Prohealth Home Care, Inc.

“Based on observation, interview and record review, on one of 4 home visits scheduled (Patient 12), the agency failed to ensure the care giver responsible for assisting Patient 12 received necessary teaching and instruction when Licensed Nurse (LN) 2 did not reconcile medications during the home visit.This failure had the potential to result in a breakdown in the coordination and continuity of care and increased the risk of medication errors. During a review of Patient 12’s clinical record, the Plan of Care (POC) for the certification period 8/20/26 through 11/17/26 indicated Patient 12 had a start of care date 8/20/26 with a diagnosis malignant neoplasm of head of pancreas (pancreatic cancer).During a review of Patient 12’s POC, the POC indicated, safety measures, “…medication safety...”During an observation of the home visit at Sherwood Healthcare Center (a skilled nursing facility) on 9/9/26 at 10 a.m., with Licensed Nurse 2 (LN 2), LN 2 did not go over medication profile/list with the skilled nursing facility nurse assigned to Patient 12. LN 2 did not discuss medication safety with the nurse at the facility.During an interview on 9/9/26 at 10:10 a.m., with LN 2, LN 2 confirmed that she did not reconcile medications with the nurse at the facility. LN 2 stated that Patient 12 does not manage her own medications. During an interview on 9/10/26 at 12:10 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the expectation was that the LN reconcile the medications with the facility staff every hospice visit. A potential problem is that the LN may miss drug interactions with medications and not communicate to the doctor. The DPCS acknowledged that this could be a break in coordination of care.During a review of the agency’s Policy and Procedure (P&P) titled, “Medication Management” dated November 2024, the P&P indicated, “During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure the patient and…caregiver, as well as other clinicians, understand the medication regimen...Using the medication profile to evaluate the use of the drugs in the home setting…Using the medication profile to teach drug purposes, dosages, routes, times side effects, and contraindications…Using the medication profile as a communication tool for other clinicians involved in care.””

“Based on interview and record review the agency failed to ensure that the Plan of Care (POC) reflected physician orders and was updated for one of nineteen sampled patients (Patient 5).This failure had the potential to result in Patient 5 not receiving services as ordered, which could have resulted in unmet care needs and compromised quality of care. Review of Patient 5’s Hospice Plan of Care for 10/24/26 through 1/21/26 indicated that Patient 5 had several diagnoses including malignant neoplasm of the uterus (uterine cancer).Review of Patient 5’s records of physician orders dated 10/24/25, indicated RN/LVN (Registered Nurse/Licensed Nurse) visits one time per week for eleven weeks and Patient 5’s Hospice Plan of Care dated 10/24/25 indicated RN/LVN visits two times per week for thirteen weeks.Review of Patient 5’s Interdisciplinary Group (IDG) meeting on 11/4/25, the IDG meeting notes indicated, RN/LVN (Registered Nurse/Licensed Nurse) visits one time per week for eleven weeks “no changes continue plan of care,” and no update to the POC on that date or during this certification period.During an interview on 9/10/26 at 2:10 p.m. with the Director of Patient Care Services (DPCS), the DPCS confirmed the above findings. The DPCS stated her expectation is that the physician orders and plan of care match each other. The DPCS also stated that the POC should be updated in the IDG meeting and if the POC is not updated this may result in hospice staff missing changes in physician orders or the patient’s condition. Review of the policy and procedure (P&P) titled, “The Plan of Care,” dated November 2024, the P&P indicated, “The plan of care will be reviewed and revised as frequently as deemed necessary, but not less than every 15 days, by the interdisciplinary group…””

“Based on interview and record review the hospice agency failed to maintain a system of communication, in accordance with their own policies, to ensure the interdisciplinary group (IDG, a team of professionals responsible for managing a patient’s end-of-life/hospice care plan) maintained responsibility for two out of 18 sampled patients, when Patient 10 and 13’s missed services were not documented as communicated to the physician (MD) and/or the IDG.These failures had the potential to result in Patient 10 and 13 having unmet needs without MD or IDG knowledge. During a review of Patient 10’s Plan of Care (POC) as of 10/5/25, Patient 10 had a diagnosis of senile degeneration of the brain (.During a review of Patient 10’s POC for the certification period 10/5/25-1/1/26 indicated orders for Home Health Aide (HHA) visits “2 per week”.During a review of Patient 10’s clinical record on 9/9/26 at 9 a.m. indicated no HHA visits were made on 10/9/25.During a concurrent interview and record review on 9/10/26 at 12:54 p.m. with the DPCS, the DPCS confirmed that no HHA visit was made on 10/9/25 for Patient 10. The DPCS further confirmed that the physician was not notified. The DPCS stated that her expectation would be that the Licensed Nurse (LN) should have attempted to reschedule the visit. If the LN could not reschedule the visit, the reason and notification to the physician should be documented in the patient’s clinical record and orders updated. The DPCS acknowledged that a missed visit would affect the quality of patient care. Findings:A review of Patient 13’s profile (also known as a face sheet, a page of the chart that contains a summary of basic information about the resident) indicated Patient 13’s start of care with the hospice agency was in December 2025 at the age of 104 years old.A review of Patient 13’s Hospice Plan of Care (POC a personalized, written roadmap that guides a patient’s end-of-life medical, emotional, and spiritual care), dated 6/29/26, indicated Patient 13 was to receive Medical Social Work (MSW) services once a month for two months starting 6/28/26 through 8/22/26. The POC also indicated Patient 13 was to receive Home Hospice Aide (HHA) visits twice a week for eight weeks from 6/29/26 through 8/22/26.During a concurrent interview and record review on 9/10/26 at 10:57 a.m., with the Director of Patient Care Services (DPCS), Patient 13’s POC, dated 6/29/26 and Patient 13’s Electronic Medical Record (EMR) were reviewed. The DPCS stated MSW and HHA visit frequencies must follow the patient’s POC and that missed visits could indicate unmet patient needs. She explained MSW visits ensure psychosocial needs for patient and family are met and missed HHA visits could result in inadequate hygiene care affecting patient dignity. The DPCS stated if there were missed visits, she expected the missed visit to be documented in the patient’s EMR. The DPCS confirmed missed visits should be communicated with the IDG (overseen by the hospice Medical Director) and the patient’s MD (if different than the Medical Director). The DPCS confirmed Patient 13’s POC required monthly MSW visits from 6/28/26 to 8/22/26 and twice-weekly HHA visits from 6/29/26 to 8/22/26. Upon initial review of the EMR, the DPCS stated there was no documentation of MSW visits during the period and that HHA visits were not provided twice weekly for the weeks of 7/12–7/18, 7/19–7/25, and 7/26–8/1/26. The DPCS denied there was any documentation in the EMR regarding the missed visits. The DPCS stated that the lack of documentation led her to “assume” the IDG nor Patient 13’s MD had been notified about missed visits. The DPCS stated she would review Patient 13’s EMR further and other locations for additional documentation before confirming there were missed visits or a lack of documentation related to missed visits.During a follow-up interview on 9/10/26 at 12:02 p.m., the DPCS stated when there are missed visits/services those should be communicated to the Registered Nurse Case Manager (RNCM) for the patient. The DPCS added, the RNCM is expected to notify the patient’s MD regarding the missed visits/services and she expected the issue to be addressed in IDG meetings. The DPCS confirmed that all searches for additional documentation regarding Patient 13’s missed services had been completed. She verified that Patient 13 did not receive services in accordance with the POC when no MSW visits were provided during the identified period, and HHA visits were provided only once during 7/12–7/18/26, once during 7/19–7/25/26, and none during 7/26–8/1/26. The DPCS confirmed there was no documentation in Patient 13’s EMR that indicated that Patient 13’s MD was notified of the missed visits or that the missed visits had been addressed during IDG meetings.A review of Facility policy and procedure (P&P) titled “Missed Visits,” revised November 2024, indicated, “….to ensure missed visits are documented and it does not affect the quality of a patient’s care…Missed visits will be communicated to the Interdisciplinary group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record…The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plan of care contain the correct number of planned visits.”A review of Facility P&P titled “Interdisciplinary Group Coordination of Care,” revised November 2024, indicated, “…To ensure the coordination of services for each patient….Each patient will be assigned an RN [Registered Nurse] Case Manager…It will be the responsibility of the RN Case Manger to facilitate communication about changes in the patient’s status among interdisciplinary group members and the patient’s attending physician…[hospice agency name] personnel will communicate changes in a timely manner….all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed and the outcome of the communication…”A review of Facility P&P titled, “Monitoring Patient’s Response/Reporting to Physician,” Revised November 2024, indicated, “…Clinicians will establish and maintain ongoing communication with the patient’s physician and the hospice Medical Director to ensure safe and appropriate care for the patient…the patient’s physician and/or the hospice Medical Director will be contacted on the same day when any of the following occur…there is any problem implementing the plan of care…all conferences or attempts to communicate with the attending physician and/or hospice Medical Director will be documented in the clinical record…””

“Based on interview and record review the Hospice agency failed to provide services in accordance with the patient’s hospice plan of care (POC, a personalized, written roadmap that guides a patient’s end-of-life medical, emotional, and spiritual care) for five of 19 sampled patients when:Patient 13 did not receive Medical Social Work (MSW) services and Home Hospice Aide (HHA) visits as indicated on their POC.Patient 10 did not receive HHA visits as indicated on their POC.Patient 15 did not receive MSW services and Volunteer visits as indicated on their POC.Patient 18 did not receive MSW visits as indicated on their POC.Patient 19 did not receive HHA visits as indicted on their POC. These failures had the potential to result in unmet psychosocial needs of affected patients and their family/caregivers and could negatively impact the dignity of the patients. Findings:1. A review of Patient 13’s profile (also known as a face sheet, a page of the chart that contains a summary of basic information about the resident) indicated Patient 13’s start of care with the hospice agency was in December 2025 at the age of 104 years old.A review of Patient 13’s POC, dated 6/29/26, indicated Patient 13 was to receive MSW services once a month for two months starting 6/28/26 through 8/22/26. The POC also indicated that Patient 13 was to receive HHA visits twice a week for eight weeks from 6/29/26 through 8/22/26. During a concurrent interview and record review on 9/10/26 at 10:57 a.m., with the Director of Patient Care Services (DPCS), Patient 13’s POC, dated 6/29/26 and Patient 13’s Electronic Medical Record (EMR) were reviewed. The DPCS stated MSW and HHA visit frequencies must follow the patient’s POC and that missed visits could indicate unmet patient needs. She explained MSW visits ensure psychosocial needs for patient and family are met, and missed HHA visits could result in inadequate hygiene care affecting patient dignity. The DPCS confirmed the POC required monthly MSW visits from 6/28/26 to 8/22/26 and twice-weekly HHA visits from 6/29/26 to 8/22/26. Upon initial review of the EMR, the DPCS stated there was no documentation of MSW visits during the period and that HHA visits were not provided twice weekly for the weeks of 7/12–7/18, 7/19–7/25, and 7/26–8/1/26. She stated she would review Patient 13’s EMR further and other locations for additional documentation before confirming missed visits.During a follow-up interview on 9/10/26 at 12:02 p.m., the DPCS confirmed that all searches for additional documentation regarding Patient 13’s services had been completed. She verified that Patient 13 did not receive services in accordance with the POC when no MSW visits were provided during the identified period, and HHA visits were provided only once during 7/12–7/18/26, once during 7/19–7/25/26, and none during 7/26–8/1/26.A record review of facility policy and procedure (P&P) titled “the Plan of Care,” revised November 2024, indicated, “…the care provided to the patient must be in accordance with the plan of care…”A record review of facility P&P titled “Hospice Aide Services,” revised November 2024, indicated, “Hospice aide services will include personal care provided by trained hospice aides…These activities, in accordance with the interdisciplinary plan of care and physician’s (or other licensed practitioner’s) orders, will be assigned and supervised by hospice registered nurse…”Facility policy and procedure titled “Psychosocial Services,” revised November 2024, indicated, “…To ensure that appropriate psychosocial services are provided to hospice patients and family/caregivers…will provide psychosocial services … under the direction of a physician and in accordance with the plan of care…” During a review of Patient 10’s Plan of Care (POC) as of 10/5/25, Patient 10 had a diagnosis of senile degeneration of the brain (cognitive decline, memory impairment).During a review of Patient 10’s POC for the certification period 10/5/25-1/1/26 indicated orders for Home Health Aide (HHA) visits “2 per week”.During a review of Patient 10’s clinical record on 9/9/26 at 9 a.m. indicated no HHA visits were made on 10/9/25.During a concurrent interview and record review on 9/10/26 at 12:01 p.m. with the DPCS, the DPCS confirmed that no HHA visit was made on 10/9/25 for Patient 10. The DPCS further confirmed that the physician was not notified. The DPCS stated that her expectation would be that the Licensed Nurse (LN) should have attempted to reschedule the visit. If the LN could not reschedule the visit, the reason and notification to the physician should be documented in the patient’s clinical record and orders updated. The DPCS acknowledged that a missed visit would affect the quality of patient care. 3. During a review of Patient 15’s POC as of 5/16/26, Patient 15 had a diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities) with late onset.During a review of Patient 15’s POC, POC indicated orders for MSW visits once a month for three months to start 5/17/26 and volunteer visits once a month for one month to start on 5/17/26.During a review of Patient 15’s clinical record indicated Patient 15 did not receive MSW or volunteer visits from 5/16/26 to 7/18/26.During a concurrent interview and record review on 9/10/26 at 9:55 a.m. with DPCS, DPCS confirmed that no MSW or volunteer visits were made between 5/16/26 and 7/18/26/. DPCS stated that Patient 15 should have received the visits and that staff should have followed up to determine why the visits were not made to ensure the patient’s and family’s needs were met.4. During a review of Patient 18’s POC as of 5/31/26, Patient 18 had a diagnosis of Alzheimer’s disease with late onset.During a review of Patient 18’s POC, POC indicated order for MSW visit once a month for three months to start 5/31/26.During a review of Patient 18’s clinical record indicated Patient 18 did not receive MSW visit from 5/31/26 to 8/8/26.During a concurrent interview and record review on 9/10/26 at 10:06 a.m. with DPCS, DPCS confirmed that there were no MSW visits made between 5/31/26 to 8/8/26. 5. During a review of Patient 19’s POC as of 7/7/26, Patient 19 had a diagnosis of dementia (a progressive state of decline in mental abilities) with psychotic disturbance.During a review of Patient 19’s POC, POC indicated order for HHA visits two times a week for 12 weeks to start 7/7/26.During a review of Patient 19’s clinical record indicated Patient 19 received only one HHA visit for the week of 7/12/26.During a concurrent interview and record review on 10/9/26 at 10:10 a.m. with DPCS, DPCS confirmed that only one HHA visit was made during the week of 7/12/26, DPCS stated that HHA visits should have been made as scheduled to meet the patient’s needs.”

“Based on observation, interview and record review the Hospice Agency failed to ensure infection control procedures were followed during home visits for three of nineteen sampled patients (Patient 7, 12 and Patient 1) when1. Licensed Nurse (LN) 1 and LN 3 used hand sanitizer to clean a blood pressure cuff for Patient 7, and Patient 1.2. LN 2 did not clean medical equipment in accordance with agency’s policy and procedure and manufacturer’s guidelines. These failures had the potential to result in the transmission of infection. Review of Patient 7’s Hospice Plan of Care for certification period 7/18/26-9/15/26, Patient 7 had several diagnoses including malignant neoplasm of the breast (breast cancer) and senile degeneration of the brain (age related deterioration of brain tissue and function).During a concurrent observation and interview of a home visit for Patient 7 on 9/9/26 at 10:05 a.m., Licensed Nurse (LN) 1 was observed taking the blood pressure of Patient 7 and then spraying the blood pressure cuff with hand sanitizer to clean it. LN 1 confirmed the above finding and stated that she only uses a wipe if a patient is “ill.”During an interview on 9/9/26 at 2:10 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that hand sanitizer should not be used to clean equipment and her expectation is that the hospice staff use the wipes the agency provides to clean equipment.During an interview on 9/9/26 at 2:20 p.m., with the Administrator (ADM), the ADM stated that the wipes given to staff are [brand name] Sani wipes.Review of the policy and procedure (P&P) titled, “Infection Prevention and Control,” dated November 2024, the P&P indicated, “When the is completed, reusable equipment will be cleaned using Sani Wipes...” During a review of Patient 12’s clinical record, the Plan of Care (POC) for the certification period 8/20/26 through 11/17/26 indicated Patient 12 had a start of care date 8/20/26 with a diagnosis malignant neoplasm of head of pancreas (pancreatic cancer).During a concurrent observation and interview of a home visit for Patient 12 on 9/9/26 at 9:17 a.m., Licensed Nurse (LN 2) was observed taking the blood pressure and measuring oxygen saturation with a pulse oximeter of Patient 12. LN 2 took wet wipes from an unlabeled plastic bag and wiped the medical equipment after use. LN 2 was observed to immediately put all medical equipment into her bag. The pulse oximeter dropped out of LN 2’s bag and onto the floor. LN 2 was observed to put the pulse oximeter bag back into her bag without cleaning it. LN 2 confirmed the above finding and stated that she took the wipes from original packaging because the container did not fit into her bag. LN 2 further confirmed that she did not clean the medical equipment per manufacturer directions. LN 2 stated that she should have waited 10 to 15 minutes before putting it in her bag. LN acknowledged that all equipment was contaminated.During a concurrent observation and interview on 9/9/26 at 12:15 p.m., with DPCS, the DPCS stated that LN should have not taken disinfecting wipes out of original packaging. DPCS confirmed that the original disinfecting wipes [brand name] stated “…unfold wipe and thoroughly wet surface. Allow surface to remain wet for three (3) minutes. Let air dry…storage…do not contaminate water…when not in use keep center of cap of lid closed…” DPCS stated her expectation is that the hospice staff use the wipes the agency provides to clean equipment. DPCS stated that if staff did not clean medical equipment there was a risk to spread infection to other patients.During a review of P&P titled, “Infection Prevention and Control,” dated November 2024, the P&P indicated, “all equipment will be cleaned before and after use...will be cleaned using Sani wipes.” During a review of Patient 1 clinical record, the Plan of Care (POC) for the certification period 7/4/26/26 through 9/1/26 indicated Patient 1 had a start of care date 1/5/26 with a diagnosis of senile degeneration of the brain.During a concurrent observation and interview of a home visit for Patient 1 on 9/9/26 at 2:10 p.m. Licensed Nurse (LN) 3 was observed taking the blood pressure and measuring oxygen saturation with a pulse oximeter. LN 3 placed the used blood pressure equipment and pulse oximeter on the clean area after being used. LN 3 was observed to use a hand sanitizer to clean the equipment that was placed on the clean area which was already considered contaminated. LN 3 was observed to put blood pressure machine and pulse oximeter into her bag after being sprayed with the hand sanitizer.During a follow up interview with LN 3 conducted on 9/10/26 at 1:29 p.m., LN 3 confirmed she used an alcohol spray to clean the reusable equipment. During an interview on 9/9/26 at 2:10 p.m. with DPCS, the DPCS stated, that her expectation was that hand sanitizer is not used for cleaning equipment such as blood pressure cuffs and pulse oximetry, and LN should use the wipes that the agency provides, and that they let the equipment dry for two minutes.During a review of P&P titled, “Infection Prevention and Control,” dated November 2024, the P&P indicated, “all equipment will be cleaned before and after use...will be cleaned using Sani wipes.””

“Based on observation, interview and record review the agency failed to ensure an ongoing comprehensive assessment was done for one of 19 sampled patients (Patient 12) when there was no documented evidence of wound measurement and documentation from 8/21/26 through 9/3/26.This failure had the potential to result in increased risk of discomfort, unmanaged symptoms and decreased quality of life. During a review of Patient 12’s clinical record, the Plan of Care (POC) for the certification period 8/20/26 through 11/17/26 indicated Patient 12 had a start of care date 8/20/26 with a diagnosis malignant neoplasm of head of pancreas (pancreatic cancer).During record review of Patient 12’s clinical record, Patient 12’s Hospice Admission Assessment (HAA) was reviewed. HAA indicated, “ Skin/Wound Assessment…Skin assessment revealed a rash to the bilateral inner thighs, appearing consistent with moisture-associated/friction-related skin irritation, as well as an abrasion to the left posterior waistline measuring approximately 13 × 6.2 cm. Subsequent hospice visits after, no documented evidence of wound measurements from 8/21/26 to 9/3/26 on hospice nursing clinical notes.During a review of Patient 12’s POC, the POC indicated, “…assess skin integrity...”During an observation of the home visit at Sherwood Healthcare Center (a skilled nursing facility) on 9/9/26 at 10 a.m., with Licensed Nurse 2 (LN 2), LN 2 did not lift up resident clothes to assess the left posterior waistline abrasion. LN 2 confirmed and stated that she did not need to do the treatment because the wound nurse had already done it. During a review of Patient 12’s active orders at Sherwood Healthcare Center, titled “Order Summary Report,” indicated that there was no active wound treatment as of 9/9/26 to posterior waistline. During an interview on 9/10/26 at 12:15 p.m. with Director of Patient Care Services (DPCS), DPCS confirmed that the last recorded measurement was on 8/20/26. DPCS acknowledged that wound assessments are documented by clinician on hospice nursing clinical notes during hospice visits. During a review of California Board of Registered Nursing document titled “Understanding the Role of Registered Nurse…” (https://www.rn.ca.gov/pdfs/regulations/npr-b-53.pdf) undated, the document indicated, “Nursing Practice Act Business & Professions Code Chapter 6 Nursing Section 2725... RN is accountable for an ongoing comprehensive assessment that includes data collection, analysis… RN uses scientific knowledge and experience to make clinical judgments about observed abnormalities and changes based on a series of complex, independent and collaborative decision making activities.” A policy procedure was requested from the agency for wound assessment and documentation and none was provided.”

“Based on interview and record review, the hospice agency failed to ensure that Registered Nurse (RN) supervisory visits for home health aides (HHA) were made at least every 14 days for three (Patient 15, Patient 18 and Patient 19) of 19 sampled patients.This failure had the potential to result in inadequate or inappropriate healthcare practices that could result in less than desirable care for Patient 15, Patient 18 and Patient 19. Findings:During a review of Patient 15’s Plan of Care (POC) as of 5/16/26, Patient 15 had a diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities) with late onset.During a review of Patient 15’s clinical record indicated that Patient 15 had an order for HHA visits. The first HHA visit was made on 5/21/26; however, the first RN supervisory visit for the HHA was not made until 7/2/26.During a concurrent interview and record review on 9/10/26 at 9:55 a.m. with Director of Patient Care Services (DPCS), DPCS confirmed that the first RN supervisory visit was competed on 7/2/26, which was more than 14 days after the first HHA visit on 5/21/26.During a review of Patient 18’s POC as of 5/31/26, Patient 18 had a diagnosis of Alzheimer’s disease with late onset.During a review of Patient 18’s clinical record indicated Patient 18 had an order for HHA visits. RN supervisory visit for the HHA was completed on 6/7/26 and the next RN supervisory visit was not completed until 6/24/26.During a concurrent interview and record review on 9/10/26 at 10:06 a.m. with DPCS, DPCS confirmed that the RN supervisory visits were completed on 6/7/26 and 6/24/26, which were 17 days apart and not within the required 14-day timeframe.During a review of Patient 19’s POC as of 7/7/26, Patient 19 had a diagnosis of dementia (a progressive state of decline in mental abilities) with psychotic disturbance.During a review of Patient 19’s clinical record indicated Patient 19 had an order for HHA visits. The clinical record indicated that an RN supervisory visit was completed on 8/3/26 and the next RN supervisory visit was not completed until 8/21/26, 18 days later.During an interview on 9/10/26 at 10:12 a.m. with DPCS, DPCS stated that RN supervisory visits for HHAs should be completed every 14 days to ensure the HHAs followed the POC, assessed how the patients tolerated the HHA POC, and ensure the HHAs practiced within their scope of practice.During a review of the facility’s policy and procedures (P&P) titled, “Hospice Aide Supervisory Visits,” dated 7/25, the P&P indicated “…the registered nurse must conduct supervisory visits to the patient’s residence at regular intervals…the frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established but are conducted every 14 days…””

“Based on observation, interview and record review, the hospice agency failed to ensure that the skilled nursing staff providing care to Patient 12 received necessary orientation and hospice training.This failure had the potential to result in Patient 12’s unmet care needs. During a review of Patient 12’s clinical record, the Plan of Care (POC) for the certification period 8/20/26 through 11/17/26 indicated Patient 12 had a start of care date 8/20/26 with a diagnosis malignant neoplasm of head of pancreas (pancreatic cancer).During a concurrent observation and record review of Patient 12’s home visit at Sherwood Healthcare Center (a skilled nursing facility) on 9/9/26 at 9:10 a.m., with Licensed Nurse 2 (LN 2), no documented evidence was seen in Patient 12’s hospice binder that the agency provided education to the skilled nursing (SN) staff of hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements.During a record review of Patient 12’s hospice binder, two forms titled, “RCFE Training” and SNF/RCFE Training Addendum”, indicated “[Agency name] has provided the following training for RCFE team members caring for resident….Acknowledgement of Receipt of Training…” Both documents were observed to be blank.During an interview on 9/8/26 at 2 p.m. with the Administrator (ADM), the ADM indicated that the education and training provided by agency will be documented in the hospice binder of the patient at the facility.During an interview on 9/9/26 at 9:48 a.m. with SN nurse, SN nurse indicated that she did not receive any hospice training from the agency.During an interview on 9/10/26 at 10:51 a.m. with Director of Nursing (DON) of the facility, the DON indicated that the agency has not provided education or training for nursing staff.During an interview on 9/10/26 12:10 p.m. with Director of Patient Care Services (DPCS), the DPCS indicated that the expectation is for SN staff to be trained by the agency. The DPCS acknowledged that Patient 12’s training forms were blank. DPCS further stated that if there is no training for facility staff there is a risk of not following plan of care, no continuity of care and patient needs not being met.During a review of the agency’s Policy and Procedure (P&P) titled, “Provision of Care Treatment and Service” dated November 2024, the P&P indicated, “ [Agency name] will consult with the SNF/NF…regarding the shared orientation and training responsibilities of staff furnishing care to patients, including: hospice philosophy…hospice policies and procedures…principles about death and dying…patient rights…appropriate forms and record keeping requirements…””

“Based on interview and record review, the Hospice Agency (HA) failed to document that education was provided to family for administration of Patient 1’s medication, when Patient 1 received an incorrectly labeled narcotic pain medication (opioid pain medication used for severe pain) from the agency’s contracted pharmacy and was given the incorrect dose. This failure resulted in Patient 1 receiving a dose of narcotic pain medication that was ten times the dosage ordered and placed the patient at risk for serious side effects including respiratory depression. A review of Patient 1’s “Medpass Hospice Physician Plan of Treatment (POC),” for certification period 2/10/24 to 5/9/24, indicated Patient 1 had a start of care date with the HA on 2/10/24 for diagnosis of chronic kidney disease (kidneys unable to filter waste as well as they should). A review of Patient 1’s POC indicated “...Orders for Skilled Nursing...SN [Skilled Nurse] visit frequency 2x [times]/week and 2 PRN [as needed] for changes in status...Implement and instruct Medication Regimen; including dosage, side effects, name, route, frequency, adverse reactions, and medication compliance/med set-up...Patient/caregiver may administer medications...” A review of Patient 1’s “Hospice Medication Profile,” dated 2/10/24, indicated “...Start Date...02/21/2024 Hospice Provided...Medication... Methadone HCL Intensol [narcotic pain medication used to treat severe pain]...Route...Oral...Dose/Amount...10 MG [milligrams]/ML[milliliter] (give 0.25 ML= 2.5MG) ...Frequency...Every 12 hours... Home Hospice Medication Policy and Procedure Review...Date: 02/10/2024... An assessment has been completed to assure that the patient, patient representative and/or family are competent to safely self-administer medications and may administer meds...Yes...” A review of Patient 1’s “Hospice Nursing Clinical Note,” dated 2/21/24, indicated “... patient had been complaining of increased pain located on his mid back. He used to be able to tolerate the pain, but now even with slight movement like lowering of the bed already triggers the pain...” Patient 1’s “Hospice Nursing Clinical Note,” dated 2/21/24, sections “Skilled Intervention/Treatment/Teaching/Pt [Patient]/Cg [Caregiver] Response” and “Coordination/ Plan” were not completed. A review of Patient 1’s “Hospice Nursing Clinical Note,” dated 2/23/24, indicated “...Patient was given 2.5 ml of Methadone at approximately 10:30 pm. family noted in early morning patient was very hard to arouse and non responsive [HA] was called at this time. SN found patient to be semi-comatose eyes are closed when open appears glossy with no tracking. No active movement or verbal response is noted to name or tactile [touch] stimuli...SN spoke with [name of HA pharmacy] to the Pharmacist who mislabeled medication, she is sending someone out with a new label to re label medication...” A review of Patient 1’s “Care Coordination Note,” dated 2/23/24, indicated “...Received a message from the patient’s [name of Family Member] that the patient was administered Methadone conc. [concentrate] 10mg/ml, 2.5 ml last night because of severe pain. She reported that this morning he was “out of it” and seemed like he wanted to vomit but he couldn’t...SN tried to clarify if it was 0.25 ml or 2.5 ml that was given and she stated that she followed what was written on the bottle. She took a picture of the bottle and it stated methadone 10mg/ml, Take 2.5 ML every 12 hours. The hospice order to [name of HA pharmacy] was rechecked and clearly written as Methadone 10mg/ml, take 2.5 mg (0.25ml) every 12 hours for pain management...” During an interview on 3/1/24 at 12:39 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that Patient 1’s medication, Methadone, was delivered to the home on 2/22/24 and had been mislabeled by the pharmacy. The DPCS stated Patient 1’s family member administered the medication on 2/22/24 according to label instructions on the bottle. Patient 1 received 2.5 ml instead of 0.25 ml that had been ordered. The DPCS stated that Patient 1 did not have a nursing visit after Methadone had been delivered to the home and before it was administered by the family on 2/22/24. Reviewed Patient 1’s “Hospice Clinical Visit Note,” dated 2/21/24, with the DPCS. The DPCS acknowledged that the note did not reflect family had been instructed in the administration of Methadone. The DPCS stated, “Teaching would have been documented in the nursing note, but the nurse did not complete her note because she had to leave the country.” The DPCS further stated, “The policy is 48 hours to complete visit note. In this instance should have been completed the same day.” During a telephone interview on 3/20/24 at 9:08 a.m. with SN 1, SN 1 stated she went to Patient 1’s home on 2/23/24. SN 1 stated Patient 1 had been given, by a family member, the incorrect dosage of Methadone on 2/22/24 due to an incorrect medication label. SN 1 stated the Methadone bottle was labeled to give 2.5 ml instead of 0.25 ml. Patient 1’s family member had given what the label instructed. SN 1 stated teaching is documented in the nursing visit note and needs to be charted within 48 hours of the visit. During a joint telephone interview with the HA Pharmacy Owner (OHAP) and the HA Pharmacist (PHM), OHAP stated methadone for Patient 1 was ordered on 2/21/24 by the HA and delivered to Patient 1’s home on 2/22/24. The OHAP stated Patient 1’s order for Methadone was labeled incorrectly because a pharmacy technician typed 2.5 ml instead of 2.5 mg. The OAH stated another pharmacy technician filled the medication and the PHM checked it off but did not catch the error. The OHAP stated, “It was our mistake.” During a telephone interview on 3/20/24 at 12:38 p.m. with SN 2, SN 2 stated Patient 1 had severe back pain on 2/21/24 and Methadone 0.25 ml for 2.5 mg every 12 hours was ordered. It was delivered to the home and family administered it on 2/22/24. SN 2 received a picture of the bottle on 2/23/24 and observed it was incorrectly labeled. The family had administered 2.5 ml instead of 0.25 ml. SN 2 stated she checked the order which was correct. Reviewed Patient 1’s “Hospice Nursing Clinical Note,” dated 2/21/24, with SN 2. SN 2 acknowledged that she did not complete the visit note within 48 hours as she had to leave the country and education on Methadone administration was not documented. A review of the HA Policy and Procedure (P&P) titled “Identification of Medication for Administration,” revised 11/20, indicated “...To provide general guidelines for the safe administration of medications in the home...Medications will be properly labeled with the patient’s name, an additional patient identifier, name of drug, dosage...The nurse will review the medication label for name, additional patient identifier, drug, dosage, and prescription....The nurses will document medication teaching, side effects, administration, and other related information in the clinical record...” A review of the HA P&P titled “Medication Profile,” revised 11/20, indicated “...the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver...understand the medication regimen...Using the medication profile to teach drug purposes, dosages...” A review of the HA P&P titled “Entries into the Clinical Record,” not dated, indicated “...A clinical record will be initiated and maintained for each patient...and will include at a minimum...Patient and family education...All entries into the clinical record will reflect the date care was provided...All visit notes must be completed within 24-48 hours...””

“Based on interview and record review, the Hospice Agency (HA) failed to ensure that medications from their contracted pharmacy and delivered to Patient 1 were labeled and administered correctly, when Patient 1’s narcotic pain medication (opioid pain medication used for severe pain) was administered by family caregiver with dosage of 2.5 milliliters (ml) instead of the correct dose of 0.25 ml. This failure had the potential to cause Patient 1 to experience adverse effects from receiving ten times the dose ordered. Findings: A review of Patient 1’s “Medpass Hospice Physician Plan of Treatment (POC),” for certification period 2/10/24 to 5/9/24, indicated Patient 1 had a start of care date with the HA on 2/10/24 for diagnosis of chronic kidney disease (kidneys unable to filter waste as well as they should). A review of Patient 1’s POC indicated “...Orders for Skilled Nursing...Implement and instruct Medication Regimen; including dosage, side effects, name, route, frequency, adverse reactions, and medication compliance/med set-up...Patient/caregiver may administer medications...” A review of Patient 1’s “Hospice Medication Profile,” dated 2/10/24, indicated “...Start Date...02/21/2024 Hospice Provided...Medication... Methadone HCL Intensol [narcotic pain medication used to treat severe pain] ...Route...Oral...Dose/Amount...10 MG [milligrams]/ML[milliliter] (give 0.25 ML= 2.5MG) ...Frequency...Every 12 hours...” A review of Patient 1’s “Hospice Nursing Clinical Note,” dated 2/21/24, indicated “... patient had been complaining of increased pain located on his mid back. He used to be able to tolerate the pain, but now even with slight movement like lowering of the bed already triggers the pain...” A review of Patient 1’s “Hospice Nursing Clinical Note,” dated 2/23/24, indicated “...Patient was given 2.5 ml of Methadone at approximately 10:30 pm. family noted in early morning patient was very hard to arouse and non responsive [HA] was called at this time. SN [Skilled Nurse] found patient to be semi-comatose eyes are closed when open appears glossy with no tracking. No active movement or verbal response is noted to name or tactile [touch] stimuli...SN spoke with [name of HA pharmacy] to the Pharmacist who mislabeled medication, she is sending someone out with a new label to re label medication...” A review of Patient 1’s “Hospice Nursing Clinical Note,” dated 2/24/24, indicated “...Upon arrival to visit SN was unable to obtain any vital signs auscultate [hear] heart sounds and noted patient to have ceased breathing...” A review of Patient 1’s “Care Coordination Note,” dated 2/23/24, indicated “...Received a message from the patient’s [name of Family Member] that the patient was administered Methadone conc. [concentrate] 10mg/ml, 2.5 ml last night because of severe pain. She reported that this morning he was “out of it” and seemed like he wanted to vomit but he couldn’t...SN tried to clarify if it was 0.25 ml or 2.5 ml that was given and she stated that she followed what was written on the bottle. She took a picture of the bottle and it stated methadone 10mg/ml, Take 2.5 ML every 12 hours. The hospice order to [name of HA pharmacy] was rechecked and clearly written as Methadone 10mg/ml, take 2.5 mg (0.25ml) every 12 hours for pain management...” During an interview on 3/1/24 at 12:39 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that Patient 1’s medication, Methadone, was delivered to the home on 2/22/24 and had been mislabeled by the pharmacy. The DPCS stated Patient 1’s family member administered the medication on 2/22/24 according to label instructions on the bottle. Patient 1 received 2.5 ml instead of 0.25 ml that had been ordered. The DPCS stated that Patient 1’s family member contacted SN 2 on 2/23/24 and notified SN 2 that Patient 1 had received the wrong dose of Methadone. The HA pharmacy was contacted and sent a new corrected label to the home for the Methadone. During a telephone interview on 3/20/24 at 9:08 a.m. with SN 1, SN 1 stated she went to Patient 1’s home on 2/23/24. SN 1 stated Patient 1 had been given, by a family member, the incorrect dosage of Methadone on 2/22/24 due to an incorrect medication label. SN 1 stated the Methadone bottle was labeled to give 2.5 ml instead of 0.25 ml. Patient 1’s family member had given what the label instructed. SN 1 stated she contacted the HA Pharmacist and a new corrected label was sent to Patient 1’s home. During a joint telephone interview with the HA Pharmacy Owner (OHAP) and the HA Pharmacist (PHM), OHAP stated methadone for Patient 1 was ordered on 2/21/24 by the HA and delivered to Patient 1’s home on 2/22/24. The OHAP stated Patient 1’s order for Methadone was labeled incorrectly because a pharmacy technician typed 2.5 ml instead of 2.5 mg. The OAH stated another pharmacy technician filled the medication and the PHM checked it off but did not catch the error. The OHAP stated, “It was our mistake.” The PHM stated she was notified by the HA nurse on 2/23/24 that Patient 1’s methadone was mislabeled and Patient 1 had received 25 mg of methadone instead of 2.5 mg. PHM contacted the OAH and a new label was sent to Patient 1’s home. The OAH stated that the staff has been retrained to ensure labeling is correct. During a telephone interview on 3/20/24 at 12:38 p.m. with SN 2, SN 2 stated Patient 1 had severe back pain on 2/21/24 and Methadone 0.25 ml for 2.5 mg every 12 hours was ordered. It was delivered to the home and family administered it on 2/22/24. On 2/23/24, Patient 1’s family member contacted her and reported Patient 1 was “out of it.” SN 2 received a picture of the bottle and observed it was incorrectly labeled. The family had administered 2.5 ml instead of 0.25 ml. SN 2 stated she checked the order which was correct. A review of the HA Policy and Procedure (P&P) titled “Identification of Medication for Administration,” revised 11/20, indicated “...To provide general guidelines for the safe administration of medications in the home...Medications will be properly labeled with the patient’s name, an additional patient identifier, name of drug, dosage...The nurse will review the medication label for name, additional patient identifier, drug, dosage, and prescription....The nurses will document medication teaching, side effects, administration, and other related information in the clinical record...” A review of the HA P&P titled “Medication Profile,” revised 11/20, indicated “...the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver...understand the medication regimen...Using the medication profile to teach drug purposes, dosages...” A review of the HA P&P titled “Entries into the Clinical Record,” not dated, indicated “...A clinical record will be initiated and maintained for each patient...and will include at a minimum...Patient and family education...All entries into the clinical record will reflect the date care was provided...All visit notes must be completed within 24-48 hours...””