Moments Hospice of Springfield LLC

“Based on document review and interview, it was determined for 1 of 4 (Pt #1) patient records reviewed, the Hospice failed to ensure that Hospice related medications to treat pain were available at the time of admission in a skilled facility. Findings include: 1. Pt #1. SOC 8/17/25. Hospice diagnosis: Parkinson’s with dyskinesia. Pt #1 was admitted to hospice from Skilled Nursing Facility (SNF) on 8/17/25 at 3:32PM. Client Medication Report noted “… Morphine (a narcotic pain medication) concentrate (liquid) 100 mg/5 mL (milligrams per milliliters, units used to measure) start date 8/17/25… dose 0.25 mL every 4 hours…” No Medication Administration Record located. Morphine initial dose was given 10/18/25 at 7:00PM per SNF records. 2. The “Hospice Nursing Facility Agreement” between the nursing facility and the Hospice dated 4/1/25 included: “…Agreements…Facility Services may include, but not limited to… (iv) Assisting in the administration of medicine…” Responsibilities of Hospice:…(vi) the hospices responsibilities include but are not limited to:...Provision of medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions;… (vii) The Hospice may use the SNF nursing staff…to assist in the administration of prescribed therapies including in the plan of care only to the extent that the Hospice would routinely use...” E#1 stated “…it is the responsibility of Hospice to order and supply medications and the nursing staff at the SNF can administer medication because Hospice staff is not with the patient 24/7 (24 hours a day, 7 days a week).” 3. The policy titled “Provision of Care to Residents of SNF/NF or ICF/IID” (policy #1-030) was reviewed on 10/7/25. The policy stated, “…Procedure… F. A delineation of the hospice’s responsibilities, which include, but are not limited to the following… 3. Providing medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with terminal illness… 4. An interview was conducted on 10/7/25 at 10:00 AM with RN/case manager (E #2). While discussing the events that took place regarding the medication delay E #2 stated, “Typically we put the prescription in at admission. I went to put (Pt #1’s) prescription in and could not get into the platform that we use for prescribing. When I typed in (Pt #1’s) name, (Pt #1) didn’t come up. There was no way I could access (Pt #1) to prescribe medications. I tried a few times while I was there at the facility and was not able to pull (Pt #1’s) name up. I left, I had to go to another admission, and while I was at the second admission, I tried again to pull (Pt #1) up again, and it did not come up. I double-checked the spelling and made sure I was putting everything in right. I was finally able to pull (Pt #1’s) name up. I put the prescription in. I sent a text to (local physician) at around 11:00 at night, so the (local physician) ended up signing it the next morning. When I went to the (local nursing home) the next morning for follow up, they had not received the medication yet from the pharmacy. I attempted to call the pharmacy on hold for a very long time and then it just hung up on me. I tried twice, and the nurse said she would keep trying so that’s where that ended. It showed that it had been sent to the pharmacy. When I got there Monday morning for the follow-up visit, they (local nursing home) said we haven’t gotten the medicine (pain medication) yet. I spoke with executive director (E #1) about it on the phone. I have a plan if I run across that again my plan is to call the AOC (administrator on call) because maybe they may have an actual number that they can call and speak to somebody. I can’t order meds without their names.” 5. An interview was conducted on 10/7/25 at 11:30 AM with executive director (E #1). While discussing the delay in (Pt #1’s) pain medication administration E #1 stated, “There was a lot of miscommunications that went on and it was unfortunate this happened. I did reeducate the nurses after this instance.” E #1 verbally agrees there was a medication delay.”

“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 7 (14%) clinical records reviewed, the agency did not ensure that the initial comprehensive assessment was completed no later than five (5) calendar days after the election of the hospice care. Clinical Record 2: The patient elected the hospice benefit on 07/30/2024 with a diagnosis of cerebral infarction and aphasia. A clinical record review revealed the patient resided in a skilled nursing facility (SNF), was his responsible party, and did not have family involvement. Additionally, the clinical record documented that the patient communicated by writing on a whiteboard and could answer questions appropriately via a written format. The initial plan of care dated 07/30/2024, ordered a spiritual care evaluation. On 08/01/2024, the Chaplain documented, “Admission visit to be moved to 08/08/2024 due to the visit needing to be by phone and patient only communicates with whiteboard so (agency name) staff need to be present to help facilitate and translate conversation.” There was no evidence that the physician was notified of the delayed evaluation nor that the spiritual assessment was completed during the initial nursing assessment. The Chaplain documented the initial visit on 08/08/2024, with nine (9) days outstanding. During the joint record review on 09/04/2024, the Administrator confirmed that the Chaplain should have scheduled the visit within the 5-day requirement and stated, “We know that visits cannot be missed or scheduled outside the requirement for our staff convenience, only per patient/family request. We will provide additional education.” Additionally, the Administrator reported that the patient wanted involvement in scheduling appointments, and the Chaplain was trying to meet the patient’s request by calling first but agreed that there were opportunities for the Chaplain to coordinate the visit within the 5-calendar day requirement.”