Acacia Hospice and Palliative Services

“Upon patient record review 1 of 19 (Patient #1) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #1 - Patient was admitted to hospice on 12/02/25. The medical record showed an order dated 12/02/25 for an MSW comprehensive to be completed. There was no evidence of a missed visit until 12/17/25 where it was noted patient declined social work visits. The nursing comprehensive completed on 12/02/25, did not include the psychosocial elements required for the psychosocial comprehensive assessment.”

“Upon patient record review, 2 of 19 (Patient #2,7) 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 #2 - Patient resides in an assisted living environment. On 02/16/26, the medical record contained an order for wound care to the left upper leg two times per week. There was no evidence of or identification as to which provider was to complete the wound care. The plan of care did not contain any evidence of the delegation of any interventions related to the other aspects of patient’s care. Patient #7 - Patient resides in an assisted living. There is no evidence of which provider is responsible for performing the interventions related to the patient’s wound care.”

“Based on interview and record review, the hospice failed to include all current medications’ potential drug interactions and duplicate drug therapy in the comprehensive assessments for two of two sampled (Patients 1 and 2), creating the risk for substandard care. 2. Review of Patient 2’s clinical record was initiated on 8/12/24. The clinical record showed the SOC was 1/10/24. The patient was certified for hospice services during the certification period from 7/8/24 to 9/5/24. The POC/POC order dated 7/18/24 and 8/1/24, and the patients Medication Profile for certification from 7/8/24 to 9/5/24, showed the medications interaction for duplicate therapy and drug to drug interaction. Under section level, review suggested for the following medication to medication interaction: a. Brilinta oral Tablet 90 mg one tablet twice a day for antiplatelet and Aspirin oral Tablet Chewable 81 mg one time daily for anticoagulant. b. Hydrocodone-acetaminophen one tablet 5-325 mg oral three times a day prn mild to moderate pain and Lorazepam 0..5 milligram one tablet oral every 4 hours prn anxiety. Review of IDG notes dated 7/18/24, and 8/1/24, showed the POC was reviewed, discussed, and approved by the Hospice Physician and IDT team. However, there was no documented evidence the IDG had identified the potential drug interactions and duplicate therapy from medication profile 7/8/24 to 9/5/24. On 8/15/24 at 1130 hours, a concurrent clinical record review and interview was conducted with QAPI Coordinator/VP of Clinical Services and DPCS. They were informed and acknowledged the findings. Findings: The hospices P&P titled Medication Profile revised date 1/22, showed a drug regimen review will be performed 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 the addition of new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy. 1. Review of Patient 1’s closed clinical record was initiated on 8/12/24. The clinical record showed the SOC was 6/24/24. The patient was certified for hospice services during the certification period from 6/24/24 to 9/21/24. The patient expired on 6/30/24. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 6/26/24 and the Client Medication Report, showed the following medications: - morphine (opioid analgesic) concentrate 20 mg/ml 0.5 ml PO/under tongue Q four hours PRN for SOB or severe pain - oxycodone acetaminophen (opioid analgesic) 5-325 mg one tablet PO Q four hours PRN for moderate to severe pain. - lorazepam (antianxiety) 1 mg/0.5 ml 0.5 mg under the tongue for anxiety/agitation. According to Lexi-Comp’s pharmacology website, the US Boxed Warning for lorazepam included concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Further review of the Client Medication Report showed all medications had been reviewed on 6/25, 6/26, 6/27, 6/29, 7/1/ and 7/18/24, for any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy . * However, there was no documented evidence the IDG had identified the potential drug interactions between lorazepam, oxycodone acetaminophen, and morphine. On 8/15/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the CEO, Chief Compliance Officer/VP of Operations, QAPI Coordinator/VP of Clinical Services, and the DPCS. They were informed of the findings.”

“Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for one of two sampled patients (Patients 2), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: Review of Patient 2’s clinical record was initiated on 8/12/24. The clinical record showed the SOC was 1/10/24. The patient was certified for hospice services during the certification period from 7/8/24 to 9/5/24. Review of the IDG meeting dated 7/3, 7/18, and 8/1/24, showed a care plan addressing self-care deficit due to the patient requiring assistance to meet his personal care needs. The intervention included to assess the need for volunteer services. However, there was no documented evidence an assessment was completed on the patient’s need for volunteer services . On 8/15/24 at 1130 hours, an interview and concurrent clinical record review was conducted with the QAPI Coordinator/VP of Clinical Services and DPCS. They were informed and acknowledged the finding.”

“Based on interview and record review, the hospice failed to ensure the individualized care plans were developed and included interventions based on the problems identified in the comprehensive assessments for two of two sampled patients (Patients 1 and 2). This failure had the potential to cause inconsistent delivery of care which can result in the decline or lack of improvement of the patients’ health conditions. 1. Review of Patient 2’s clinical record was initiated on 8/12/24. The clinical record showed the SOC was 1/10/24. The patient was certified for hospice services during the certification period from 7/8/24 to 9/5/24. a. Review of the POC/ POC order dated 7/18/24 and 8/1/24, showed the patient was identified to have Imodium A-D Oral Tablet 2 MG one tablet After each loose stool and Take 2 tablets at onset of diarrhea and maximum 24 tablet per 24 hours. However, the care plan problem did not address the gastrointestinal issue. In addition, Review of the IDG review dated 7/18/24 and 8/1/24 showed POC was reviewed, discussed and approved by the Hospice Physician and IDT team. However, the care plan problem did not address the gastrointestinal issue. Review of the RN-skilled nursing visit note dated 7/8/24 showed the patient continues to have gastrointestinal issues and Intermittent Diarrhea. Review of the RN-Skilled Nursing visit note dated 7/11/24, 7/15/24 and 7/18/24 showed the digestive nutrition assessment included Incontinent of bowel. The patient continues to have intermittent diarrhea and has been worsening. Review of the RN-Skilled Nursing visit note dated 7/22/24 showed the digestive nutrition assessment included have intermittent diarrhea and has been worsening per patient. Review of the RN- Skilled Nursing visit note dated 7/29/24 showed the digestive nutrition assessment included incontinent of bowel and does have intermittent diarrhea. Review of the RN - Skilled Nursing Visit note dated 8/8/24 and 8/12/24, showed the SN had performed body system assessment. The digestive nutrition assessment included the patient have bowel incontinence. Patient does have intermittent Diarrhea. b. Review of the POC/POC care dated 7/18/24 and 8/1/24 showed the patient was identified to have Basaglar KwikPen Subcutaneous Solution Pen-injector 26 units at bedtime for diabetes type two. However, the care plan problem did not address the diabetes, the use and side effect of insulin. c. Review of the POC/POC care dated 7/18/24 and 8/1/24 showed the patient was identified to have Naloxone Hydrochloride nasal liquid 4 milliliter 1 spray every day Opioid Overdose and Give 1 spray to nostril intranasally every day. May give additional Spray if no response after. However, the care plan problem did not address the use and side effects of Narcan. On 8/15/24 at 1130 hours, an interview and concurrent clinical record review was conducted with the QAPI Coordinator/VP of Clinical Services and DPCS. They were asked if the POC of gastrointestinal, the diabetes, the insulin and Narcan administration was develop. The DPCS reviewed the clinical record and was unable to provide the documentation. The QAPI Coordinator/VP of Clinical Services and DPCS designee were informed and acknowledged the findings. Findings: The hospices P&P titled The Plan of Care revised date 1/22, showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. 1. Review of Patient 1’s closed clinical record was initiated on 8/12/24. The clinical record showed the SOC was 6/24/24. The patient was certified for hospice services during the certification period from 6/24/24 to 9/21/24. The patient expired on 6/30/24. a. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 6/26/24, showed the patients medications included morphine (opioid analgesic) concentrate 20 mg/ml 0.5 ml by mouth/under tongue Q four hours PRN for SOB or severe pain and oxycodone acetaminophen (opioid analgesic) 5-325 mg one tablet PO Q four hours PRN for moderate to severe pain. * However, there was no documented evidence a care plan problem was developed to address the potential side effects of the opioid medications. b. The Visit Note Report dated 6/24/24, showed under Integumentary assessment the patient had three Stage 2 pressure injuries and there was no Stage 3 pressure injury. The Visit Note Report under the Wound Assessment showed the patient had a Stage 3 “;MID POST” perineum pressure injury and Stage 2 right and left low buttock pressure injuries. The Hospice Certification and Plan of Care, for the certification period from 6/24/24 to 9/21/24, showed SN to provide wound care per orders; SN to educate CG in performing wound care; SN to educate CG in maintaining standard precautions; and SN to educate patient/CG in basic principles of wound healing. The physicians order dated 6/24/24, showed to cleanse Stage 2 mid posterior perineum wound with warm soap and water, pat dry, mix A&D (protective barrier) and Calmoseptine (moisture barrier) and apply to affected site daily with each diaper change for 14 days, then reassess. The physicians order dated 6/27/24, showed SN visits 4W1 (four times a week for one week), 3W12, and 3 PRN for urgent symptom management, needs, or changes in condition effective 6/24/24. The physicians order dated 7/5/24, with a verbal order date of 6/24/24, showed to cleanse Stage 2 right and left lower buttocks wound with warm soap and water, pat dry, mix A&D and Calmoseptine (moisture barrier) and apply to affected site daily with each diaper change for 14 days, then reassess. * However, there was no documented evidence the POC included who will be responsible for wound care during non-SN days. On 8/15/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the CEO, Chief Compliance Officer/VP of Operations, QAPI Coordinator/VP of Clinical Services, and the DPCS. They were informed of the findings. Findings: The hospices P&P titled The Plan of Care revised date 1/22 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. 1. Review of Patient 1’s closed clinical record was initiated on 8/12/24. The clinical record showed the SOC was 6/24/24. The patient was certified for hospice services during the certification period from 6/24/24 to 9/21/24. The patient had expired on 6/30/24. a. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 6/26/24, showed the patients medications included morphine (opioid analgesic) concentrate 20 mg/ml 0.5 ml by mouth/under tongue Q four hours PRN for SOB or severe pain and oxycodone acetaminophen (opioid analgesic) 5-325 mg one tablet PO Q four hours PRN for moderate to severe pain. * However, there was no documented evidence a care plan problem was developed to address the potential side effects of the opioid medications. b. The Visit Note Report dated 6/24/24, showed the Integumentary assessment section showing the patient had three Stage 2 pressure injuries and there was no Stage 3 pressure injury. The Visit Note Report under the Wound Assessment showed the patient had a Stage 3 “;MID POST” perineum pressure injury and Stage 2 right and left low buttock pressure injuries. The Hospice Certification and Plan of Care, for the certification period from 6/24/24 to 9/21/24, showed SN to provide wound care per the orders and educate the CG in performing wound care, maintaining standard precautions, and basic principles of wound healing. The physicians order dated 6/24/24, showed to cleanse Stage 2 mid posterior perineum wound with warm soap and water, pat dry, mix A&D (protective barrier) and Calmoseptine (moisture barrier) and apply to affected site daily with each diaper change for 14 days then, reassess. The physicians order dated 6/27/24, showed SN visits 4W1 (four times a week for one week), 3W12, and 3 PRN visits for urgent symptom management, needs, or changes in condition effective 6/24/24. The physicians order dated 7/5/24, with a verbal order date of 6/24/24, showed to cleanse Stage 2 right and left lower buttocks wound with warm soap and water, pat dry, mix A&D and Calmoseptine (moisture barrier) and apply to affected site daily with each diaper change for 14 days then, reassess. * However, there was no documented evidence the POC included who will be responsible for wound care during non-SN days. On 8/15/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the CEO, Chief Compliance Officer/VP of Operations, QAPI Coordinator/VP of Clinical Services, and DPCS. They were informed of the findings. 2. Review of Patient 2’s clinical record was initiated on 8/12/24. The clinical record showed the SOC was 1/10/24. The patient was certified for hospice services during the certification period from 7/8/24 to 9/5/24. a. Review of the POC Order dated 7/18 and 8/1/24, showed to administer Imodium A-D (antidiarrheal) 2 mg one tablet after each loose stool and take two tablets at onset of diarrhea with a maximum of 24 tablets per 24 hours. However, there was no documented evidence a care plan problem was developed to address diarrhea. Review of the RN-skilled nursing visit note dated 7/8/24, showed the patient had gastrointestinal issues and intermittent diarrhea. Review of the RN-Skilled Nursing visit note dated 7/11, 7/15, and 7/18/24, showed under the digestive nutrition assessment section, the patient was incontinent of bowel and continued to have worsening intermittent diarrhea. Review of the RN-Skilled Nursing visit note dated 7/22/24, showed the patient had worsening intermittent diarrhea. Review of the RN- Skilled Nursing visit note dated 7/29/24, showed the patient had intermittent diarrhea. Review of the IDG review dated 7/18 and 8/1/24, showed the POC was reviewed, discussed, and approved by the Hospice Physician and IDG. However, there was no documented evidence a care plan problem was developed to address diarrhea. Review of the RN - Skilled Nursing Visit note dated 8/8 and 8/12/24, showed the patient had intermittent diarrhea. b. Review of the POC dated 7/18 and 8/1/24, showed the patient had physician’s order for Basaglar Kwikpen Subcutaneous Solution Pen-injector (antidiabetic) 26 units at bedtime for diabetes type II. However, there was no documented evidence a care plan problem was developed to address diabetes; and the use and side effects of insulin. c. Review of the POC dated 7/18 and 8/1/24, showed the patient had physician’s order for naloxone hydrochloride nasal liquid (opioid antagonist) 4 ml one spray to nostril intranasally every day and may give additional spray if no response after. However, there was no documented evidence a care plan problem was developed to address the use and side effects of naloxone. On 8/15/24 at 1130 hours, an interview and concurrent clinical record review was conducted with the QAPI Coordinator/VP of Clinical Services and DPCS. They were informed of the above findings. The DPCS reviewed the clinical record. The QAPI Coordinator/VP of Clinical Services and DPCS designee were acknowledged the findings.”

“Based on interview and record review, the hospice failed to ensure the POC included measurable outcome for one of two sampled patients (Patient 1), creating the risk of not evaluating the POC and providing appropriate care and services to this patient. Findings: The hospice’s P&P titled Plan of Care revised date 1/22 showed the written plan of care will contain, but not limited to measurable outcomes anticipated from implementing and coordinating the plan of care. The Hospice IDG Comprehensive Assessment dated 6/26/24, showed the patient’s identified problems included pain management/altered comfort, with the following goals: - Objective signs and symptoms of pain will improve with prescribed interventions - Patients pain is managed at a level acceptable to the patient. - Patient/caregiver understands need to report changes in the pain level to hospice staff - Patient/family will understand and teach back how to effectively manage pain and associated symptoms * However, there was no documented evidence of the measurable outcome as to what the acceptable pain level for the patient would be. On 8/15/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the CEO, Chief Compliance Officer/VP of Operations, QAPI Coordinator/VP of Clinical Services, and DPCS. They were informed of the finding.”

“Based on interview and record review, the hospice failed to include the specific indication for the use of medications and the accurate frequency for the use of an anxiolytic medication for one of two sampled patients (Patient 1), creating the risk for the patient not receiving the appropriate care and services necessary to improve the patient’s health condition. 2. Review of Patient 2’s clinical record was initiated on 8/12/24. The clinical record showed the SOC was 1/10/24. The patient was certified for hospice services during the certification period from 7/8/24 to 9/5/24. a. The medication profile for the certification period from 7/8/24 to 9/5/24, showed the patient’s medication included Aspirin low strength oral tablet chewable 81 mg one tablet daily oral for chest pain and Aspirin oral tablet chewable 81 mg one tablet daily for anticoagulant. However, there was no direction for which aspirin medication to be administered first. b. The medication profile for the certification period from 7/8/24 to 9/5/24, showed the patients medication included Fentanyl transdermal patch 72-hour 50 mcg per hour one patches every 3 days for pain, hydromorphone hydrochloride 4 mg one tablet oral every 4 hours prn severe pain. Hydrocodone-acetaminophen one tablet 5-325 mg oral three times a day prn mild to moderate pain. However, there was no direction for which pain medication to be administered first. On 8/15/24 at 1130 hours, a concurrent clinical record review and interview was conducted with the QAPI Coordinator/VP of Clinical Services and DPCS Designee. They were informed and acknowledged the findings. Findings: 1. Review of Patient 1’s closed clinical record was initiated on 8/12/24. The clinical record showed the SOC was 6/24/24. The patient was certified for hospice services during the certification period from 6/24/24 to 9/21/24. The patient expired on 6/30/24. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 6/26/24, showed the following medications: - morphine (opioid analgesic) concentrate 20 mg/ml 0.5 ml by mouth/under tongue Q four hours PRN for SOB or severe pain - oxycodone acetaminophen (opioid analgesic) 5-325 mg one tablet PO Q four hours PRN for moderate to severe pain. - lorazepam 1 mg/0.5 ml 0.5 mg under the tongue for anxiety/agitation. * However, there was no documented evidence which opioid medication was to be administered first for severe pain. * On 8/15/24 at 1100 hours, an interview was conducted with the DPCS. She stated Ativan should have a PRN added in the physicians order. On 8/15/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the CEO, Chief Compliance Officer/VP of Operations, QAPI Coordinator/VP of Clinical Services, and the DPCS. They were informed of the findings. Findings: Review of Patient 1’s closed clinical record was initiated on 8/12/24. The clinical record showed the SOC was 6/24/24. The patient was certified for hospice services during the certification period from 6/24/24 to 9/21/24. The patient had expired on 6/30/24. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 6/26/24, showed the following medications: - morphine (opioid analgesic) concentrate 20 mg/ml 0.5 ml by mouth/under tongue Q four hours PRN for SOB or severe pain - oxycodone acetaminophen (opioid analgesic) 5-325 mg one tablet PO Q four hours PRN for moderate to severe pain. - lorazepam 1 mg/0.5 ml 0.5 mg under the tongue for anxiety/agitation. * However, there was no documented evidence which opioid medication was to be administered first for severe pain. On 8/15/24 at 1100 hours, an interview was conducted with the DPCS. She stated Ativan should have a PRN added in the physicians order. On 8/15/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the CEO, Chief Compliance Officer/VP of Operations, QAPI Coordinator/VP of Clinical Services, and the DPCS. They were informed of the findings.”

“Based on interview and record review, the hospice failed to ensure the IDG maintained the responsibility for directing, coordinating, and supervising the care and services related to the content of the Hospice Admission Booklet and clinical records for two of two sampled patients (Patients 1 and 2), creating the risk of not addressing the care needs for this patients. 2. Review of Patient 2’s clinical record was initiated on 8/12/24. The clinical record showed the SOC was 1/10/24. The patient was certified for hospice services during the certification period from 7/8/24 to 9/5/24 Review of the RN-Skilled Nursing visit note dated 7/11/24, showed the pain assessment for intensity 10 severe, pain intervention: medication and rest, primary site ; generalized pain, current pain management: Dilaudid and Norco effective. Movement usually what make pain worse. Under section pain assessment comment, Chronic back pain and Chest Pains. Reports 10/10 aching pain. -Reports that Fentanyl Patch ineffective for him. Will refer to MD. Will refer to MD for recommendations regarding his worsening chest pains. Review of the RN-Skilled Nursing visit note dated 7/22/24 showed the pain assessment for intensity 10 severe., pain intervention: medication and rest, primary site; generalized pain, current pain management: Dilaudid and Norco effective. Movement usually what make pain worse. -Chronic back pain and Chest Pains. Reports 10/10 aching pain. -Fentanyl Patch adjusted. Reports patient does not feel like it is helping. We will refer to MD. Review of the RN-skilled Nursing visit note dated 7/29/24 showed the pain assessment for intensity 10 severe., pain intervention: medication and rest, primary site; generalized pain, current pain management: Dilaudid and Norco effective. Under section pain assessment comment, patient had Chronic backpain and Chest Pains. Reports 10/10 aching pain. Reports that Fentanyl Patch 25mcg/hr is ineffective. We will refer it to MD. Patient would like to refer it to MD and to see if the Doctor has any recommendations. * However, there was no documented evidence the MD response or recommendation of SN visit dated 7/11/24, 7/22/24, and 7/29/24. The medication profile the certification period from 7/8/24 to 9/5/24, showed on 7/17/24 fentanyl transdermal patch 25 mcg per hour every 72 hours was change to 50 mcg per hour every 72 hours on 7/30/24. On 8/15/24 at 1200 hours, a concurrent clinical record review and interview was conducted with the QAPI Coordinator/VP of Clinical Services, RN 1, and DPCS. RN 1 was asked if he informed the physician regarding the resident had severe pain during his visit on 7/11/24, 7/22/24 and 7/29/24. RN 1 stated the resident always said that his pain 10/10 but the behavior or body posture was relaxed. RN 1 stated he had informed the MD regarding the resident pain and resident was offered another medicine morphine, but resident refused and agreed to increase medication for fentanyl patch following MD order. Physician would like to finish series of his fentanyl patch, gradually increasing the dose and monitoring the residents pain. RN 1 stated patient knew his condition was declining. When asked if he documented the MD recommendation or response. RN 1 stated he should have document it. They were informed and acknowledged the findings. Findings: The hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities dated 1/22, showed the IDG responsibilities include but are not limited to: - Consulting with the patients attending physician if any, completes the initial comprehensive assessment within 5 calendar days after the election of hospice care. - Participation in the establishment of the plan of care for each patient admitted to the hospice service - Participation in the periodic review and updating of the plan of care for each patient receiving hospice services - Provision or supervision of hospice care and services - Oversight of complementary and alternative medicine services if applicable. - Establishment of policies and procedures governing the day-to-day provision of hospice care and services - Reviewing and resolving conflict of care and ethical issues - Provision of an ongoing support for and techniques to avoid overstepping boundaries - Planning for community education regarding Hospice services - Participating in performance improvement activities The hospices P&P titled Interdisciplinary Group Coordination of Care dated January 2022, showed the Hospice interdisciplinary Group will retain professional management responsibilities for the provision of services, including inpatient care, and will ensure that services are furnished in a safe and effective manner. 1. Review of Patient 1’s closed clinical record was initiated on 8/12/24. The clinical record showed the SOC was 6/24/24. The patient was certified for hospice services during the certification period from 6/24/24 to 9/21/24. The patient expired on 6/30/24. a. Review of the Hospice Admission Booklet revised date on 5/24, showed under “;Responsible Use Of Opioids and Overdose Prevention,” in an effort to prevent an overdose from the use of opioid medications, California law requires anyone authorized to prescribe medications to offer you a prescription for naloxone hydrochloride (or another drug approved by the FDA for the complete or partial reversal of opioid depression) if one or more of the following conditions present: - The prescription dosage is 90 or more morphine milligram equivalents of an opioid medication per day; - An opioid medication is prescribed concurrently with a prescription for benzodiazepine; and/or - You present with an increased risk for overdose, including a history of overdose, substance use disorder or are at risk for returning to a high dose of opioid medication to which you are no longer tolerant. According to the Business and Profession Code Division 2 Chapter 1 Article 10.7 Section 741 (a) (1) (a) (b) (c) and (c) (3), amended on 2019 and effective 9/5/19, showed: (a) Notwithstanding any other law, when prescribing an opioid or benzodiazepine medication to a patient, a prescriber shall do the following: (1) Offer the patient a prescription for naloxone hydrochloride or another drug approved by the United States Food and Drug Administration for the complete or partial reversal of opioid-induced respiratory depression when one or more of the following conditions are present: (A) The prescription dosage for the patient is 90 or more morphine milligram equivalents of an opioid medication per day. (B) An opioid medication is prescribed within a year from the date a prescription for benzodiazepine has been dispensed to the patient. (C) The patient presents with an increased risk for opioid overdose, including a patient with a history of opioid overdose, a patient with a history of opioid use disorder, or a patient at risk for returning to a high dose of opioid medication to which the patient is no longer tolerant. (c) This section does not apply to a prescriber under any of the following circumstances: (3) When prescribing medications to a patient who is terminally ill, as defined in subdivision (c) of Section 11159.2 of the Health and Safety Code. * However, the Hospice Admission Booklet was not updated as per the amended Business and Profession Code Division 2 Chapter 1 Article 10.7 Section 741 (a) (1) (a) (b) (c) and (c) (3). * The IDG failed to supervise the care and service related to the accuracy in the content of the Hospice Admission Booklet. b. The P&P titled Contents of the Clinical Record revised date 1/22, showed a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. Documentation will include summary of care and coordination of care provided in other settings, when indicated. Each entry will be dated and signed including title and credentials by the person providing the care and services. The IDG failed to supervise the accuracy and the completeness of the clinical record. For example: a. On 8/14/24 at 1319 hours, an interview was conducted with RN 1. RN 1 stated he conducted a follow-up visit on the morning of 6/30/24. RN 1 stated on the afternoon of 6/30/24, he received a telephone call from the B&C Owner and the family member who was on the speakerphone. RN 1 stated the B&C Owner wanted a patient update. RN 1 stated one of them (B&C Owner or family member) said if he can ask the physician about naloxone (opioid antagonist). RN 1 stated he called and informed the physician that the patient received one dose of morphine sulfate from the previous day and RN 1s assessment. RN 1 stated the physician stated the patient do not need naloxone. RN 1 stated he explained the information to the B&C Owner and the family member. * However, there was no documented evidence of the communication with the B&C Owner and the family member; and the physician on the afternoon of 6/30/24 in the patients clinical record. b. The SN notes showed inconsistency with the patients wound assessment. For example: * The Visit Note Report dated 6/24/24, showed under Integumentary assessment the patient had three Stage 2 pressure injuries and there was no Stage 3 pressure injury. The Visit Note Report under the Wound Assessment showed the patient had a Stage 3 “;MID POST” perineum pressure injury and Stage 2 right and left low buttock pressure injuries, wherein the number of Stage 2 and 3 pressure injuries were not consistent under the Integumentary assessment. * The Visit Note Report dated 6/27/24, showed under Integumentary Assessment the patient had one Stage 2 pressure injury, and there were two Stage 3 pressure injuries. The Visit Note Report under the Wound Assessment showed the patient had a Stage 3 “;MID POST” perineum pressure injury and Stage 2 right and left low buttock pressure injuries, wherein the number of Stage 2 and 3 pressure injuries were not consistent under the Integumentary Assessment. c. The Visit Note dated 6/28/24, showed under Pain Assessment to indicate any pain medications used and the number of PRN doses for each over the past 24 hours. Documentation showed the answer was “;NORCO” (opioid analgesic). * However, review of the clinical record failed to show documented evidence of a physicians order for Norco. On 8/15/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the CEO, Chief Compliance Officer/VP of Operations, QAPI Coordinator/VP of Clinical Services, and the DPCS. They were informed of the findings. Findings: The hospice’s P&P titled Interdisciplinary Group Membership and Responsibilities dated 1/22 showed the IDG responsibilities include but are not limited to: - Consulting with the patients attending physician if any, completes the initial comprehensive assessment within 5 calendar days after the election of hospice care. - Participation in the establishment of the plan of care for each patient admitted to the hospice service - Participation in the periodic review and updating of the plan of care for each patient receiving hospice services - Provision or supervision of hospice care and services - Oversight of complementary and alternative medicine services if applicable. - Establishment of policies and procedures governing the day-to-day provision of hospice care and services - Reviewing and resolving conflict of care and ethical issues - Provision of an ongoing support for and techniques to avoid overstepping boundaries - Planning for community education regarding Hospice services - Participating in performance improvement activities The hospice’s P&P titled Interdisciplinary Group Coordination of Care dated January 2022 showed the Hospice interdisciplinary Group will retain professional management responsibilities for the provision of services, including inpatient care, and will ensure that services are furnished in a safe and effective manner. 1. Review of Patient 1’s closed clinical record was initiated on 8/12/24. The clinical record showed the SOC was 6/24/24. The patient was certified for hospice services during the certification period from 6/24/24 to 9/21/24. The patient had expired on 6/30/24. a. Review of the Hospice Admission Booklet revised date on 5/24 showed under “;Responsible Use Of Opioids and Overdose Prevention,” in an effort to prevent an overdose from the use of opioid medications, California law requires anyone authorized to prescribe medications to offer you a prescription for naloxone hydrochloride (or another drug approved by the FDA for the complete or partial reversal of opioid depression) if one or more of the following conditions present: - The prescription dosage is 90 or more morphine milligram equivalents of an opioid medication per day; - An opioid medication is prescribed concurrently with a prescription for benzodiazepine; and/or - You present with an increased risk for overdose, including a history of overdose, substance use disorder or are at risk for returning to a high dose of opioid medication to which you are no longer tolerant. Review of the Business and Profession Code Division 2 Chapter 1 Article 10.7 Section 741 (a) (1) (a) (b) (c) and (c) (3), amended on 2019 and effective 9/5/19, showed the following: (a) Notwithstanding any other law, when prescribing an opioid or benzodiazepine medication to a patient, a prescriber shall do the following: (1) Offer the patient a prescription for naloxone hydrochloride or another drug approved by the United States Food and Drug Administration for the complete or partial reversal of opioid-induced respiratory depression when one or more of the following conditions are present: (A) The prescription dosage for the patient is 90 or more morphine milligram equivalents of an opioid medication per day. (B) An opioid medication is prescribed within a year from the date a prescription for benzodiazepine has been dispensed to the patient. (C) The patient presents with an increased risk for opioid overdose, including a patient with a history of opioid overdose, a patient with a history of opioid use disorder, or a patient at risk for returning to a high dose of opioid medication to which the patient is no longer tolerant. (c) This section does not apply to a prescriber under any of the following circumstances: (3) When prescribing medications to a patient who is terminally ill, as defined in subdivision (c) of Section 11159.2 of the Health and Safety Code. * However, the Hospice Admission Booklet was not updated related to offering a prescription for naloxone hydrochloride as per the amended Business and Profession Code Division 2 Chapter 1 Article 10.7 Section 741 (a) (1) (a) (b) (c) and (c) (3). b. The hospice’s P&P titled Contents of the Clinical Record revised date 1/22 showed a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. Documentation will include summary of care and coordination of care provided in other settings, when indicated. Each entry will be dated and signed including title and credentials by the person providing the care and services. The IDG failed to ensure the accuracy and the completeness of the clinical record. For example: a. On 8/14/24 at 1319 hours, an interview was conducted with RN 1. RN 1 stated he conducted a follow-up visit on the morning of 6/30/24. RN 1 stated on the afternoon of 6/30/24, he received a telephone call from the B&C Owner and the family member who was on the speakerphone. RN 1 stated the B&C Owner wanted a patient update. RN 1 stated one of them (B&C Owner or family member) said if he can ask the physician about naloxone (opioid antagonist). RN 1 stated he called and informed the physician that the patient received one dose of morphine sulfate from the previous day and RN 1s assessment of Patient 1’s condition. RN 1 stated the physician stated the patient did not need naloxone. RN 1 stated he explained the information to the B&C Owner and the family member. * However, there was no documented evidence of the communication with the B&C Owner and the family member; and the physician on the afternoon of 6/30/24 in the patients clinical record. b. Resident 1’s SN notes showed inconsistency with the patients wound assessment. For example: * The Visit Note Report dated 6/24/24, showed under Integumentary assessment, the patient had three Stage 2 pressure injuries and there was no Stage 3 pressure injury. The Visit Note Report under the Wound Assessment showed the patient had a Stage 3 “;MID POST” perineum pressure injury and Stage 2 right and left low buttock pressure injuries, wherein the number of Stage 2 and 3 pressure injuries were not consistent under the Integumentary assessment. * The Visit Note Report dated 6/27/24, showed under Integumentary Assessment, the patient had one Stage 2 pressure injury, and there were two Stage 3 pressure injuries. The Visit Note Report under the Wound Assessment showed the patient had a Stage 3 “;MID POST” perineum pressure injury and Stage 2 right and left low buttock pressure injuries, wherein the number of Stage 2 and 3 pressure injuries were not consistent under the Integumentary Assessment. c. The Visit Note dated 6/28/24, showed under the Pain Assessment section to indicate any pain medications used and the number of PRN doses for each over the past 24 hours. Documentation showed the answer was “;NORCO” (opioid analgesic). * However, review of the clinical record failed to show documented evidence of a physicians order for Norco. On 8/15/24 at 1100 hours, an interview and concurrent clinical record review was conducted with the CEO, Chief Compliance Officer/VP of Operations, QAPI Coordinator/VP of Clinical Services, and DPCS. They were informed of the findings. 2. Review of Patient 2’s clinical record was initiated on 8/12/24. The clinical record showed the SOC was 1/10/24. The patient was certified for hospice services during the certification period from 7/8/24 to 9/5/24. Review of the RN-Skilled Nursing visit notes dated 7/11, 7/22, and 7/29/24, showed Patient 2 had severe back and chest pain, with a pain level 10 (on a pain scale of 0 to 10, with 0= no pain and 10 = severe pain) and fentanyl (opiate analgesic) patch was not effective. Documentation showed the RN would refer the worsening chest pain to the physician. * However, there was no documented evidence the RN had consulted the physician regarding Patient 2’s worsening chest pain on 7/11, 7/22, and 7/29/24. Review of the medication profile the certification period from 7/8/24 to 9/5/24, showed on 7/30/24, fentanyl transdermal patch was changed from 25 to 50 mcg per hour every 72 hours On 8/15/24 at 1200 hours, an interview and concurrent clinical record review was conducted with the QAPI Coordinator/VP of Clinical Services, RN 1, and DPCS. RN 1 was asked if he informed the physician regarding Patient 2’s severe pain during his visit on 7/11, 7/22, and 7/29/24. RN 1 stated the patient would always say his pain level was 10; however, his behavior or body posture was relaxed. RN 1 further stated he had informed the physician regarding Patient 2’s pain and was offered morphine but the patient refused and opted to increase the dosage of fentanyl patch. RN 1 further stated the physician would like to finish the series of his fentanyl patch and gradually increasing the dose. RN 1 stated Patient 2’s condition was declining. When asked if he documented the physician’s recommendations or responses, RN 1 replied he should have documented it. They were informed and acknowledged the findings.”