Mercy Health Hospice Metropolis

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure all members of the Interdisciplinary Group completed their initial assessment within 5 days after the election of the hospice benefit. CLINICAL RECORD 1: The patient elected the hospice benefit on 01/28/2026, with the admission visit by the Registered Nurse documented the same day, and the initial Social Work assessment performed on 02/02/2026. There was no initial Chaplain visit documented, no missed visit or attempt documented in a Care Coordination Note or in the Interdisciplinary Group meeting on 01/28/2026. No declination of Chaplain services was documented. After a joint clinical record review and interview with the Hospice Senior Director of Clinical Services (DCS - Personnel Record 3) on 04/07/2026, she confirmed the finding and explained that this patient had transferred from another of the Corporation’s offices (different CCN [CMS certification number]) and was admitted to their office on 01/28/2026. The Chaplain’s hire date was 09/23/2025, and, being relatively new, he stated to DCS that he did not understand that he was required to perform an initial assessment, even with the inter-corporate transfer.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure that the patients’ plans of care included problems, patient-specific planned interventions, and measurable goals identified from data in the patients’ comprehensive assessments. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/05/2026 with the terminal diagnosis of malignant neoplasm of the right breast with secondary malignancies of the bone. During the Registered Nurse (RN) Admission visit, the patient was oriented to person, place, and time, with intermittent confusion and forgetfulness, and at times reported restlessness, anxiety, and agitation. The patient’s medication list included Celexa 40mg daily for depression (discontinued 03/17/2026), Haloperidol 0.5mg every night scheduled for agitation, Haloperidol Lactate 2mg/mL: 0.5mL every 6 hours as needed (PRN) for agitation or hallucinations, and Lorazepam 0.5mg every 4 hrs PRN for agitation. On 02/17/2026, the nurse noted during a visit that the patient was taking Oxycodone 10mg and Lorazepam 0.5mg every 4 hours. On 03/11/2026 at 2136 pm, a call was received, and the patient’s daughter reported the patient had received Haldol 2 hours prior and wears a Fentanyl patch, but the patient continues to try to get out of bed. The nurse suggested using Lorazepam and informed the daughter that she would call in one hour to see if the medication was effective. On the return call at 2239pm, the patient was resting quietly after the Lorazepam dose. On 03/16/2026, the RN made a “...visit to follow up on patient’s agitation and aggression at night...alert and oriented to person and place...Patient tries to get out of bed, hits family, curses, and does not sleep. Reached out to the doctor who ordered Seroquel.” An order for Seroquel 50mg every night at bedtime for agitation was documented. During the IDG (interdisciplinary group) meeting on 03/19/2026, the addition of Seroquel on 03/16/2026 resulted in unrelieved restlessness and agitation after Haldol use was noted, but no goals of care were defined. The patient’s plan of care for the benefit period dated 02/05/2026 to 05/05/2026 was reviewed, and there were no problems identified or planned interventions with goals related to the treatment and management of the patient’s restlessness and agitation. CLINICAL RECORD 10: The patient elected the hospice benefit on 07/26/2025 with the terminal diagnosis of Parkinson’s disease with secondary comorbidities of dementia, severe with behavioral disturbances, heart failure, asthma, and dysphagia. The physician’s initial certification of terminal illness for the benefit period dated 07/26/2025 to 09/23/2025 included in part that the patient presented with “...end-stage Parkinson’s disease with increasing difficulty swallowing...He is having increasing agitation and persistent pain...He now requires oxygen, and O2 saturation is 81% on 2 L via nasal cannula. Bradycardia is also present with heart rate in the 40’s at times...” During the RN Admission visit on 07/26/2025, it was noted that the patient had mild anxiousness and irritability, exhibited abnormal respirations - labored and tachypneic - and shortness of breath, and was on continuous oxygen. The patient was unable to verbalize goals, and no goals related to vital signs or signs of agitation or mood were noted. “Significant functional decline, increased agitation...high symptom burden with cognitive impairment and behavioral disturbances. Respiratory status compromised (O2 81% on 2L via NC [nasal cannula]), vital sign bradycardia (HR [heart rate] 43)...” The initial plan of care included the need for thickened liquids but there was no documented risk for aspiration safety precautions. The patient’s medication list included Risperidone 1mg/mL: 0.5mL twice daily, scheduled for agitation, and Lorazepam 1mg every 6 hours as needed for anxiety/restlessness. For the subsequent benefit period dated 09/24/2025 to 11/22/2025, the physician’s recertification noted in part “...Unfortunately, his agitation has increased. Oxygen had to be increased to 3 L and pulse ox is 90%...He is now on a honey-thickened pureed diet...” The recertification plan of care contained no updated goals or safety measures related to dysphagia, and no updated interventions or goals for agitation or respiratory treatment. The Nurse Practitioner’s Face-to-Face visit on 12/31/2025 noted in part that “...at times he has increased agitation which includes verbal outbursts, inappropriate comments to staff, and hitting/kicking. He does have dysphagia requiring pureed texture honey consistency...” During the IDG meeting on 02/19/2026, no patient behaviors were addressed. It was noted that the patient slept 18 hours a day, required staff feeding, and needed a pureed diet with honey-thick fluids. During the RN visit on 03/18/2026, it was documented that the patient had to be hand-fed by the facility staff and required a pureed diet with honey-thickened fluids, and there were safety concerns regarding the patient’s inability to summon help due to his inability to communicate. The patient continued on oxygen at 2 liters per minute (LPM). The nurse noted during the IDG meeting on 03/19/2026, the patient was at a heightened acuity level due to the need for increased support from the team for reassurance, training, and symptom management. The comfort goals documented for the next 2 weeks included “managing” nighttime agitation with PRN (as needed) Lorazepam, continuing oxygen support for dyspnea relief, and being unable to make his needs known. On 03/25/2026, the patient presented with abnormal breath sounds with crackles ausculated throughout all lobes and remained on continuous oxygen. Audible congestion and a loose cough were noted, but no sputum was coughed up. New orders were documented for DuoNebs every 4 hours for 5 days, and for Robitussin DM 5-100mg/5mL: 5mL 4 times daily for 5 days. A review of the patient’s plans of care for the benefit periods dated 03/23/2026 to 05/21/2026 and 01/22/2026 to 03/22/2026 was conducted, and a problem was identified: the need for comfort, with the goal that the patient would experience relief from shortness of breath and maintain comfort with supplemental oxygen as needed. The documented intervention was to assess the patient’s comfort level and shortness-of-breath symptoms, and adjust interventions as necessary. No definitive, patient-specific goal was documented for the patient’s ongoing respiratory symptoms, and treatments that were ordered. The patient’s safety was included as one of the patient’s problems, with the goal that the patient’s safety would be observed and fall risks assessed, and the patient’s safety needs would be met, as evidenced by no falls or injuries. There was no identified problem, interventions, or patient goals for the patient’s documented dysphagia, as the safety concern was that the patient was unable to make his needs known or summon facility staff for help. There was no identification of any problems, planned interventions, or treatment goals for the patient’s behaviors that required medical intervention. A joint clinical record review and interview with the Hospice Senior Director of Clinical Services (Personnel Record 3) on 04/07/2026 confirmed that the patients’ plans of care did not accurately reflect all the problems identified in the comprehensive assessments.”

“A revised plan of care includes Information from the patient’s updated comprehensive assessment and 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, observation, and interview. 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure that the patients’ plans of care were updated to reflect new data from the patients’ comprehensive assessments. The hospice’s policy titled “Interdisciplinary Team Meeting (Procedure: HOS-C_09E)” last reviewed and revised 08/11/2025 included in part “...The IDT (interdisciplinary team) will follow the cadence of discussing each patient’s needs/condition over the previous 2 weeks and plan to meet the patient’s needs for the next 2 weeks...Comfort, Safety, and Quality of Life...each team member contributes insight, information, assessment data, and details concerning problems, goals, and interventions. The focus of the discussion is what has happened in the previous 2 weeks and what is expected to happen in the next 2 weeks...includes...changes in the Plan of Care (POC)...and changes in interventions for the patient...” CLINICAL RECORD 3/HOME VISIT 3: The patient elected the hospice benefit on 03/25/2026. During the Registered Nurse (RN) Admission visit on 03/25/2026, the nurse noted the patient’s usual bowel pattern was daily, and she complained of some nausea. The patient’s medication list included Bisacodyl 10 mg suppository daily as needed (PRN) for constipation; Senna-S 8.6 mg-50 mg twice daily PRN for constipation; Ondansetron 4mg every 6 hours PRN for nausea; and Compazine 10 mg every 6 hours PRN for nausea. During the nurse’s visit on 04/02/2026, the nurse noted the patient was experiencing constipation with no bowel movement (BM) since 03/26/2026. The patient had hypoactive bowel sounds, and it was suggested to the patient and caregiver that a Bisacodyl suppository be given. An order was documented to change the Senna-S from PRN to scheduled dosing. The Interdisciplinary Group (IDG) meeting, held the same day, noted the change in the Senna order but provided no update on the patient’s constipation status. On 04/05/2026, the nurse documented a phone call stating “...Daughter called 0733am...Pt becoming more and more confused...Discussed that the patient was seeing little girls who were not there. Discussed with daughter to start Haldol...for hallucinations...” The patient’s medication list included Haloperidol Lactate 2mg/mL: 0.5mL every 6 hours PRN for agitation or hallucinations. During the home visit observation with the Social Worker (Personnel Record 8) on 04/06/2026, the daughter medicated the patient with Ondansetron due to the patient’s complaints of nausea during the visit. A review of the plan of care for the benefit period dated 03/25/2026 to 06/22/2026 identified the need for comfort as a patient goal, with the goals for the patient to maintain an effective bowel program, and that symptoms would be identified promptly and interventions initiated quickly to minimize discomfort, as evidenced by a pain score less than the patient’s identified pain goal. Interventions included instructing on the bowel protocol as needed and instructing the caregiver to notify the hospice of any changes in the patient’s pain. The patient’s plan of care was not updated to reflect a patient-specific goal for the treatment of her constipation, there was no identified problem of the patient’s increasing nausea with updated planned interventions and specific measurable goals for the treatment of nausea, nor the patient’s hallucinations requiring the initiation of the use of Haldol. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/15/2024 with the terminal diagnosis of sequelae of cerebrovascular disease and a comorbid condition of vascular dementia. During the Licensed Practical Nurse (LPN) visit on 02/09/2026, she noted that the patient refused to stop for an assessment and could not be redirected. This information alone was documented in the IDG meeting on 02/19/2026. The Nurse Practitioner made a face-to-face visit on 02/27/2026 and documented that “...He is very pleasant today, but staff at nursing home states he has episodes of being combative - hitting, kicking, etc. He also refuses to get dressed or participate at times...” And on 03/02/2026, the nurse noted the patient was more disoriented and became slightly agitated when she tried to redirect him. It was noted during the IDG Meeting on 03/05/2026 that the patient was exhibiting increased confusion and agitation and required increased Lorazepam doses. On 03/19/2026, the nurse included only pain in the focused comfort goal for the next 2 weeks. The patient’s medication list included Lorazepam 0.5mg every 6 hours PRN (as needed) for anxiety and Seroquel 25mg at bedtime for behaviors. A review of the patient’s plans of care for the benefit periods dated 03/10/2026 to 05/08/2026 and from 01/09/2026 to 03/09/2026 identified a problem related to quality of life, with the goal of the patient exhibiting peace of mind at the end of life. The interventions included monitoring for signs of agitation, consulting with the physician for medication to keep anxiety and agitation controlled, and providing a calm environment. There were no updated interventions or goals to address the patient’s increasing agitation. The last update to the patient’s care plan (problems, interventions, or goals) was on 07/09/2025. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/05/2026 with the terminal diagnosis of malignant neoplasm of the right breast with secondary malignancies of the bone. During the RN Admission visit, no problem with constipation was assessed. The patient’s medication list included Senna-S 8.6-50mg twice daily for constipation, and Bisacodyl 10mg Suppository daily for PRN constipation as the patient was on opioid medications for neoplastic pain. On 02/17/2026, the nurse noted during a visit that the patient was taking Oxycodone 10mg and Lorazepam 0.5mg every 4 hours. No BM for 5 days was documented in the RN’s visit note on 03/03/2026. Senna Plus was ordered on 02/05/2026 to be given on a scheduled basis; however, the patient had not received any of the medication. The nurse recommended 2 tablets a day for 2 days and to give a Bisacodyl suppository if no BM is produced. During the IDG meeting on 03/05/2026, the patient’s constipation was not addressed. During the nurse’s visit on 03/10/2026, the date of the patient’s last BM was unknown, and the patient and caregiver were encouraged to use a Bisacodyl Suppository with the next bowel movement. Then, on 03/11/2026, the nurse documented that the patient’s usual bowel habit is every 3 days. On 03/11/2026 at 2109 pm, a call was documented that “SN (skilled nursing) received a call from daughter stating the patient was on the floor. States no injuries...instructed on how to give Morphine, and the nurse would be there to assist...Gave patient Bisocodyl for constipation (Daughter had forgotten to give last night)...last BM is unknown....” During the IDG meeting on 03/19/2026, medication changes with Senna and Colace were reviewed without further documentation about the patient’s ongoing problem with constipation. A review of the patient’s plan of care for the benefit period dated 02/05/2026 to 05/05/2026 evidenced no updates to the identified problems, interventions, or patient goals for the patient’s constipation and treatment. During a joint clinical record review and interview with the Hospice Senior Director of Clinical Services (Personnel Record 3) on 04/07/2026, she confirmed that the plans of care had not been updated to reflect new patient problems, interventions, and goals and noted this was an area of documentation that the staff needed more attention, education, and training to accomplish.”