Compassus-Savannah

“Based on record review, family and staff interviews, it was determined that the Registered Nurse (RN) failed to assess patients current needs and current symptoms and document in writing a patient-specific comprehensive assessment that identifies the patients need for appropriate treatment and services related to the palliation and management of the terminal illness for one patient (P) (P#1) of four sampled patients. Specifically, RN AA failed to document the effects of medications that was administered to P#1. Findings include: Review of the document titled “;Physician Order” dated 1/4/2025 for P#1 revealed the following: morphine sulfate (used to treat severe pain) 20mg/ml; take 0.5ml (10mg) by mouth every 2 hours as needed for pain and shortness of breath. lorazepam 0.5mg by mouth every 4 hours as needed for anxiety or shortness of breath. Review of record for P#1 revealed an order for antibiotic (medications that fight bacterial infections) dated 12/31/24, due to cough and aspiration from cough. Levaquin 500mg ,1 tablet by mouth for 7 days. However, the medication was not administered to P#1. Clinical records failed to reveal that MD was notified of patients inability to swallow, order to hold the antibiotic, and revised care plans to meet patients current assessment and/or change in patients condition. Review of Registered Nurse (RN) AA visit note dated 1/4/25, RN AA documents morphine given to P#1, second dose given to P#1. The visit note failed to specify the effectiveness and the response of the medication. An interview was conducted at the agency on 1/31/25 at 12:30 p.m., with RN AA, who revealed on 1/4/25 she administered morphine sulfate 1ml at 1:36 p.m., along with lorazepam 0.5mg. RN AA further confirmed she administered morphine sulfate 1ml at 2:18 p.m., along with lorazepam 0.5mg again to P#1 for symptoms of agitation and confusion. RN AA stated that she notified the MD only after giving the increased dosage of morphine sulfate and she did not obtain order prior to giving the medications. RN AA also stated that Levaquin 500 mg was not given to patient because patient could not swallow. An office interview was conducted on 1/31/25 at 1:35 p.m., with the Director of Clinical services (DOCS), who verbalized that on 1/4/25 while P#1 was enroute to the hospital, RN AA notified the MD and the Director of clinical services that the RN AA sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. The Director of clinical services verbalized that clinical record failed to reveal documentation of the effectiveness of the medications and the reason for the second dose that was given P#1 less than 2 hours. An office interview was conducted on 1/31/25 at 1:45 p.m., with Area Director of Clinical Operations (ADCO), who revealed that on 1/23/25 MD informed the ADCO that RN AA gave morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. Area Director of Clinical Operations verbalized that the visit note dated 1/4/25 lacked documentation of the response to the medication that was given to P#1. ADOC also verbalized that there is no MD order to hold the medications, including Levaquin 500 mg, and no further assessments done on swallowing issues.”

“Based on record review staff interview, the hospice failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program. Findings include: Review of the document titled, “;Physician Order” dated 1/4/2025 for P1 revealed the following: morphine sulfate (used to treat severe pain) 20mg/ml; take 0.5ml (10mg) by mouth every 2 hours as needed for pain and shortness of breath. lorazepam 0.5mg by mouth every 4 hours as needed for anxiety or shortness of breath. Review of the medication note dated 1/4/25 revealed that RN AA administered morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. RN AA failed to administer the medication as ordered in the verbal order dated 1/4/25. Review of the agency QAPI (Quality Assessment and Performance Improvement) manual for the dates of 1/4/25 to 1/31/25 revealed that the agency had not initiated a performance improvement plan to address the medication error. An interview on 1/31/25 at approximately 1:35 pm, an office interview was conducted with the Director of Clinical Services (DCS). During the interview the DCS stated that she was notified by RN AA while P#1 was enroute to the hospital that RN AA administered to P#1 morphine sulfate 1ml at 1:36 p.m. and second dose of morphine sulfate 1ml at 2:18 pm. The DCS stated that P#1 received morphine sulfate /ml, 1ml twice within 42 minutes. The DCS stated that the RN AA also notified the MD that morphine 1ml was administered twice within 42 minutes. The DCS stated that a phone call was received from family of P#1 on 1/13/25 at 2:00 p.m. asking for medication information. DCS verbalized that the RN AA admitted to the family of P#1 that she administered 1ml of morphine sulfate at 1:36 p.m. and 2:18 p.m. The DCS stated that she as well as the Medical Director, and RN AA was also on the call with the family of P#1. The DCS stated that she created a complaint report on 1/13/25, however it was not placed in the complaint log until 1/31/25. The hospice failed to initiate a performance improvement plan.”

“Based on record review and staff interviews, it was determined that the agency failed to update the plan of care as the condition changed for one patient (P) (P#1) of four patients reviewed. Findings include: Review of the Client Coordination Note Report dated 1/3/25 revealed that P#1 coughed and threw up grits. RN AA advised that P#1 may be aspirating during intake. RN AA advised to sit P#1 up in bed and prop pillows behind his back. RN AA advised to administer the most important medications when P#1 was alert and safe to swallow. Review of visit note dated 1/4/25 by RN AA reveals the following: “;PRN visit D/T restlessness, medication, and education. Patient unsafe to swallow. Explained to spouse that patient was unable to take regular medications.” During an interview conducted on 1/31/25 at approximately 12:30 p.m. RN AA acknowledged that she had not updated the plan of care and had not notified the physician that P#1 was unable to safely swallow and may have experience aspiration. RN AA did not notify physician that she advised the caregiver hold medications by mouth to P#1 until it was safe to swallow. The agency failed to document patient condition changes and notify the physician of changes.”

“Based on record review, family and staff interviews, it was determined the hospice failed to protect and promote the exercise of patient’s rights by not following physician’s order for one patient (P) (P#1). Specifically, Registered Nurse (RN) RN AA failed to provide the medication as ordered in the verbal order dated 1/4/25. Findings include: Review of the document titled, “;Physician Order” dated 1/4/2025 for P#1 revealed the following: morphine sulfate (used to treat severe pain) 20mg/ml; take 0.5ml (10mg) by mouth every 2 hours as needed for pain and shortness of breath. lorazepam (antianxiety agent) 0.5mg by mouth every 4 hours as needed for anxiety or shortness of breath. Review of the medication note dated 1/4/25 revealed that Registered Nurse (RN) AA administered morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. RN AA failed to administer the medication as ordered in the verbal order dated 1/4/25. Review of the email note which was sent by the Medical Director (MD) to the Director of clinical services on 1/23/25 at 11:15 a.m., revealed that the MD was notified by RN AA that she increased the morphine dose and lorazepam dose for P#1 without approval of MD. The email note reads as follows: “I wanted to clarify that I had actually been informed after the nurse took the initiative to increase the medications and the patient subsequently arrested at home and was transported to the hospital for aggressive care”. Review of record for P#1 revealed an order for Levaquin 500mg Take 1 by mouth daily for 7 days; Reason: URI, Cellulitis. Order dated 12/31/2024 with start date of 1/2/2025. Review of visit note dated 1/4/25 by RN AA reveals the following: “;PRN visit D/T restlessness, medication, and education. Patient unsafe to swallow. Explained to spouse that patient was unable to take regular medications.”Clinical records failed to reveal MD was notified of patients inability to swallow; failed to reveal physician’s order to hold the antibiotic and failed to reveal revised care plans to meet patients current assessment and/or change in patients condition. A telephone interview was conducted on 1/31/25 at 9:30 a.m., with the family member who revealed that RN AA informed the family member on 1/16/25 at 1:37 p.m., that RN AA administered morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m., on 1/4/25. A telephone interview was conducted on 1/31/25 at 10:35 a.m., with Medical Director (MD) who revealed that the RN AA advised the MD that she gave morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 pm and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. MD stated that he educated RN AA that she is to call the MD prior to changing the current order which was to give 0.5 ml every 2 hours. MD stated that he did not approve of RN AA to administer morphine sulfate 20mg/ml (1ml) less than 2 hours. An interview was conducted at the agency on 1/31/25 at 12:30 p.m., with Registered Nurse (RN) AA, who revealed on 1/4/25, she administered morphine sulfate 1ml at 1:36pm. RN AA further confirmed she administered morphine sulfate 1ml at 2:18 pm to P#1 for symptoms of agitation and confusion. RN AA verbalized that MD was notified after the administration of the increased dose of morphine which was given twice less than 2 hours. RN AA also verbalized that P#1 had difficulty swallowing so she told the family not to take any medications by mouth including Levaquin. RN AA stated that she did not inform the MD of P1’s inability to swallow and did not inform the MD that all medications taken by mouth were on hold including Levaquin 500 mg every day for 7 days. An office interview was conducted on 1/31/25 at 1:35 p.m., with the Director of Clinical Services (DOCS), who verbalized that the RN AA (while P#1 enroute to hospital), notified the MD and the DOCS that the RN AA gave morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. The DOCS verbalized that on 1/13/25 at 2:00 p.m., the DOCS received a call from the patient’s family member inquiring about the medications. The DOCS verbalized that the RN AA verbalized to the caregiver via phone that she gave morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. DOCS did not provide documents supporting if any appropriate corrective action was taken to address not following the MD”s order/medication error and lack of coordination/communication with MD and other clinical staff of patient’s current status. An office interview was conducted on 1/31/25 at 1:45 p.m., with Area Director of Clinical Operations, (ADCO) who revealed that on 1/23/25 MD informed the Area Director that RN AA gave morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. The Area Director of Clinical Operations did not provide any evidence or documents to support whether any appropriate corrective action was implemented for P#1.”

“Based on record review, and family and staff interviews, it was determined that the agency failed to provide services as ordered by the physician in the plan of care and to communicate and coordinate patients current assessment and change in patient’s condition with physician and other health care practitioners for one patient (P) (P#1) of four sampled patients. Specifically, the agency failed to include services and treatments in the plan of care that address the patient and family-specific needs related to the terminal illness and related conditions for P#1. Findings include: Review of the document titled, “;Physician Order” dated 1/4/2025 for P1 revealed the following: morphine sulfate (used to treat severe pain) 20mg/ml; take 0.5ml (10mg) by mouth every 2 hours as needed for pain and shortness of breath. lorazepam 0.5mg by mouth every 4 hours as needed for anxiety or shortness of breath. Review of the medication note dated 1/4/25 revealed that Registered Nurse (RN) AA administered morphine sulfate 20 mg/ml;1ml and lorazepam 0.5 mg by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml;1 ml and lorazepam 0.5mg by mouth at 2:18 p.m. RN AA failed to provide medications as per MD verbal order dated 1/4/25. Clinical record failed to reveal documentation that the MD was notified prior to giving extra dose of morphine sulfate 20mg/ml; 1 ml and lorazepam 0.5mg less than 2 hours. RN AA failed to coordinate P#1’s current assessment and change in patient’s status with MD. Clinical records failed to reveal the following: MD was notified of patients inability to swallow; order to hold the antibiotic, and revised care plans to meet patients current assessment and/or change in patients condition. Review of the email note which was sent by the Medical Director (MD) to the Director of clinical services on 1/23/25 at 11:15 am revealed that the MD was notified by RNAA that she increased the morphine dose and lorazepam dose for P1 without prior approval of MD. The email note reads as follows: “I wanted to clarify that I had actually been informed after the nurse took the initiative to increase the medications and the patient subsequently arrested at home and was transported to the hospital for aggressive care”. Telephone interview was conducted on 1/31/25 at 9:30 a.m., with the family member who revealed that RN AA admitted to the member on 1/16/25 at 1:37 p.m., that RN AA administered morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. RN AA verbalized that MD was not notified prior to giving increased dosage of morphine sulfate. Telephone interview was conducted on 1/31/25 at 10:35 a.m., with the Medical Director (MD) who revealed that the RN AA advised the MD that she gave morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. MD stated that he educated RNAA that she is to call the MD prior to changing the current order which was to give 0.5 ml every 2 hours. MD stated that he did not approve of RN AA to administer morphine sulfate 20mg/ml within 2 hours. An office interview was conducted at the agency on 1/31/25 at 12:30 pm with Registered Nurse (RN) AA, who revealed on 1/4/25, she administered morphine sulfate 1ml at 1:36 p.m., along with lorazepam 0.5mg. RN AA further confirmed she administered morphine sulfate 1ml at 2:18 p.m., along with lorazepam 0.5mg again to P#1 for symptoms of agitation and confusion. RN AA confirmed that MD was not notified of the increased dosage of morphine that was given to P#1, and MD was not notified of P#1’s inability to swallow. An office interview was conducted on 1/31/25 at 1:35 pm with the Director of Clinical services (DOCS) who verbalized that the RNAA notified the MD and the DOCS that the RN AA gave morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 pm and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18pm. The DOCS verbalized that the RNAA did not notify the MD prior to giving the higher dose of morphine. DOCS verbalized that there is no communication and coordination between the RNAA and the MD prior to giving the higher dose of morphine and no communication between MD and RNAA about holding the medications due to difficulty in swallowing. An office interview was conducted on 1/31/25 at 1:35 pm with the Area director of clinical operations (ADCO), who revealed that on 1/23/25 MD informed the ADCO that RN AA gave morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 pm and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18pm. ADCO verbalized that there is no coordination between the RNAA and the MD prior to giving the higher dose of morphine and no communication and coordination about holding the medications due to difficulty in swallowing.”

“Based on clinical record reviews and family and staff interviews, it was determined the agency failed to organize, manage, and administer its resources to provide the hospice care and services necessary for patients for the palliation and management of the terminal illness and related conditions for patients as evidenced by agency failed to provide and manage proper care for one patient (P) (P#1) of four sampled patients. . Findings include: Review of the “;Physician Order” dated 1/4/2025 for P1 revealed the following: morphine sulfate (used to treat severe pain) 20mg/ml; take 0.5ml (10mg) by mouth every 2 hours as needed for pain and shortness of breath. lorazepam 0.5mg by mouth every 4 hours as needed for anxiety or shortness of breath. Review of the medication note dated 1/4/25 revealed that RN AA administered morphine sulfate 20 mg/ml, 1ml along with lorazepam 0.5mg by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml; 1 ml along with lorazepam 0.5mg by mouth at 2:18pm. RN AA did not administer the medication as ordered in the verbal order dated 1/4/25. Telephone interview was conducted on 1/31/25 at 9:30 a.m., with the family member who revealed that RN AA admitted to the family member on 1/16/25 at 1:37 pm, that RN AA administered morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m., on 1/4/25. An office interview was conducted at the agency on 1/31/25 at 12:30 p.m., with Registered Nurse (RN) AA, who revealed on 1/4/25, she administered morphine sulfate 1ml along with lorazepam 0.5mg by mouth at 1:36 p.m. RN AA further confirmed she administered morphine sulfate 1ml along with lorazepam 0.5mg by mouth at 2:18 pm to P#1 for symptoms of agitation and confusion. RN AA stated that she notified the MD and the Director of Clinical services while (P#1 was enroute to the hospital) that she gave an increased dose of Morphine and Lorazepam to the patient in less than two hours. RN AA stated that she did not obtain verbal order prior to administering an increased dosage of morphine sulfate to P#1. Furthermore, the medical record lacks documentation that appropriate corrective action was taken regarding the medication error incident. An office interview was conducted on 1/31/25 at 1:35 p.m., with the Director of Clinical services (DOCS), who verbalized that the RN AA notified the MD and the (DOCS) that RN AA gave morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. The DOCS verbalized that on 1/13/25 at 2:00 p.m., the DOCS received a call from the patient’s family member inquiring about the medications. DOCS verbalized that the RNAA verbalized to the caregiver via phone that she gave morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 pm and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. However, DOCS did not provide any documentation that supports whether any appropriate corrective action was taken regarding the medication error incident. Review of complaint log on 1/30/25 did not have this complaint / incident documented. The DOCS verbalized that the complaint report was completed on 1/13/25 but was not entered into the complaint log until 1/31/25.”

“Based on record reviews, family and staff interviews, it was determined the hospice failed to investigate the complaint reported by patient’s family member and take appropriate corrective action for one patient (P) (P#1). Specifically, the Registered Nurse (RN) failed to administer the medication as per physicians order for P#1 and investigate the complaint filed by P#1s caregiver. Findings include: Review of the document titled “;Physician Order” dated 1/4/2025 for P#1 revealed the following: morphine sulfate (used to treat severe pain) 20mg/ml; take 0.5ml (10mg) by mouth every 2 hours as needed for pain and shortness of breath. lorazepam (antianxiety medication) 0.5mg by mouth every 4 hours as needed for anxiety or shortness of breath. Review of the policy titled, “Procedure: Complaints and Grievances” revision date 1/24/2021 revealed the following: Definitions for the purpose of this procedure: A) Complaint or grievance - a concern expressed by anyone about quality of care, care delivery, services, colleagues, or any area under the influence or responsibility of the Compassus program; if from a patient or family member, this may include issues of discrimination, access, or violation of rights. 3. If a patient or family member voices a complaint regarding hospice services or providers of hospice services to a hospice colleague, the COLLEAGUE will be responsible for the following actions: 4. The DIRECTOR OF CLINICAL SERVICES OR DESIGN EE will be responsible for the following actions:a. Complete the top portion of the written Complaint Reporti. Detail the complaint as related by colleagues and/or complainant:ii. Begin initial investigation of the complaint to include initial determination of nature of complaint, whether escalation to the internal compliance/ legal team is needed, and take immediate corrective steps to mitigate concern if appropriateiii. Communicate with complainant regarding the progress of the investigation as neededb. Submit the Complaint Report to the Area Executive of Clinical Services or Designee within 24-hours of receiving the complaint.5. The AREA EXECUTIVE OF CLINICAL SERVICES OR DESIGN EE will be responsible for the following actions:a. Assign a number to the Complaint Report and begin record of complaint on the Complaint Log. Assign numbers consecutively in the order the complaint is received {1, 2, 3, ... ).b. Review progress of investigation within five {5} working days and determine appropriate corrective actions including steps the SUPERVISOR may have already implemented. The investigation does not have to be completed in this time frame - it is appropriate for the ACO and the DCS to conduct as thorough and comprehensive an investigation as the situation requires. The 5-day timeframe ensures follow up, follow through, and coordination of corrective actions can be accomplished with an eye on ensuring service delivery is aligned with Compassus’ values. d. Should the investigation reveal actions that violate Compassus policy, and/or local, state, or federal laws/regulations, consult with Regional Vice President, Regional Executive of Clinical Operations, Vice President of Human Resources and/or Compliance Officer for further decision-making. f. Complete SUPERVISOR section of the complaint form g. Complete the Complaint Log. i. Provide information regarding complaints to the QAPI coordinator for review at scheduled QAPI meetings. Serious events and anything reported to the legal/ compliance team must also be reported to the Governing Body as part of the quarterly QAPI report. j. If the corrective action includes any kind of colleague disciplinary action, place a copy of the Complaint Report, investigative data, and resolution information in the colleague’s personnel file. Review of Complaint Log on 1/30/2025, revealed the agency failed to investigate the complaint reported by family member of P#1 and failed to complete a Complaint Report according to their policy titled, “Complaint and Grievance. After further review, the DCS provided a Complaint Report on 1/31/2025, with her signature dated 1/13/25, 18 days after the complaint was reported to the agency by family member of P#1. A telephone interview was conducted on 1/31/25 at 10:35 a.m., with Medical Director (MD) who revealed that RN AA advised the MD that she gave morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. MD stated that he educated RN AA that she is to call the MD prior to changing the current order which was to give 0.5 ml every 2 hours. MD stated that he did not approve RN AA to administer morphine sulfate 20mg/ml less than 2 hours. An interview was conducted on 1/31/25 at 1:00 pm with the Administrator aka Director of Clinical Services (DCS) who reported that RN AA has been removed from the field as of 1/31/25. She further reported the complaint by the family of P#1 was received on 1/13/25; Surveyor did not see the complaint in the log on review on 1/30/25. The administrator confirmed the complaint was added on 1/31/25. The Administrator stated that on 1/23/24, the MD informed the Administrator that RNAA had administered an increased dosage of morphine sulfate without MDs approval. P#1 received Morphine sulfate 1ml at 1:36pm and second dose of morphine sulfate 1ml at 2:18 pm. Administrator further revealed that she received a call from family member on 1/13/25 at 2 pm and asked about the medication. Administrator said that RNAA was with her while on the conference call with family member. The Administrator stated that the nurse admitted to the family member giving the extra dose of morphine. An interview was conducted on 2/4/25 at 3:00 pm, with the Area Executive of Clinical Operations (ACO), Regional Executive of Clinical Operations (RCO), and Director of Quality Operations (DQO) who revealed RN AA worked on 1/27/25, 1/28/25, and 1/29/25, before being placed on leave on 1/31/25, and termination on 2/3/25. Review of Medical records failed to reveal if any appropriate corrective action was taken to address not following the MD”s order / medication error and lack of coordination/communication with MD and other clinical staff of patient’s current status. Cross reference to L0500 relating to Patients Rights”

“Based on record reviews, staff interviews, and family interview, it was determined that the agency failed to manage the patients pain and symptoms related to the terminal illness. Specifically, the Registered Nurse (RN) failed to administer the medication as per physicians order for one patient (P) (P#1) of four patients reviewed. Findings include: Review of the document titled, “;Physician Order” dated 1/4/2025 for P1 revealed the following: morphine sulfate (used to treat severe pain) 20mg/ml; take 0.5ml (10mg) by mouth every 2 hours as needed for pain and shortness of breath. lorazepam 0.5mg by mouth every 4 hours as needed for anxiety or shortness of breath. Review of the medication note dated 1/4/25 revealed that RN AA administered morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml; 1 ml at 2:18 p.m. RN AA failed to administer the medication as ordered in the verbal order dated 1/4/25. Cross reference to L0500 relating to Patients Rights”

“Based on clinical record review and staff interview, the hospice failed to update the comprehensive assessment by the interdisciplinary group in collaboration with the attending physician to include information on the patients progress toward desired outcome. Findings include: Review of clinical record revealed that RN AA administered morphine 1ml (20mg) (used to treat severe pain) by mouth on 1/4/25 at 1:36 p.m., to P#1, stated no relief. RN AA recorded that a second dose of morphine 1ml (20 mg) was administered within 42 minutes. RN AA explained to family of P#1 that P#1 was unable to take regular medications by mouth as it was unsafe to swallow. An interview was conducted on 1/31/25 at 12:30 p.m., with RN AA. RN AA stated that plan of care did not reveal an update to include changes in P#1’s declining condition or that medications were being withheld due to it being unsafe for P#1 to swallow them. Cross reference to L0520 relating to Initial and Comprehensive assessment of the patient”

“Based on clinical record reviews, family and staff interviews, it was determined the agency failed to ensure that the care and services are provided in accordance with the plan of care for one Patient (P) (P#1) of four patients reviewed. Findings include: Review of the document titled, “;Physician Order” dated 1/4/2025 for P1 revealed the following: morphine sulfate (used to treat severe pain) 20mg/ml; take 0.5ml (10mg) by mouth every 2 hours as needed for pain and shortness of breath. lorazepam 0.5mg by mouth every 4 hours as needed for anxiety or shortness of breath. Review of the medication note dated 1/4/25 revealed that RN AA administered morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml; 1 ml at 2:18 p.m. RN AA failed to administer the medication as ordered in the verbal order dated 1/4/25. Cross reference to L0536 relating to Interdisciplinary group, are planning, and coordination of services”

“Based on record review and staff interview, the hospice failed to initiate performance improvement activity that focused on high risk, high, volume, or problem-prone area. Findings include: The DCS stated that a phone call was received from the family of P#1 on 1/13/25 at 2:00 p.m. asking for medication information. The DCS stated that the RN AA admitted to the family of P#1 that the RN gave 1 ml of morphine sulfate at 1:36 p.m. and 2:18 p.m. The DCS confirmed that participants of the call included the DCS, the Medical Director, RN AA and the family member of P#1. The DCS stated that she created a complaint report on 1/13/25, it was not placed in the complaint log until 1/31/25. The agency failed to initiate performance improvement activity that focused on high risk, high, volume, or problem-prone area. Cross reference to L0559 relating to Program Activities”

“Based on record review, staff and family interviews, it was determined that the agency failed to ensure that hospice services and treatment were provided as per patient and family needs and optimize comfort and dignity for one patient (P) (P#1) of four patients reviewed. Findings include: Review of the “;Physician Order” dated 1/4/2025 for P1 revealed the following: morphine sulfate (used to treat severe pain) 20mg/ml; take 0.5ml (10mg) by mouth every 2 hours as needed for pain and shortness of breath. lorazepam 0.5mg by mouth every 4 hours as needed for anxiety or shortness of breath. Review of the medication note dated 1/4/25 revealed that RN AA administered morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml; 1 ml at 2:18 p.m. RN AA failed to administer the medication as ordered in the verbal order dated 1/4/25. Review of record for P#1 revealed an order for Levaquin 500mg Take 1 by mouth daily for 7 days; Reason: URI, Cellulitis. Order dated 12/31/2024 with start date of 1/2/2025. Review of visit note dated 1/4/25 by RN AA reveals the following: “;PRN visit D/T restlessness, medication, and education. Patient unsafe to swallow. Explained to spouse that patient was unable to take regular medications.” Telephone Interview was conducted on 1/31/25 at 10:35 am, with Medical Director (MD) who revealed that the RN AA advised the MD that she gave morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 pm and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18pm. MD stated that he educated RNAA that she is to call the MD prior to changing the current order which was to give 0.5 ml every 2 hours. MD stated that he did not approve of RNAA to administer morphine sulfate 20mg/ml within 2 hours. An Interview was conducted at the agency on 1/31/25 at 12:30 p.m. with Registered Nurse (RN) AA, who revealed on 1/4/25, she administered morphine sulfate 1ml at 1:36pm along with lorazepam 0.5mg. RN AA further confirmed she administered morphine sulfate 1ml at 2:18 p.m. along with lorazepam 0.5mg again to P1 for symptoms of agitation and confusion. RN AA also verbalized that Levaquin 500 mg was not given to patient due to patient’s inability to swallow. the RN AA also verbalized that MD was not informed of patient’s in- ability to swallow and Levaquin and all other medications that are taken by mouth were on hold. An office interview was conducted on 1/31/25 at 1:35 p.m., with the Director of Clinical Services (DOCS), who verbalized that the RN AA notified the MD and the DOCS that the RN AA gave morphine sulfate 20 mg/ml;1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml; 1 ml at 2:18 p.m. The DOCS verbalized that on 1/13/25 at 2:00 p.m., the DOCS received a call from the patient’s family member inquiring about the medications. DOCS verbalized that the RN AA verbalized to the family member via phone that she gave morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. However, review of medical record lack evidence to support if any appropriate corrective actions were taken by the DOCS to further investigate medication errors and coordination of care for P#1.”

“Based on record review, staff and family interviews, it was determined that the agency failed to ensure that a governing body (or designated persons so functioning) assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, and continuous quality assessment and performance improvement. The agency failed to ensure that the governing body is responsible for the day-to-day operations of the hospice. Findings include: Review of the medication note dated 1/4/25 revealed that RN AA administered morphine sulfate 20 mg/ml, 1ml by mouth at 1:36 p.m., and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18 p.m. RN AA failed to administer the medication as ordered in the verbal order dated 1/4/25. Cross reference to L0500 relating to Patients Rights Cross reference to L0520 relating to Initial and Comprehensive assessment of the patient Cross reference to L0536 relating to Interdisciplinary group, care planning, and coordination of services”

“Based on record review, review of policy “;Written and Verbal Orders,” and staff interview, it was determined that the agency failed to authenticate and date a verbal order in accordance with hospice policy and currently accepted standards of practice. Findings include: Review of policy “Written and Verbal Orders” revised 9/24/24 revealed that only a physician, a physician assistant, or a nurse practitioner in accordance with plan f care and state law may order drugs for the patient. If the order is verbal, it must be given only to a licensed nurse, practitioner, pharmacist, or physician and the individual receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with State and Federal regulations, or within 30 days from the date the order is documented whichever is sooner. Review of “Hospice Physician Order” dated 1/16/24 with a verbal date of 1/4/24 written by RN AA for P#1, order reads as morphine sulfate (used to treat severe pain) 20mg/ml oral solution, give 1ml (10mg) PO (by mouth) every two hours as needed for pain and shortness of breath. Lorazepam .5mg give 1 tablet by mouth every 4 hours for anxiety or shortness of breath. Levsin 0.125mg tablet by mouth or under tongue every four hours for secretions. In an interview with RN AA on 1/31/25 at approximately12:30 p.m. she stated that she wrote the order on 1/16/25 for 1/4/25. RN AA stated that she realized after reviewing her notes that she had not written an order for the medication change at the time it occurred. She acknowledged that it had not been signed by the ordering physician. An interview with the Director of Clinical Services (DCS) on 1/31/25 approximately 1:30 p.m. the DCS verbally acknowledged that the verbal order dated 1/16/25 for 1/4/25 written by RN AA for P#1 had not been signed by the physician within 30 days per hospice policy. The hospice failed to authenticate the verbal order in accordance with hospice policy.”

“Based on record review, policies and procedures, and staff interview, it was determined that the agency failed to record and sign a verbal order in accordance with State and Federal regulations for one patient (P) (P#1) of four patients reviewed. Findings include: Review of policy “Drugs, Biologicals, Medical Supplies, and DME” revised 11/27/24 revealed that orders for drugs, biologicals, medical supplies, and DME will be documented by an appropriately licensed colleague and will adhere to (facility) policy for “Written and Verbal Orders”. Review of policy “Written and Verbal Orders” revised 9/24/24 revealed that only a physician, a physician assistant, or a nurse practitioner in accordance with plan of care and state law may order drugs for the patient. If the order is verbal, it must be given only to a licensed nurse, practitioner, pharmacist, or physician and the individual receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with State and Federal regulations, or within 30 days from the date the order is documented whichever is sooner. Review of the “;Physician Order” dated 1/4/2025 for P#1 revealed the following: morphine sulfate (used to treat severe pain) 20mg/ml; take 0.5ml (10mg) by mouth every 2 hours as needed for pain and shortness of breath. lorazepam 0.5mg by mouth every 4 hours as needed for anxiety or shortness of breath. A second verbal order was written on 1/16/25 as follows: morphine sulfate20mg/ml; take 1ml (20 mg) by mouth every 2 hours as needed for pain and shortness of breath. lorazepam 0.5mg by mouth every 4 hours as needed for anxiety or shortness of breath. The verbal order was not signed by the attending physician. An interview with the Director of Clinical Services stated that the verbal order dated on 1/16/25 for 1/4/25 had not been signed by the physician within 30 days per hospice policy. A telephone interview was conducted on 1/31/25 at 0:35 a.m., with Medical Director (MD) who revealed that the RN AA advised the MD that she administered morphine sulfate 20 mg/ml, ml (10mg) by mouth at 1:36 pm and second dose of morphine sulfate 20mg/ml: 1 ml at 2:18pm. MD stated that he educated RN AA that she is to call the MD prior to changing the current order which was to give 0.5 ml every 2 hours. MD stated that he did not give approval for RN AA to administer morphine sulfate 20mg/ml within 2 hours. The MD did not sign the verbal order written on 1/16/25 for 1/4/25.”

“Based on record review and staff interview, it was determined that the agency failed to identify on the care plan the patient, caregiver, or family member that has the ability to self-administer medications in the home for one patient (P) (P#1) of four patients reviewed. Findings include: Review of the clinical record “;Plan of Care” dated 12/22/25 failed to reveal who was identified to safely administer drugs and biologicals in the home. In an interview on 1/31/25 at approximately 1:50 p.m., with RN AA, the Area Director of Clinical Operations (ADCO) and Director of Clinical Services (DCS), RN AA, the ADCO, and DCS acknowledged that the plan of care did not identify who in the home would safely administer drugs to P#1 in the home. The hospice failed to identify the family/caregiver of P#1 to safely self-administer drugs and biologicals to the patient in his or her home.”

“Based on record review, review of policy titled “;Non-discrimination and Grievances,” and staff interview, the hospice failed to immediately investigate discrepancies in the administration of controlled drugs, failed to report to the appropriate State authority and failed to make a written account of the investigation available to State officials. Findings include: Review of the policy titled “;Non-discrimination and Grievances,” revised on 1/24/21 revealed that the hospice will ensure appropriate reporting, investigation and resolution processes are completed and documented. Review of the medical records failed to reveal a report of the incident/complaint on 1/30/25. The incident report was received on 1/31/25 with a date of 1/13/25. The medical record failed to reveal documentation of an investigation by the agency of the incident or documentation that the medication error had been reported to the State authority. The hospice failed to immediately investigate discrepancies in the administration of controlled drugs, failed to report to the appropriate State authority and fail to make a written account of the investigation available to State officials. During an interview on 1/31/25 at 1:35 p.m. with the Director of Clinical Services (DCS) the DCS stated that the incident of RN AA administering morphine sulfate 20mg/ml oral solution, give 1ml (10mg) PO (by mouth) every two hours as needed for pain and shortness of breath within 42 minutes without an authenticated order had not been investigated immediately or reported to the appropriate State authority. The DCS stated that she reported the incident to Human Resources (HR) on 1/13/25 and they had begun an investigation.”

“It is required that The documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure that the medication profile included the patient’s current medications. Clinical Record 3/Home Visit 3: The patient elected hospice care on 05/29/2024. During the home visit with the Medical Social Worker (MSW )[Personnel Record 7] on 06/04/2024, the home medications, hospice plan of care dated 05/29/2024, and the hospice medication profile were reviewed. The medication profile documented “Amlodipine 2.5mf po once a day (qd).” The patient’s medication bottle documented “Amlodipine 10mg po qd,” effective 05/28/2024. The patient stated that the physician had changed the dose when the patient was discharged from the hospital on 05/28/2024. Additionally, the medication profile documented “Scopolamine patch every 72 hours and Rosuvastatin 10mg po once a day at bedtime (qhs).” Both medications were absent in the home and had been discontinued with the recent hospital discharge on 05/28/2024. The hospice medication profile did not document the patient’s current medication regimen. Clinical Record 5: The patient elected hospice care on 04/10/2024. The signed physician’s order dated 04/12/2024 and the medication profile documented “Oxygen @ 2-4 liters per minute (lpm) continuous via nasal cannula.” A review of the clinical record revealed the updated comprehensive assessment completed by the Registered Nurse dated 05/31/2024 documented “Oxygen @ 7 lpm as needed via nasal cannula.” The hospice medication profile did not document the patient’s current medication regimen. During an interview on 06/06/2024, the Administrator reviewed the associated records and stated that the medication profiles have been reviewed and corrected.”

“It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C19 “Bereavement Services” (Revision Date 01/14/2019) read in part, “A comprehensive bereavement risk assessment is completed not later than 5 days after admission.” In 8 of 19 (42%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. Clinical Record 1: The hospice election of benefit was dated 05/28/2024 and resided in a skilled nursing facility (SNF). The start of care/initial comprehensive assessment was completed by the Registered Nurse (RN) on 05/28/2024. The initial bereavement assessment was documented as completed on 06/03/2024, with six (6) days outstanding. Clinical Record 3: The hospice election of benefit was dated 05/29/2024. he start of care/initial comprehensive assessment was completed by the RN on 05/29/2024. The initial bereavement assessment was documented as completed on 06/04/2024, with six (6) days outstanding. Clinical Record 5: The hospice election of benefit was dated 04/10/2024.The start of care/initial comprehensive assessment was completed by the RN on 04/10/2024. The initial bereavement assessment was documented as completed on 04/18/2024, with eight (8) days outstanding. Clinical Record 8: The hospice election of benefit was dated 10/19/2023.The start of care/initial comprehensive assessment was completed by the RN on 10/19/2023. The initial bereavement assessment was documented as completed on 10/26/2023, with seven (7) days outstanding. Clinical Record 9: The hospice election of benefit was dated 05/01/2024.The start of care/initial comprehensive assessment was completed by the RN on 05/01/2024. As of the clinical record review on 06/04/2024, the initial bereavement assessment had not been completed. Clinical Record 13: The hospice election of benefit was dated 05/15/2024 and resided in a SNF. The start of care/initial comprehensive assessment was completed by the RN on 05/15/2024. The initial bereavement assessment was documented as completed on 05/23/2024, with eight (8) days outstanding. Clinical Record 14: The hospice election of benefit was dated 04/26/2024.The start of care/initial comprehensive assessment was completed by the RN on 04/26/2024. As of the clinical record review on 06/05/2024, the initial bereavement assessment had not been completed. Clinical Record 18: The hospice election of benefit was dated 06/27/2023.The start of care/initial comprehensive assessment was completed by the RN on 06/27/2023. The initial bereavement assessment was documented as completed on 10/12/2023, with 107 days outstanding. During the interview on 06/06/2024, the Administrator reviewed the associated records and stated that remedial staff education would need to be provided to ensure future compliance.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs; and ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C9 “Written Interdisciplinary Plan of Care” (Revision Date 04/22/2024) read in part, “The interdisciplinary group (IDG/IDT) ensures the provision of care and services according to the plan of care and that the plan of care reflects updated patient and family/caregiver needs as determined in updated comprehensive assessments... Care is provided to the patient in accordance with the plan.” In 2 of 19 (11%) clinical records reviewed, the agency did not ensure care was provided as indicated on the plan of care. Clinical Record 5: The patient elected hospice care on 04/10/2024. On 05/31/2024, the physician ordered, “skin tear left forearm- cleanse with NS, pat dry with gauze, apply antibiotic ointment, cover with nonadherent dressing by Hospice Nurse 2xweek and by Caregiver as needed/pro re nata (prn) soiled/dislodged.” For the week of 05/31/2024, the hospice agency staff documented one dressing change. There was no evidence of communication with the physician to change the visit frequency or communication with the patient/caregiver. Clinical Record 6: The hospice election of benefit was dated 02/23/2024. On 05/27/2024, the physician ordered, “clean area to gluteal fold with wound cleanser, pat dry, apply skin protectant cream and cover with foam dressing. Hospice Nurse to change dressing 2xweek and Caregiver to change when bandage soiled or detached.” For the week of 5/27/2024, the hospice agency staff documented one dressing change. There was no evidence of communication with the physician to change the visit frequency or communication with the patient/caregiver. During an interview on 06/06/2024, the Administrator reviewed the associated records and stated that remedial education would be provided to ensure future compliance.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C9 “Written Interdisciplinary Plan of Care” (Revision Date 04/22/2024) read in part, “The interdisciplinary group (IDG/IDT) ensures the provision of care and services according to the plan of care and that the plan of care reflects updated patient and family/caregiver needs as determined in updated comprehensive assessments...Care is provided to the patient in accordance with the plan...The content of the plan includes at a minimum...Treatments, drugs biologicals f. measurable goals and outcomes for planned interventions.” In 5 of 19 (26%) clinical records reviewed, the agency did not ensure that the written plan of care included the medications and treatments needed to meet the patient’s needs. Clinical Record 1: The patient elected hospice care on 05/28/2024 and resided in a skilled nursing facility (SNF). The initial comprehensive assessment completed by the Registered Nurse (RN) dated 05/28/2024 documented that a Foley catheter had been ordered. The updated comprehensive assessment completed by the RN dated 06/03/2024 documented that the patient had bilateral Unna boots. At the time of the review on 06/04/2024, the hospice plan of care did not document the care and maintenance of the Foley catheter or instructions for the Unna boots. Clinical Record 2: The patient elected hospice care on 04/19/2024. The initial comprehensive assessment completed by the RN dated 04/19/2024 documented that the patient performed daily blood sugar checks. The hospice plan of care dated 04/19/2024 documented the patient’s diagnosis of Type II diabetes mellitus (DM) with chronic kidney disease (CKD) and ordered: “Farxiga 10mg once a day (qd)” and “Levemir 100U/ml 20U SQ once a day at bedtime (qhs).” At the time of the review on 06/04/2024, the hospice plan of care did not document the blood sugar checks. Clinical Record 5: The patient elected hospice care on 04/10/2024. The initial comprehensive assessment completed by the RN dated 04/10/2024 documented that the patient had a colostomy. At the time of the review on 06/04/2024, the hospice plan of care did not document the colostomy care. Clinical Record 15: The patient elected hospice care on 04/18/2024. The initial comprehensive assessment completed by the RN dated 04/18/2024 documented that the patient had a “14 French (Fr) 10 cubic centimeters (cc) Foley catheter inserted on 04/02/2024. At the time of the review on 06/05/2024, the hospice plan of care did not document the care and maintenance of the Foley catheter. Clinical Record 16: The patient elected hospice care on 03/07/2024 and resided in an adult living facility (ALF). The updated comprehensive assessment completed by the RN dated 05/05/2024 documented that the patient had a “14Fr10cc” Foley catheter inserted on 05/05/2024. At the time of the review on 06/05/2024, the updated hospice plan of care dated 05/08/2024 did not document the care and maintenance of the Foley catheter. During an interview on 06/06/2024, the Administrator reviewed the associated records and stated that the plans of care had since been reviewed and updated.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C9 “Written Interdisciplinary Plan of Care” (Revision Date 04/22/2024) read in part, “The hospice IDG, in collaboration with the hospice physician and the patient’s attending physician, reviews and updates the plan of care at least every 15 days or more often as needed as dictated by the patient’s condition and the review is documented.” In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that the revised plan of care included information from the patient’s updated comprehensive assessment. Clinical Record 6: The hospice election of benefit was dated 02/23/2024. The hospice plan of care dated 05/23/2024 ordered Social Work (MSW) and Spiritual Care (SC) services: “SC to evaluate and develop a plan of care and MSW to evaluate and develop a plan of care.” The initial MSW evaluation was dated as completed on 02/26/2024, and services were declined. The SC evaluation was declined. The interdisciplinary team meeting on 05/22/2024 and the updated assessments documented the plan to continue to monitor MSW and SC needs. There was no planned service provision due to the patient’s declination of the services. At the time of the review on 06/04/2024, the MSW and SC interventions had not been removed from the plan of care dated 05/23/2024. Clinical Record 8: The hospice election of benefit was dated 10/19/2023. The plan of care dated 04/26/2024 ordered: “SC to evaluate and develop a plan of care.” The initial SC evaluation was dated as completed on 10/20/2023. The interdisciplinary team meeting dated 04/10/2024 and the updated assessments documented the plan to continue to monitor SC needs. There was no planned service provision due to the patient’s declination of the service. At the time of the review on 06/04/2024, the SC interventions had not been removed from the plan of care dated 04/26/2024. Clinical Record 11: The hospice election of benefit was dated 10/26/2023. The 04/23/2024 hospice plan of care ordered MSW and SC services: “1M2” and “1M2” effective 05/01/2024,” respectively, and “SC to evaluate and develop a plan of care and MSW to evaluate and develop a plan of care.” The initial MSW and SC evaluations and plans of care were dated as completed on 10/27/2023. The interdisciplinary team meeting dated 04/10/2024 and the updated assessments documented the plan to continue MSW and SC interventions and goals into the next certification period due to continued psychosocial and spiritual needs. At the time of the review on 04/05/2024, the updated MSW and SC interventions were not documented on the plan of care dated 04/23/2024. Clinical Record 18: The hospice election of benefit was dated 07/27/2023. The plan of care dated 05/22/2024 ordered: “SC to evaluate and develop a plan of care.” The initial SC evaluations and plans of care were dated as completed on 07/31/2023. The interdisciplinary team meeting dated 05/22/2024 and the updated assessments documented the plan to continue to monitor SC needs. There were no plans for service provision due to no current spiritual needs. At the time of the review on 06/05/2024, the SC interventions had not been removed from the plan of care dated 05/22/2024. During the interview on 06/06/2024, the Administrator reviewed the associated records and stated that the interventions were inadvertently carried over into the new certification periods and had since been corrected.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C21 “Hospice Aide and Homemaker Services” (Revision Date 09/10/2021) read in part, “The specific activities of the hospice aide or homemaker are written by the RN for each patient and the hospice aide or homemaker follows the assigned activities in the delivery of care and services to the patient.” In 3 of 17 (18%) clinical records reviewed that included the provision of Hospice Aide services, the agency did not ensure that the HA received written patient care instructions specific to the patient’s needs. Clinical Record 1: The patient elected hospice care on 05/28/2024 and resided in a skilled nursing facility (SNF). The initial comprehensive assessment completed by the Registered Nurse (RN) dated 05/28/2024 documented a coccyx wound with wound care and dressing provided daily. The visit note completed by the Licensed Practical Nurse (LPN) dated 05/30/2024 documented the presence of a right lower extremity wound with associated wound care and dressing. The updated comprehensive assessment completed by the RN dated 06/03/2024 documented the presence of bilateral Unna boots. The HA care plan dated 05/30/2024 was not updated to include documentation of instruction for the HA related to the wounds and Unna boots during the provision of personal care. Clinical Record 5: The patient elected hospice care on 04/10/2024. The updated comprehensive assessment completed by the RN dated 04/24/2024 and the interdisciplinary team meeting documentation included initiating patient oxygen use on 04/12/2024. The updated comprehensive assessment completed by the RN dated 05/31/2024 documented the presence of a left forearm skin tear with associated wound care and dressing. The updated HA care plan dated 04/25/2024 was not updated to include documentation of instruction for the HA related to the patient’s use of oxygen and the skin tear during the provision of personal care. Clinical Record 6: The patient elected hospice care on 02/23/2024. The updated comprehensive assessment completed by the RN dated 05/27/2024 documented the presence of a gluteal fold wound and the associated wound care and dressing. The updated comprehensive assessment completed by the RN dated 05/31/2024 documented the initiation of patient oxygen use. The updated HA care plan dated 04/17/2024 was not updated to include documentation of instruction for the HA related to the patient’s use of oxygen and the gluteal fold wound during the provision of personal care. During an interview on 06/06/2024, the Administrator reviewed the associated records and stated that the aide care plans had since been reviewed and corrected.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; [and] included in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C21 “Hospice Aide and Homemaker Services” (Revision Date 09/10/2021) read in part, “...provides hospice aide and homemaker services according to the patient’s plan of care as determined by the IDT and assigned by the Registered Nurse. .” In 1 of 17 (6%) clinical records reviewed that included the provision of Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) provided services as indicated on the plan of care. Clinical Record 13: The patient elected hospice care on 05/15/2024 and resided in a skilled nursing facility (SNF). The plan of care ordered HA services “1week1, 3week12, 1week1.” The HA care plan dated 05/15/2024 assigned the HA the relevant task: shave weekly. The HA visit notes for the week of 05/20/2024 documented the completion of the task during the visits dated 05/20/2024, 05/23/2024, and 05/24/2024, three (3) times in one week. The HA visit notes for the week of 05/27/2024 documented the completion of the task during the visits dated 05/29/2024 and 05/31/2024, two (2) times in one week. As of the clinical record review on 05/05/2024, there was no documented explanation of why the HA completed the task at each visit instead of weekly as ordered. During an interview on 06/06/2024, the Administrator reviewed the associated record and stated that the HA care plan and task frequency had since been reviewed with the patient, the HA, and the RN and subsequently updated.”

“It is required that hospice aides are supervised by a registered nurse who makes 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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical records reviewed that included the provision of Hospice Aide (HA) services, the agency did not ensure that the Registered Nurse supervised the HA no less frequently than every 14 days to assess the quality of care and services provided by the HA. Clinical Record 4: The hospice election of benefit was dated 06/05/2023. The hospice plan of care dated 03/31/2024 ordered HA services “2week9.” The hospice plan of care dated 05/30/2024, for the 05/30/2024 hospice episode of care, ordered HA services “1week1, 2week8.” HA services were provided from 04/01/2024 through 06/04/2024. At the time of the review on 06/04/2024, the HA supervisions were documented as completed by the RN on 04/15/2024 and 04/30/2024, with 15 days outstanding. The last HA supervision was documented as completed by the RN on 05/20/2024. A clinical record review revealed no documented HA supervision has been completed since 05/20/2024. Clinical Record 5: The patient elected hospice care on 04/10/2024. The hospice plan of care dated 04/10/2024 ordered HA services “1week1, 2week12.” The HA documented providing services from 04/12/2024 through 05/31/2024. At the time of the review on 06/04/2024, the HA supervisions were documented as completed by the RN on 05/16/2024 and 05/31/2024, with 15 days outstanding. During an interview on 06/06/2024, the Administrator reviewed the associated records and stated that education would need to be provided to ensure future compliance.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients that resided in a Skilled Nursing Facility (SNF), the agency did not ensure that the written plan of care specified each provider’s responsibility for care provision. Clinical Record 1: The patient elected hospice care on 05/28/2024 and resided in a SNF. The initial comprehensive assessment completed by the Registered Nurse (RN) dated 05/28/2024 documented a coccyx wound with wound care and dressing provided daily. The visit note completed by the Licensed Practical Nurse (LPN) dated 05/30/2024 documented the presence of a right lower extremity wound with associated wound care and dressing. The updated comprehensive assessment completed by the RN dated 06/03/2024 documented the presence of bilateral Unna boots. A coordination of care note documented, “Facility nurse to change the foley cath per physician’s order...complete wound care per facility protocol.” The coordination note did not include the wound care or frequency to be performed, the size of the Foley catheter, or the frequency to be changed. The hospice plan of care dated 05/28/2024 did not include the delineation of care provision for the coccyx wound, the Foley catheter, the bilateral Unna boots, or the right lower extremity wound care. Clinical Record 13: The patient elected hospice care on 05/15/2024 and resided in a SNF. The hospice plan of care dated 05/15/2024 did not specify the delineation of care for the documented planned interventions. During an interview on 06/06/2024, the Administrator reviewed the associated records and stated that the hospice plans of care had since been updated with each provider’s responsibilities.”