Healthflex Hospice

“Based on interview and record review, the hospice agency’s licensed staff did not provide adequate symptom control for one of three sampled patients (Patient 1) when staff did not educate the family on hospice medications and indications for use. This resulted in unnecessary distress for Patient 1 and her caregiver (Family Member 1). Record review of the document “(Hospice Name) Hospice Patient Information Handbook” dated 2022 showed the following: “Because of pain, disorientation, confusion, and/or loss of sleep, a hospice patient can often exhibit a wide range of emotions within just a few minutes, hours or days. Agitation and anxiety are caused by a variety of factors. Medication is a dependable way to decrease agitation or anxiety and to increase peacefulness.”Record review of Patient 1’s clinical document “RN Initial Assessment” dated 11/12/2025 showed, Patient 1’s primary diagnosis was malignant breast cancer (malignant: spread to other organs.) Patient 1’s level of anxiety was described as “Slight.” The “Medication Administration Record” was blank and signed by Registered Nurse 1 (RN 1) on 11/12/2025. There was no documentation in the clinical record which showed Patient 1 or Family Member 1 were educated on the types of hospice medications and indications for use.Record review of Patient 1’s clinical document “RN Initial Assessment” dated 11/12/2025 showed Patient 1 had been experiencing abdominal pain which was treated with pain medication when seen by Registered Nurse 1 (RN 1) at 6 p.m. Patient 1 had also been experiencing slight shortness of breath and anxiety. Record review of the document “Delivery Manifest” showed the hospice medications were delivered on 11/13/2025 at 11:12 p.m. (17 hours and 12 minutes later). In a concurrent interview, the Director of Patient Care Services (DPCS) confirmed the delivery date and time and stated there were no other hospice medications available to the patient and caregiver until the medications arrived. The DPCS stated, the delay in receiving the medications and necessary education regarding indications for use can lead to a delay in adequate symptom control.Record review of Patient 1’s clinical document “RN Initial Assessment” dated 11/12/2025 showed no documentation that hospice medications were available and reviewed with the caregiver. In a concurrent interview at 12:19 p.m. on 2/4/2026 with RN1, RN 1 confirmed there was no documentation which showed the medications had been reviewed. RN 1 stated it was important to provide the education so caregivers are prepared for the stages of hospice and can anticipate how to control the symptoms.Record review of Patient 1’s clinical document “RN Skilled Nursing Visit” dated 11/13/2025 showed no documentation that staff had educated Patient 1’s caregiver regarding the hospice medications and indications for use.Record review of the documents “Patient Communication” showed Patient 1’s caregiver called the agency on 11/16/2025 at 1 p.m. stating Patient 1 was vomiting “Fresh bright red blood.” Agency staff advised the caregiver to give Zofran to Patient 1 (Zofran: an anti-nausea medication). The caregiver called again at 4 p.m. stated the Zofran was “Ineffective.” The caregiver called a third time on 11/17/2025 at 4:15 p.m. stating Patient 1 was having “Discomfort” and was heard through the phone “Moaning in the background.”During an interview on 2/5/2026 at 11:52 a.m. with Family Member 1, FM1 denied staff had educated her on hospice medications and indications for use. She stated if she had been made aware of the anti-anxiety medication sooner, she would have used them. Family Member 1 sated Patient 1 had taken a turn “Very quickly.” She stated the bag of hospice medications had been delivered to her home on 11/13/2025 and remained unopened until 11/17/2025 (the day Patient 1 passed.) Family Member 1 stated Patient 1 was “Fighting her symptoms.” It was then that she started to give the lorazepam (anti-anxiety medication) but it was not working. She stated by the time she gave the medication the “Symptoms were out of control” and it was “Harder to get them back under control.” Family Member 1 stated Patient 1 had been restless leading up to her death and if she had been aware of the lorazepam she would have given it sooner.”

“Based on interview and record review, licensed agency staff did not follow the plan of care for one of three sampled patients. (Patient 1), when Home hospice aide services had been ordered for Patient 1 and were never provided.This resulted in unnecessary distress for Patient 1’s caregiver and high probability of discomfort for Patient 1. Record review of the document “(Hospice Name) Hospice Patient Information Handbook,” dated 2022, showed “Hospice Aide services are provided under the supervision of a Registered Nurse to patients whose primary caregivers are unable to assume full patient care due to physical or emotional limitations or when patients live alone and are unable to care for themselves.” The Home Hospice Aide “Assists with the patient’s personal care, including bathing, hair care, shaving, skin care, linen changes, catheter care, dressing, and straightening up the patient’s immediate surroundings.” The Aide also “Helps to move the patient in bed, moving to a wheelchair, or walking if the patient is mobile.”Record review of Patient 1’s clinical document “RN Initial Assessment” dated 11/12/2025 showed Patient 1’s primary diagnosis was malignant breast cancer (malignant: cancer had spread to other organs). Patient 1’s primary caregiver (Family Member 1) provided assistance with bathing, dressing, toileting, bowel/bladder, eating/feeding, medications, psychosocial support, housekeeping and laundry. Further review of the record showed Patient 1 required a Hospice Aide.Record review of Patient 1’s clinical document RN – Skilled Nursing Visit, dated 11/13/2025 showed Patient 1’s abdomen was “Enlarged and hard to touch.”During a concurrent interview and record review on 2/3/2026 at 11:49 a.m. with the Agency’s Administrator (ADM 1). ADM 1 stated there was no documentation in the clinical records regarding setting up home hospice aide services for Patient 1.Record review of the document “Patient Communication” dated 11/13/2025 showed the home health aide documented “Called to schedule a visit. No call back received.” In a concurrent interview at 12:18 p.m. on 2/3/2026, the Director of Patient Care Services (DPCS) stated the communication note did not reflect who the aide had called, the phone number called, nor the time of the call. The DPCS confirmed it was not possible to confirm the call had taken place. During an interview at 11:52 a.m. on 2/5/2026, Family Member 1 stated an aide never showed up in the home nor had she received a call from the hospice agency regarding scheduling one. She stated having an aide would have been “Super helpful” as Patient 1 had gained a lot of weight due to her retention of fluids. Family Member 1 stated it was difficult to move, bathe, and reposition Patient 1 without assistance.”

“Upon patient record review, 2 of 19 (Patients #6, #8) 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 Patient 6: During home visit caregiver states no longer taking Seroquel 25mg and denies having haloperidol concentrate in home however, these remain on medication profile-corrected on site Patient 8: During home visit caregiver states not taking acetaminophen and no longer taking senna tabs due to inefficiency however, these remain on the medication profile-corrected on site”

“Upon patient record review, 2 of 19 (Patients #6, #8) 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 6: Caregiver states no longer taking Seroquel 25mg and denies having haloperidol concentrate in home however, there is no order to discontinue these medications-corrected on site Patient 8: Caregiver states not taking acetaminophen and no longer taking senna tabs due to inefficiency, neither medication found in home and not order to discontinue these medications-corrected on site”

“Upon patient record review, 3 of 19 (Patients #1, #10, #14) 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 equipment and supply needs. Patient 1: Patient has oxygen on medication order, but there is no oxygen concentrator equipment order-corrected on site. Patient 10: has duonebs on order, but there is no nebulizer ordered for delivery-corrected on site. Patient 14: has duonebs on order, but there is no nebulizer ordered for delivery-corrected on site”

“Upon patient client record review, 1 of 19 (Patient #6) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 6: In the recert visit the nurse charts that there are no current wounds, but in the narrative, nurse charts that there is “an unspecified stage pressure ulcer to sacral area” Upon investigation, hospice notes that the patient does not have any active wounds.”