nystatin ointment to be applied BID PRN for rash, without indication of location to apply ointment. Patient #5 Skilled nurse note on 11/3/24, 11/15/24, 11/19/24, 11/26/24 and 12/3/24 state patient had a foley in place, however there are no orders for foley care. Patient #9 Orders on 6/7/24 for Norco 5mg/325mg, 1 tab Q8 PRN and Acetaminophen 650mg Q4 PRN and order does not contain “Not to exceed 4000mg/24 hours” Patient #10 Orders on 5/21/24 for Tylenol ES 500mg 1 tab Q8 PRN and Acetaminophen 650mg Q4 PRN and order does not contain “Not to exceed 4000mg/24 hours””