Avera at Home

“Based on hospice clinical record review, hospice policy review, nursing home staff interview, home visit observation, patient interview, patient representative interview and hospice staff interview, the hospice failed to: 1) Ensure all hospice care and services furnished to patients and families must follow an individualized written plan of care (L0543); 2) Ensure standing orders are individualized to meet the patient’s needs (see L0547); 3) Ensure the medical supplies and appliances necessary to meet the needs of the patient are provided as directed by the Interdisciplinary Group in collaboration with the attending physician (L0550); 4) Ensure the hospice Interdisciplinary Group developed and maintained a system of communication to direct, coordinate and supervise the care and services provided (L0554); and, 5) Ensure the care and services provided are based on all assessments of the patient and family needs (L555) The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel promoted and supported the safe, comprehensive and effective delivery of patient care to their hospice patients.”

“The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and a child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a dependent adult abuse or child abuse record check for 1 of 9 sampled employees (Staff D) who began serving hospice patients since their last survey, dated 5/27/2021. The hospice reported hiring 26 employees since the last survey. Failure to complete dependent adult and child abuse record checks as required by State regulation, increased the potential risk of harm to agency patients from staff who had direct patient contact. Findings include: On 5/22/24 at 3:59 PM, the Administrator verified Staff D’s, Registered Nurse (RN), criminal history, dependent adult abuse and child abuse record check was done outside of the 30 day window prior to hire. Staff D had a start date of 12/4/23. Staff D’s personnel file included documentation of a completed criminal history, dependent adult abuse and child abuse record checks, dated 11/2/23, greater than 30 days prior to Staff D’s hire date. Hospice staff failed to complete criminal history, dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff. The above information was reviewed with the Administrator and Clinical Manager.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the drug regimen review (DRR) identified effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy currently associated with lab monitoring for 3 of 14 sampled patients. Failure to ensure the Interdisciplinary Group (IDG) members involved in the assessment of patient needs identified actual or potential issues when performing the DRR increased the risk of unidentified side effects and actual or potential interactions of medications. 2. Patient #4 had a hospice admission date of 3/29/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 3/29/24 to 5/27/24, included physician orders for medications with the following potential drug interactions: Lorazepam and Morphine may increase the risk of central nervous system (brain and spinal cord) depression of function. b. The initial comprehensive assessment completed by the registered nurse (RN) at the start of care, dated 3/29/24, included documentation the RN assessed the patient did not take any medications with actual or potential drug interactions or adverse reactions. The DRR completed by the RN failed to identify any actual or potential drug interactions. c. The initial IDG meeting note, dated 4/3/24, included documentation which identified the patient took the following medications with actual or potential drug interactions: Hyoscyamine/Potassium and Azithromycin/Ondansetron. The patient continued to have active orders for Lorazepam and Morphine. The initial IDG meeting note failed to identify all actual or potential drug interactions or adverse reactions. 3. Patient #10 had a hospice admission date of 8/23/23, a revocation date of 9/4/23, and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 8/23/24 to 11/20/23, included physician orders for medications with the following potential drug interactions: Lorazepam and Morphine may increase the risk of central nervous system (brain and spinal cord) depression of function. b. The initial comprehensive assessment completed by the RN at the start of care, dated 8/23/23 , included documentation the RN assessed the patient did not take any medications with actual or potential drug interactions or adverse reactions. The DRR completed by the RN failed to identify any actual or potential drug interactions. c. The IDG meeting, dated 9/6/23, included documentation which identified the patient did not take any medications associated with potential or actual drug interactions. The patient continued to have active orders for Lorazepam and Morphine at the time of revocation on 9/3/23. The above findings were reviewed with the Administrator and Clinical Manager. The hospice team did not provide any further information prior to the end of the survey. According to hospice policy titled, Medication Profile, last revised 11/9/23, in pertinent part, hospice patients: A DRR 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 a new medication. In an interview on 5/22/24 at 10:30 AM, the Clinical Manager reported that she thought the hospice was getting better with DRRs and one of the nurses that was not very good at DRRs was no longer working at the hospice. The Clinical Manager clarified that NA meant not applicable. Patient #7 had a hospice admission date of 8/30/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The admission visit on 8/30/23 included a DRR that documented NA for the sections actual or potential drug interactions, effectiveness of drug therapy, and drug side effects. The Interdisciplinary Team Reports on 3/20/24, 4/3/24, 4/17/24, 5/1/24, and 5/15/24 included DRR that documented NA for the sections actual or potential drug interactions, effectiveness of drug therapy, and drug side effects. The Plan of Care (POC) dated 8/30/23 to 11/27/23 included orders for lorazepam 0.5 mg one tablet every four hours as needed and morphine concentrate 100 mg/5mL 0.25 mL every hour as needed. The POC dated 4/26/24 and 6/24/24 included orders for lorazepam 0.5 mg one tablet every two hours as needed for mild anxiety, 2 tablets every two hours as needed for mild anxiety, three tablets as needed for moderate anxiety, four tablets every two hours as needed for high anxiety. Morphine concentrate 100 mg/5mL 0.5 mL every hour as needed.”

“Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient condition regarding wound measurements for 2 of 6 sampled patients with an open wound (Patients #7 and #9). Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment with complete wound measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient’s wound status and effectiveness of treatments and interventions. Findings include: 2. Patient #7 had a hospice admission date of 8/30/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 2/26/24 to 4/25/24, included orders for skilled nurse services and orders for wound care. b. The IDG Report on 5/1/24 documented no change in wound care. c. The IDG Report on 4/3/24 documented the patient had a wound on the 2nd toe. d. The Nursing Recertification Visit on 4/24/24 revealed the patient had a wound on the 2nd toe. e. The clinical record did not contain a comprehensive assessment of the patients 2nd toe wound the weeks of: 3/24/24, 4/7/24, 4/21/24, and 4/28/24. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. Review of the hospice’s policy, titled Pressure Injury and Wound, dated 5/20/24, the hospice nurse using the organization-approved assessment tool assess key wound characteristics including wound length, width and depth of wound measured in centimeters. During an interview on 5/20/24 at 3:00 PM the Clinical Manager stated the wound assessment includes wound description and measurements of length, width and depth of the wound completed every week. 1. Patient #9 had a hospice admission date of 2/16/23 and received routine home care hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The plan of care (POC), dated w/11/24 to 4/10/24 and 4/11/24 to 6/9/24, included orders for skilled nurse services and orders for wound care. b. A skilled nurse visit note, dated 4/2/24, included documentation the patient had a mid-coccyx wound with treatment provided to cleanse with soap and water and apply foam dressing with border. The wound measured 2.5 centimeters (cm) length by 3 cm width by 0.2 cm depth. c. The skilled nurse visit notes, dated 4/3/24, 4/5/24, 4/9/24, 4/12/24, 4/16/24, 4/19,24, 423/24 identified the patient had a wound to the mid-coccyx area. No measurements of the wound were documented. d. The skilled nurse visit note, dated 4/25/24, revealed the wound healed. The hospice nurse failed to complete an assessment of a skin change related to a wound per the hospice’s policy.”

“Based on clinical record review, hospice policy review, home visit observation, patient interview and staff interview, the hospice failed to ensure the provision of care in accordance with the patient’s plan of care (POC) for 3 of 14 sampled patients (Patient #3, #9, and #13). Failure to follow the patient’s POC as directed by the Interdisciplinary Group (IDG) put the patients at risk for inconsistent care that may not meet the needs of the patients. Findings include: 3. Patient #13 had an admission date of 2/27/24 and received services while residing in a nursing home. Review of the clinical record revealed the following: a. The Hospice Drug Regimen Review (DRR) Fax Notification signed by a physician on 2/8/24 included orders to discontinue Vitamin D3 and probiotic. b. The Physician Orders form signed by a physician on 3/4/24 included orders to discontinue lisinopril, probiotic, medroxyprogesterone, and Vitamin D3. c. The POC dated 2/27/24 to 5/26/24 documented that it was prepared by a Registered Nurse (RN) on 3/6/24 and included orders for lisinopril 20 milligrams (mg) daily and medroxyprogesterone 10 mg 2 tablets monthly, 20 mg for 10 days every month starting on the 10th. d. The IDG reports on 3/6/24 and 3/20/24 included Vitamin D3 and probiotic in the DRR. Hospice failed to update the POC with the patients current medications. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. 2. Patient #9 had a hospice admission date of 2/16/23 and received hospice services while residing in a private residence. Clinical record review and home visit observation revealed the following: a. The POC dated 2/11/24 to 4/10/24 and 4/11/24 to 6/9/24, included orders for medications and treatments the patient was receiving including the order for oxygen at 8 liters per minute. b. The skilled nurse visit note, dated 3/27/24, identified the patient utilized oxygen at 9 liters per minute for shortness of breath. c. Review of the clinical record failed to include documentation the hospice received orders to increase the flow of oxygen from 8 liters to 9 liters. The hospice failed to obtain orders for all medications and treatments the patient uses for symptom relief. Review of the hospice policy, titled Hospice Plan of Care, dated 1/2/24, identified a written individualized patient and caregiver POC will be established and maintained for each patient. The care provided to the patient must be in accordance with the plan of care. All treatments, orders, and interventions in the POC are ordered by the primary care physician and/or Medical Director. 1.Patient #3 had a hospice admission date of 7/11/23 and received hospice services while residing in a private residence. Clinical record review and home visit observation revealed the following: a. The POC dated 5/6/24 to 7/4/24 included orders for medications and treatments the patient was receiving. b. On 5/21/24 at 11:05 AM, during a home visit observation with Staff C, Registered Nurse (RN), the surveyor observed Icy Hot Dry Spray sitting on the table next to the patient in addition to Biotene Dry Mouth Spray in the patient’s bathroom. The patient identified the Icy Hot Dry Spray is being utilized for knee pain and the Biotene is being utilized for dry mouth. The patient reported both sprays have been used for about a year. The hospice failed to obtain orders for all medications and treatments the patient uses for symptom relief.”

“Based on clinical record review, hospice policy review, and staff interview, the hospice failed to ensure the Plans of Care (POC) and all updates included a specific frequency for the planned delivery of hospice services for 6 of 14 sampled patients (Patients #3, #4, #5, #6, #7, and #9). Failure to establish and individualized POC and identify a scope and frequency for all ordered services placed patients and families at risk of receiving treatments and/or services that did not adequately meet their needs. Findings include: 5. Patient #6 had an admission date of 10/19/23 and received hospice services while residing in a nursing home. a. The POC, dated 3/9/24 to 5/7/24, included orders for hospice aide services 3 times a week and 10 as needed. b. The IDG notes, dated 3/20/24, 4/3, 4/17/24, 5/1 and 5/15/24, included orders for patient aide visits 3 times per week. c. The clinical record review revealed the patient received scheduled 5 hospice aide visits a week the weeks of 3/31/24 to 4/6/24, 4/7/24 to 4/13/24, 4/28/24 to 5/4/24, 5/5/24 to 5/11/24 and 5/12/24 to 5/18/24. The hospice IDG failed to include documentation the patient aide visits increased to 5 scheduled visits per week. 6. Patient #9 had an admission date of 2/16/23 and received services while residing in a private home residence. a. The POCs, dated 2/11/24 to 4/10/24 and 4/11/24 to 6/9/24, included orders for hospice aide services 5 times a week and 10 as needed. The POCs also included orders for volunteer services as needed times 3. b. The clinical record review revealed the patient received scheduled 5 hospice aide visits a week the weeks of 3/16/24 to 3/24/24, 3/25/24 to 3/31/24, 3/31/24 to 4/6/24, 4/7/24 to 4/13/24, 4/14/24 to 4/27/24 4/28/24 to 5/4/24, 5/5/24 to 5/11/24 and 5/12/24 to 5/18/24. The hospice IDG failed to include documentation the patient aide visits increased to 5 scheduled visits per week and specific orders for hospice aide and volunteer services. The above findings were reviewed with the Administrator and Clinical Manager. The hospice provided no further information prior to the end of the survey. 3. Patient #5 had an admission date of 11/9/23 and received services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 2/7/24 to 5/6/24 included orders for volunteer services 0-4 per month per patient/family request. The hospice POC failed to include specific orders with a valid range of the number of visits for volunteer services. 4. Patient #7 had an admission date of 8/30/23 and received services while residing in a nursing home. Review of the clinical record revealed the following: The POC from 8/30/23 to 11/27/23 included an order for volunteer services to start 9/12/23 0-4 times per month per patient/family request. The POC from 11/28/23 to 2/26/24 included an order for volunteer services 0-4 times per month per patient/family request. The hospice POC failed to include specific orders with a valid range of the number of visits for volunteer services. Review of the hospice’s policy, titled Hospice Plan of Care, dated 1/2/24, identified a written individualized patient and caregiver POC will be established and maintained for each individual admitted to the hospice program. The POC will identify patient needs and the services necessary to meet patient needs. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs. 1.Patient #3 had an admission date of 7/11/23 and received hospice services while residing in a private residence. The POCs, dated 3/7/24 to 5/5/24 and 5/6/24 to 7/4/24, included orders for Spiritual Counseling services; 5 as needed for spiritual care. The POCs failed to identify a specific frequency for spiritual counseling visits. 2. Patient #4 had an admission date of 3/29/24 and received hospice services while residing in a private residence. The POC, dated 3/29/24 to 5/27/24 included orders for Volunteer services; 2 as needed per patient/family request. The POC failed to identify a specific frequency for volunteer visits.”

“Based on observation, clinical record review, hospice policy review, and hospice staff interview, the hospice failed to ensure the Plan of Care (POC) for 2 of 14 sampled patients (Patients #1 and #2) included all medical equipment and supplies necessary to meet identified patient needs. Failure to include all needed items of medical equipment and supplies the patient used on the POC placed the patients at risk of unanticipated decline or injury of needs not met. Findings include: 2. Patient #1 had an admission date of 7/28/23 and received services while residing in a private home setting. a. The POC, dated 3/24/24 to 5/22/24, included documentation the patient required use of the following DME: thermometer, incontinent supplies, grab bars, cane, blood pressure cuff, walker, stool riser, scale, pulse oximeter, pill cutter, oxygen & supplies, nebulizer and lifeline. b. During a home observation visit with Staff D, Registered Nurse the surveyor identified the following DME utilized by the patient: hospital bed and bed rails. c. During an interview during the same home visit the patient stated the DME present in the home for approximately 1 year. The hospice failed to include the DME hospital bed and bed rails on the patient’s plan of care. The above findings shared with the Administrator and Clinical Manager. The hospice provided no additional information prior to the end of the survey. According to hospice policy titled, Plan of Care, last revised 2/16/23, in pertinent part, a written individualized patient and caregiver POC will be established and maintained for each individual admitted to the hospice program. The written POC will contain DME (durable medical equipment) and medical supplies necessary to meet patient needs. In an interview on 5/22/24 at 10:30 AM, when the Administrator and Clinical Manager were informed about the concern with DME not listed in the POC, they responded by saying okay and writing on paper. Patient #2 had a hospice admission date of 4/29/24 and received hospice services while residing in a nursing home. In an observation on 5/21/24 at 1:00 PM, an oxygen concentration was located in the patients room and the patient had a low air loss mattress on his bed. Review of the clinical record revealed the following: The POC dated 4/29/24 to 7/27/24 included an order for oxygen 1 lpm (liter per minute), may increase up to 4 lpm via nasal cannula per patient comfort. The POC dated 4/29/24 to 7/27/24 did not include either an oxygen concentrator was located in the patients room and the patient had a low air loss mattress on his bed.”

“Based on hospice clinical record review, hospice policy review, nursing home staff interview, and hospice staff interview, the hospice failed to ensure the coordination and collaboration among Interdisciplinary Group (IDG) members and patient’s attending physician to ensure hospice staff provided treatment and services to the patients according to team decisions with 1 of 6 sampled patients in long term care setting (Patient #11). Failure of the hospice IDG members to communicate and collaborate with each other to update the plan of care increased the risk that patients did not receive services and treatments to meet the needs of the patients. Review of the policy, titled The Plan of Care, dated January 2024, revealed each patient will have an individualized, written Plan of Care (POC). Hospice staff will provide care and services based on the POC. The POC will identify the needs and services to meet those needs. The members of the Interdisciplinary Group (IDG) perform the initial and ongoing comprehensive assessments which are the basis of the POC. The IDG will update the POC at least once every 15 days. The hospice IDG failed to ensure they maintained a system of communication which allowed for the hospice’s coordination of the patient’s care in relation to advance directives, treatments, medications and medical equipment and supplies. 1. Patient #11 had a start of care date of 6/1/2023, and received routine home care hospice services while residing in a nursing facility and was discharged to a different hospice agency on 6/23/23. a. The comprehensive initial assessment, dated 6/1/23, indicated the pain rating for the patient was a 2 on a scale of 1-10 (with 1 being the lowest pain level and 10 being the highest pain level possible). The Registered Nurse (RN), documented pain was present with any activity and constant in duration, pain control was limited, and patient satisfaction with pain level was neutral. b. The skilled nurse phone call note, dated 6/1/23 at 3:37 PM, documented contact with the pharmacy and indicated the pharmacy couldnt fill the pain medications of Tramadol and Hydromorphone without written scripts. c. The skilled nurse phone call note, dated 6/1/23 at 3:47 PM with the primary physician office revealed the RN attempted to obtain scripts for Tramadol and Hydromorphone (medications used for pain control), and documented the physicians nurse did not know if he could fill the pain medications as the patient had not been seen by that physician as of 6/1/23. d. The skilled nurse phone call note, dated 6/1/23 at 4:55 PM with the Director of Nursing (DON) in the facility, indicated the hospice nurse relayed the information from the call to the primary physicians office in an attempt to get scripts for the pain medications of Tramadol and Hydromorphone. The DON gave the hospice nurse the number of the hospital the patient had just been discharged from and suggested she call there to get the needed scripts for the pain medications. The hospice nurse indicated she would attempt to call the discharging hospital for the scripts needed to fill the medications. The clinical record lacked documentation for phone call to the discharging hospital. e. The skilled nurse phone call note, dated 6/3/23, indicated the RN made a phone call to the nursing facility to inquire about pain. The facility indicated the patient was comfortable the morning of 6/3/23; however, patient needed PRN (as needed) pain medication the night before. The clinical record lacked a hospice skilled nurse visit on 6/3/23. f. The Medical Social Worker (MSW) visit note, dated 6/6/23, indicated the patient stated he/she could now sleep in bed and indicated some relief, but the patient stated the pain was still constant. The documentation lacked communication with any IDG team members about the patients complaint of pain. g. The skilled nursing visit note, dated 6/8/23, revealed the patient rated his/her pain as a 7 on a scale of 1-10 with movement, however the nurse documented the pain was controlled with medication. h. Hospice aide documentation, dated 6/12/23, indicated the the hospice aide called to the hospice Administrator to report patient pain when in the wheelchair. i. During an interview with the Administrator on 5/22/23 at 9:00 AM, she stated the hospice aide called to the hospice office on 6/12/23 to report patient pain when in the wheelchair. The Administrator stated she placed a call to the case manager to address the reported pain. j. Phone call documentation, dated 6/13/23, at 3:46 PM revealed a phone call from the patients spouse inquiring when a hospice nurse would come to see the patient next. He/she voiced concern over pain and what could be changed to keep the pain level down. A return call was made to the patient’s spouse at 4:33 PM to inform spouse a fax was sent for pain control to the physician. The clinical record lacked a skilled nurse visit on 6/13/23. k. Fax order request, dated 6/13/23 at 11:54 AM, the hospice nurse faxed the physician for pain control recommendations based on reported pain. No nursing visit was completed to assess the patients pain. The fax returned from the physician with orders to use Morphine (pain medication) as listed. The physicians signature lacked the date. l. IDG meeting note, dated 6/14/23, included documentation the skilled nurse referenced the reason for admit as pain had increased; however, lacked updates for pain control, assessments and interventions that had been attempted. The IDG note documented the review of medications and that medications were effective. The MSW note revealed the patients pain had improved some, but the patient had stated the pain was still constant. m. The social worker visit note, dated 6/14/23, indicated the patient demonstrated intermittent moments of excruciating pain and for the first half of the visit the patient was preoccupied with pain and was somewhat agitated. The social worker sent a team communication text during the visit indicating the patient was having excruciating pain when in his/her wheelchair and had requested the hospice aide visit at lunch time to reduce the time he/she had to spend in the wheelchair. n. The chaplain visit note, dated 6/15/23, revealed the patient was begging for pain medication and asked if he/she could get something stronger. The patient stated he/she was not afraid of going to sleep or being non functional, and also stated he/she just couldnt stand the pain. The chaplain documented in the same note, the hospice RN came part way through her visit and addressed pain control with patient and the facility DON. o. The skilled nurse visit note, dated 6/15/23, revealed the nursing facility requested they be notified of any fax orders, requests or responses to and from the physician, and that the DON was appreciative the hospice aide had called the hospice office on 6/12/23 to report the patient’s pain level. Also noted was the request from the nursing facility for a nursing visit from the hospice on 6/15/23. During this visit patient rated his/her pain as a 10. The nurse noted his/her pain is relieved if he/she remains immobile and in a fixed position in the recliner or in bed. Pain becomes severe with movement and spasms. The skilled nurse requested during this visit the patient be given the morphine, after one dose minimal improvement noted, after second dose, patient stated the morphine did nothing to alleviate his/her pain. The nurse noted muscle spasms observed every ten minutes were severe with no relief noted with morphine, 2 doses of Morphine was given. Documentation also revealed discussion with patients spouse, who had concerns the patients pain was not being managed well. The hospice nurse documented hospice would fax physician for an increase in the Fentanyl Patch (pain medication absorbed slowly and continuously through a patch place on the skin and secured). Also noted, discussion related to finding balance between opioids and mental clarity and it was noted patient became upset stating “;I dont care about mental clarity, I dont want to have pain”. Patient stated, “;Im anxious all of the time, I yell at people and that is not me, and I dont want to do that. Its the pain”. p. Fax order request to the physician, dated 6/15/23, the Hospice RN detailed observations from the 6/15/23 skilled nurse visit and requested orders to increase the dosage of the Fentanyl Patch, schedule the Hydromorphone in addition giving Hydromorphone PRN (as needed or per patient request), schedule the medication cyclobenzaprine (medication used for relaxing muscles) and to schedule Lorazepam, (medication used for treating anxiety). Fax was returned signed on 6/16/23, however, the physicians nurse noted on the fax, the facility had called the evening before and requested an increase in the dose of the Fentanyl Patch, as the patient’s pain was not controlled. The physician did sign orders for the rest of the medication changes/requests the hospice nurse had asked for. q. The skilled nursing visit note dated, 6/17/23, indicated improved pain control and the patient expressed improvement with the increase in the Fentanyl Patch and with scheduling the Hydromorphone. The patient still rated his/her pain high at a 7 on a scale of 1-10. r. The skilled nursing visit note, dated 6/20/23, revealed the patient rated his/her pain at a 5 on a scale of 1-10. Documentation also revealed a discussion with spouse related to pain not being controlled the day before. s. The communication note, dated 6/21/23, stated the hospice was contacted by alternate hospice requesting a transfer of care per spouses request 6/21/23. Request made to transfer care. Communication note also revealed hospice Administrator attempted to contact the spouse by phone with no answer. t. The skilled nurse visit note, dated 6/22/23, revealed that patient had not had a bowel movement for six days. Patient rated his/her pain at a 10. Documentation revealed the hospice nurse requested the facility give some Milk of Magnesia (laxative) and to administer a laxative suppository after the patient laid down for the afternoon. Hospice nurse did request an order for enema if needed through fax to the primary physician. u. The discharge nurse visit note, dated 6/23/23, revealed the transfer of care to alternate hospice completed with patient and spouse. In an interview with the nursing home DON on 5/22/23 at 10:00 AM, she stated the hospice agency lacked any urgency in addressing the patients pain levels, so the facility nurses called the physician to get orders the night of the 6/15/23 for better pain control. The nursing home DON stated the pain management hospice provided was too slow and follow through was slow with poor communication between hospice, the facility and the physician. The Hospice failed to collaborate, communicate, and coordinate with the interdisciplinary team to control and address patient’s pain timely and effectively. The Administrator and Clinical Manager received the above findings.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 2 of 3 sampled patients (Patients #2 and #3 ) with a missed visit. Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. 2. Patient #2 had a hospice admission date of 4/29/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The POC dated 4/29/24 to 7/27/24 included orders for aide services 2 every week for 1 week starting 4/29/24 and then 3 every week for 12 weeks. Music Therapy 1-3x a month with 2 PRN (as needed) visits. The patient schedule documented that the aide visit on 5/1/24 was refused because the patient received a bath from the facility just prior to the visit. The Comfort Therapies Visit Note signed by the contracted music therapist on 5/10/24 documented that the visit was canceled due to additional hospice staff arriving for cares. The Interdisciplinary Report on 5/1/24 and 5/15/24 documented that there were no missed visits. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. 1.Patient #3 had an admission date of 7/11/23 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The POC, dated 5/6/24 to 7/4/24, included physician orders for skilled nursing services two times every week for eight weeks. b. The clinical record identified only one skilled nursing visit the week of 5/12/24. c. The IDG update to the POC, dated 5/15/24, lacked documentation indicating the Interdisciplinary Group (IDG) was aware of the missed skilled nursing visit the week of 5/12/24. According to the hospice policy titled Hospice Interdisciplinary Group Meeting, dated 8/8/23, the patient’s plan of care will be updated no less frequently than every 15 days or more frequently if the patient’s condition requires based on assessment of bio/psycho/social and spiritual needs.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure hospice aides provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 1 of 14 sampled patients receiving hospice aide services. (Patient #6). Failure to ensure that hospice aide services are provided only as ordered by the physician and according to the hospice aide care plan increased the risk that patients’ personal care needs were not adequately met. Findings include: During an interview on 7/24/23 at 11:10 AM, the Administrator stated the Registered Nurse (RN) completes the aide care plan and the hospice aide documents a reason why a task was not completed. 1. Patient #6 had a hospice admission date of 10/19/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks of personal care, skin care lotion arms, hands legs, feet and back, pressure relief, bath, shower Monday and Friday, oral care, lip care, oral swabs, brush/comb, shampoo caps, condition, electric razor, nail care, clip file fingernails and toenails, dress upper body, dress lower body, incontinence care, incontinent pad/shield, reposition, hoyer lift for all transfers, broda chair, report falls, clean bathroom after bathing, companionship and check incontinent supplies and alert office. b. The hospice aide visit note, dated 4/8/24, 4/10/24 and 4/12/24, included documentation the tasks of provide shower 3 times a week. The note failed to include documentation the RN notified of the change. The hospice aide failed to provide services as instructed by the RN assignment. The above findings were reviewed with the Administrator and Clinical Manager. The hospice provided no further information prior to the end of the survey.”

“Based on clinical record review, hospice policy review and staff interview, the hospice failed to document all required components of hospice aide supervision including following the patient plan of care, creating successful interpersonal relationships with the patient and family, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition every 14 days when the patient receives skilled services in conjunction with the hospice aide services for 2 of 14 sampled patients (Patients #1 and #7) with hospice aide services that required and received hospice aide supervision. The hospice reported 9 patients received hospice aide services at the time of the survey. Failure to ensure the supervision of hospice aide by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients’ personal care needs. Findings include: 2. Patient #7 had an admission date of 8/30/23 and received services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC dated 2/26/24 to 4/25/24, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 3/28/24 and 4/24/24, included documentation that the nurse supervised the hospice aide. No supervision of the aide occurred in between the two nursing visits. The hospice failed to document aide supervision every 14 days. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. Review of the hospice’s policy, titled Care Assistant/Aide Supervisory Visits, dated 5/23/24, identified supervision of aide services must occur at least every 14 days unless the payer dictates that supervision should occur at some other frequency. The aide does not need to be present in the home; however every aide must have one direct, on site/in the home supervision every 12 months. During an interview on 5/20/24 at 3:00 PM the Clinical Manager stated the aide should be supervised weekly. 1. Patient #1 had a hospice admission date of 7/28/23 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The Plans of Care (POCs), dated 3/24/24 to 5/22/24, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 4/29/24 and 5/14/24, included documentation the nurse supervised the hospice aide. (one day late) The hospice failed to document aide supervision every 14 days.”

“Based on clinical record review, policy review, and staff interview the hospice failed to ensure staff obtained physician certification of the patients terminal illness (CTI) for 1 of 14 sampled patients (Patient #2). Failure to obtain the physicians certification of terminal illness puts the patient at risk of receiving hospice care inappropriately and/or without a funding source. Findings include: According to the hospice policy titled, Hospice Plan of Care (POC), last revised 8/16/22, in pertinent part, the plan of care will be provided to both the attending primary care provider and the Medical Director for approval of verbal orders and certification of the terminal illness signatures. In an interview on 5/21/24 at 3:30 PM, the Administrator reported that the patients attending physician was out of the office and a different physician in the clinic signed the CTI. The Administrator reported that the Clinical Manager was not aware that the health care provider that signed the CTI was a physicians assistant (PA) and not a medical doctor or a doctor of osteopathic medicine. When a list of healthcare providers and their credentials at the patients attending physicians clinic were found on the internet to confirm this information with the Administrator, the Administrator agreed the signature on the CTI was from a PA. Patient #2 had a hospice admission date of 4/29/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The POC dated 4/29/24 to 7/27/24 included the patients attending physician. The CTI signed by a PA on 5/15/24 listed the same attending physician as the POC. The Administrator and Clinical Manager received the above findings.”

“Based on clinical record review, hospice policy review, and staff interview, the hospice failed to ensure all entries completed in the clinical record were done so timely, and included an appropriate date and signature for 7 of 14 sampled patients (Patients #1, #2, #3, #4, #5, #6, and #7). Failure to ensure all clinical record documentation was completed timely and was appropriately authenticated, increased the risk of ineffective coordination of patient care. Findings include: 5. Patient #2 had a hospice admission date of 4/29/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The POC dated 4/29/24 to 7/27/24 included orders for Music Therapy 1-3x a month with 2 PRN (as needed) visits and spiritual counseling 3 within 13 weeks for 13 weeks with PRN (as needed) 5. The Comfort Therapies Visit Notes on 5/3/24 and 5/10/24 failed to include the music therapists credentials. The hospice chaplain visit note on 5/17/24 was not signed until 5/20/24. 6. Patient #5 had an admission date of 11/9/23 and received services while residing in a nursing home. Review of the clinical record revealed the following: The POCs dated 2/7/24 to 5/6/24 and 5/7/24 to 7/5/24 included orders for skilled nursing visits, aide services and volunteer visits. The patients electronic medical record (EMR) did not contain volunteer documentation for visits that occurred in February 2024 or April 2024. The volunteer visits on 3/5/24 and 3/14/24 were not signed. The following visits were signed longer than 24 hours after the visit: skilled nursing visit on 4/6/24 signed on 4/9/24m aide visit on 4/11/24 signed on 4/14/24, aide visit on 4/12/24 signed on 4/15/24, and aide visit on 5/1/24 signed on 5/4/24. 7. Patient #7 had a hospice admission date of 8/30/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The POC dated 2/26/24 to 4/25/24 included orders for aide visits. The POC dated 8/30/23 to 11/27/23 included orders for volunteer visits. The aide visit on 4/2/24 was signed longer than 24 hours on 4/4/24, the aide visit on 4/12/24 was signed 4/14/24, and the aide visit on 4/19/24 was signed on 4/21/24. The patients EMR did not include documentation of volunteer visits from September 2023 and October 2023. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. 3. Patient #1 had a hospice admission date of 7/28/23 and received services while residing in a private home residence. a. The plan of care, dated 3/24/24 to 5/22/24, included orders for volunteer services 3 to 5 times a month. b. The clinical record lacked documentation of volunteer notes for the month of February, March and April, 2024. c. During an interview on 5/22/24 at 2:00 PM the Clinical Manager stated the patient continued to receive volunteer services during the months of February, March and April. 4. Patient #6 had an admission date of 10/19/23 and received hospice services while residing in a nursing home. a. The clinical record review revealed Music Therapy visit notes, dated 3/28/24, 4/11/24 and 4/24/24, included an electronic signature but lacked a discipline title. b. The volunteer visit note, dated 4/25/24, included a visit note, date of service but lacked a signature. The hospice failed to ensure staff signatures appropriately authenticated. Review of the hospice policy, titled Documentation, dated 8/8/23, identified all entries should include a date, time, and signature. On 5/20/24 at 3:00 PM, during an interview, the Clinical Manager reported hospice staff are expected to complete documentation within 24 hours following a visit. 1.Patient #3 had a hospice admission date of 7/11/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POCs, dated 3/7/24 to 5/5/24 and 5/6/24 to 7/4/24, included physician orders for skilled nursing services. b. The RN visit note, dated 4/19/24, was not signed until 4/21/24. c. The RN visit note, dated 5/9/24, was not signed until 5/11/24. The hospice failed to ensure timely documentation based on agency expectations. 2. Patient #4 had a hospice admission date of 3/29/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 3/29/24 to 5/27/24 included orders for volunteer services. b. The volunteer visit note, dated 4/15/24, failed to include the volunteer’s signature and date.”

“Based on clinical record review, nursing home medication records, hospice policy review, and hospice staff interview, the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the nursing home for 1 of 1 sampled patients with visits observed who resided at nursing homes (Patient #2) including a review of the patients nursing home residence medication records. Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: According to the hospice policy titled, Hospice Interdisciplinary Group Meeting, last revised 7/1/13, in pertinent part, each patients plan of care (POC) will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or as patients condition requires. For patient residing in a facility, any changes in plan of care or patient education that has occurred during the visit will be communicated to the nursing staff of the facility. In an interview on 5/22/24 at 10:30 AM, when this concern was brought to the attention of the Administrator and Clinical Manager, the Clinical Manager reported that she would look into it. Patient #2 had a hospice admission date of 4/29/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The nursing homes medication and treatment administration record, dated 4/15/24, included the following order discrepancies when reconciled against the medications listed on the hospice Plan of Care dated 2/18/24 to 4/17/24: a. The hospice POC included the following medications that were not included on the nursing home medication list: Miralax 17 grams per dose 1 scoop every 24 hours as needed. b. The nursing home medication list included the following medications that were not included on the hospice POC: Morphine sulfate 20 milligrams (mg)/milliliter (mL) give 0.5 mL one time a day 30 minutes to getting up in the morning. Acetaminophen suppository 650 mg insert rectally every 6 hours as needed. c. Hospice POC included Triad wound dressing paste 1 application two times a week and as needed discontinue as of 5/3/24. Nursing home medication list included an active order for Triad hydrophilic wound dress external paste apply to buttocks topically as needed for wound healing with a start date 4/9/24. The hospice RN failed to ensure coordination of medications with the nursing home staff. The Administrator and Clinical Manager received the above findings.”

“Based on clinical record review, policy review, and staff interview the hospice failed to communicate with long term care staff to ensure quality of care for 1 of 1 sampled patient who was prescribed warfarin medication (Patient #7). Failure to effectively communicate with long term care staff where a patient resides potentially reduces the opportunity for adequate coordination and exchange of information to ensure appropriate updates to the patients plan of care and provision of services by the two entities. This risk increases when the patient takes a high risk medication in timely communication is critical to the health of the patient. According to the hospice policy titled, Hospice Interdisciplinary Group Meeting, last revised 7/1/13, in pertinent part, for patient residing in a facility, any changes in plan of care (POC) that has occurred during the visit will be communicated to the nursing staff of the facility. In an interview on 5/22/24 at 3:30 PM, the Administrator reported that sometimes the clinic nurse calls the nursing home the patient resides at with international normalized ratio (INR) orders and warfarin medication orders, if needed. The Administrator reported if the clinic called the nursing home, then the hospice does not call the nursing home. When asked, if the phone calls are documented in the patients electronic medical record (EMR), the Administrator reported that they are probably not. Patient #7 had a hospice admission date of 8/30/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The POC from 4/26/24 to 6/24/24 included an order for warfarin 3 milligrams (mg) on Monday, Wednesday, and Friday; warfarin 4 mg on Tuesday, Thursday, Saturday, and Sunday. a. Skilled Nurse Visit (SNV) on 3/22/24 with a physician notified of the INR result obtained during the visit. The visit, or the patients electronic health record (EMR) did not contain nursing home notification of orders for the next INR lab, changes or no need for changes in warfarin medication dosing. b. SNV on 5/10/24 with the patients attending physician notified of the INR result obtained during the visit. Staff at the attending physicians clinic reported to the hospice nurse that they would call hospice and the nursing home with orders for today as well as going forward. Failure to manage the patients warfarin medication and coordinate care of the patient residing in long term care placed the patient at risk for potentially life threatening complications related to excessive bleeding or clot formation. The Administrator and Clinical Manager received the above findings.”