Matrix Care Hospice

“Upon patient record review, 2 of 14 (Patient #1,6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: It was observed during the home visit the patient was taking Seroquel 50mg BID. The hospice medication sheet identified Seroquel 100 mg BID. This was corrected on site by updating medication sheet for Seroquel 50 mg BID. Patient #6: There is evidence of a DME order for Oxygen concentrator and the Nursing admission note states the patient uses Oxygen as needed. Oxygen is not listed on the hospice medication sheet.”

“Upon patient record review, 4 of 14 (Patient #2,3,6,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: There is evidence the patient is on ASA. The plan of care does not include risk of bleeding. Patient #3: There is evidence the patient is on Pradaxa. The plan of care does not include risk of bleeding. Patient #6, 10: The social worker has a visit frequency of 1X month. There is no problems, interventions, and goals on the plan of care for psychosocial needs. The patient had no mortuary identified and the social worker is meeting with the patient to discuss arrangements.”

“Upon patient record review, 2 of 14 (Patient #1,2) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1: There is evidence the Chaplain visit frequency is PRN for spiritual issues. There is no frequency for those visits. Patient #2: There is evidence the Chaplain visit frequency was PRN for spiritual issues and recertification. There is no frequency for those visits.”

“Upon patient record review, 3 of 14 (Patient #1,2,6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: It was observed during the home visit the patient was taking Seroquel 50mg BID. The hospice plan of care identified Seroquel 100 mg BID. This was corrected on site by getting a order for Seroquel 50 mg BID. Patient #2: There is an order for left foot wound, cleanse with NS, pat dry, apply ointment, cover with tegaderm and change every 3-5 days and as needed for soiling. There is no indication who will change the dressing. Patient #6: There is evidence of a DME order for oxygen and the nursing admission note states the patient uses oxygen as needed. There is no order for oxygen.”

“Upon client record review, 3 of 14 (Patient #1,6,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: There is evidence the Chaplain visit frequency is PRN for spiritual issues. The chaplain completed visits monthly in October, November and December and visits identified as “routine” visits. Patient #6: There is evidence the SN visit frequency was 2X wk. The last SN visit was on 12/30/25. No 2nd visit the week of 12/30/25 and no visit the week of 1/4 to 1/10/26. Patient #10: There is evidence the MSW visit frequency was 1X mo. There is no visit in Oct., 2025.”

“Upon patient record review, 1 of 14 (Patient #13) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #13: There is no evidence of a bereavement plan of care. There is no documentation of unsuccessful attempts to reach the bereaved.”

“Upon patient record review 1 of 14 (Patient #3) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #3: There is evidence the last RN supervisory note was on 12/13/25. There is no supervision for the aide visits on 12/16, 12/18 and 12/23/25.”

“Based on interview and record review, the agency failed to ensure a medication reconciliation (process of identifying the most accurate list of all medications that the patient is taking) was conducted during the initial and recertification assessment for one of four sampled patients (Patient 3) when two medications Patient 3 was taking were not on the Medication Profile (MP-a current list of all medications prescribed for a specific patient). This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy, which could place Patient 3s health and safety at risk. Findings: A review of Patient 3s face sheet (document that gives a summary of patients information) indicated a start of care date of November 11, 2024, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of February 14, 2025, to May 15, 2025. Patient 3 had primary diagnoses that included chronic obstructive pulmonary disease (lung condition that makes it hard to breathe), insomnia (trouble falling or staying asleep) and osteoporosis (condition where bones become weak and brittle, making them more likely to break). During a home visit, on March 4, 2025, at 12:10 PM, at Patient 3’s house, with a Licensed Vocational Nurse 1 (LVN 1), in the presence of Patient 3 and Patient 3s daughter, LVN 1 inspected Patient 3s medication bottles, which were available at home, and were compared with Patient 3s most current MP. During a concurrent observation, interview, and record review, on March 4, 2025, at 12:20 PM, with LVN 1, LVN 1 checked Patient 3’s bottle of Melatonin (supplement used to help with sleep problems) 5 mg (milligram-a unit of measure). LVN 1 reviewed Patient 3s MP and was not able to find the order of Melatonin. LVN 1 acknowledged Melatonin was not listed on Patient 3’s MP. During an interview on March 4, 2025, at 12:15 PM, with Patient 3s daughter, Patient 3s daughter stated, “;She [Patient 3] had been taking Melatonin since in the beginning of starting hospice (care that helps people with a terminal illness feel comfortable and supported in their final stages of life). Her doctor is aware of it.” During further observation and interview on March 4, 2025, at 12:20 PM, with LVN 1, LVN 1 checked Patient 3’s bottle of Tramadol (prescription medication used to relieve moderate to severe pain) 50 mg one tablet by mouth four times a day. LVN 1 reviewed Patient 3’s MP and was not able to find the order of Tramadol. LVN 1 acknowledged Tramadol was not on Patient 3s MP. During an interview on March 4, 2025, at 12:30 PM, with Patient 3s daughter, Patient 3s daughter stated, “;She [Patient 3] had been taking Tramadol at least for the last two years for her mother right arm pain. Her doctor is aware of it.” During an interview on March 5, 2025, at 2:30 PM, with the Director of Patient Care Services (DPCS), the DPCS stated, “;It was the visiting nurse and case managers responsibility to update Medication Profile when there’s any new order or changes. Nurses should have been reviewing, updating medication profile on their visits and the printed MP should have been updated accordingly.” During a concurrent interview and record review on March 5, 2025, at 3:20 PM, the DPCS reviewed the agencys policy and procedure (P&P) titled “;Medication Profile,” revised November 2020, which indicated, “;PURPOSE To define the use of the medication profile in evaluating a patient’s current medication regimen. POLICY Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. PROCEDURE... 2. The admitting nurse will initiate a medication profile to document the current medication regiment... 5. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. ...”. The DPCS stated the agency did not follow the policy.”

“Based on observation, interview, and record review, the agency failed to ensure necessary essential documents were provided for one of four sampled patients (Patient 1), when Patient 1’s home clinical record binder did not contain his current care plan (a guide that lists their medical and emotional needs, including treatments, medications, and personal wishes, to ensure their comfort and care) including his most current Medication Profile (MP-a current list of all medications prescribed for a specific patient). This failure had the potential to result in ineffective care coordination, unmanaged symptoms, and medication errors (mistakes with medicines that can cause harm or stop proper treatment), which could place Patient 1s safety, comfort, and overall well-being at serious risk in his end-of-life care. Findings: A review of Patient 1s face sheet (document that gives a summary of patients information) indicated a start of care date of January 14, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice (medical care for people who are expected to live six months or less) services) of January 14, 2025, to April 13, 2025. Patient 1 had primary diagnoses that included chronic obstructive pulmonary disease (lung condition that makes it hard to breathe), hypertension (blood pressure too high), and insulin-dependent diabetes mellitus (chronic condition where body produce little or no insulin [a hormone that controls blood sugar]). During a home visit on March 3, 2025, at 3:15 PM, in Patient 1’s home, with the Spiritual Counselor (SC), in the presence of Patient 1 and Patient 1s care giver, the SC reviewed Patient 1s home clinical record binder, and was unable to find Patient 1s current care plan including the most recent MP. It was not found in the binder or anywhere in the house. Both the SC and Patient 1 confirmed that these essential documents were not available. During an interview on March 5, 2025, at 2:30 PM, with the Director of Patient Care Services (DPCS), the DPCS stated, “;It is the responsibility of the visiting nurse and case manager to ensure that the current care plan including the most recent Medication Profile (MP), and other essential documents are left at the patients location and are easily accessible.” Furthermore, the DPCS stated the current care plan including the most recent MP were crucial for maintaining effective care coordination, proper medication management, and timely clinical responses. During a concurrent interview and record review on March 5, 2025, at 3:00 PM, the DPCS reviewed the agencys policy and procedure (P&P) titled “;Home Binder and Content Policy”, which indicated, “;Purpose. To provide safe home visits and follow the content of the binder. The home binder shall: 1. Be left at the patients location or dwelling, in an area that is dry and easily located... 2. Contain the following: ... i. Initial order & plan of care comprehensive assessment... k. Medication Profile...”. The DPCS stated the agency did not follow the policy.”