Amberwell Hospice

“Based on review of agency documents, and interview it was determined the Hospice failed to maintain an up-to-date comprehensive emergency preparedness program plan (EPP). The cumulative effect of this deficient practice has the potential to place patients and staff at risk for harm during an emergency or disaster. Findings Include: 1. The hospice agency failed to review and update the emergency preparedness plan at least every 2 years, failed to address patient population and failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials (Refer to tag E0004, E0007 and E0009) 2. The hospice failed to develop and implement policies and procedures, based on the EPP risk assessment and communication plan. (Refer to E0013) 3. The hospice failed to develop a communication plan to inform State and local emergency preparedness officials about homebound hospice patients, failed to include policies and procedures for a communication plan that included the names and contact information for hospice employees, entities providing services under arrangement, patients’ physicians and other hospices, and failed to develop an emergency officials contact list. (Refer to E0019, E0030, E0031) 4. The hospice failed to develop and maintain an EPP training and testing program that is based on the emergency plan, its risk assessment and the communication plan, failed to provide a training and testing program that reflects the risks identified in the risk assessment, failed to provide annual training in emergency preparedness policies and procedures that are consistent with their roles in an emergency to all existing staff and individuals providing services under arrangement or any other individuals who provide services on an intermittent basis and would be expected to assist during an emergency and failed to participate in a full-scale community-based emergency preparedness program (EPP) exercise or conduct an annual facility-based functional exercise in the past 2 years. (Refer to E0036, E0037 and E0039) 5. As part of an integrated healthcare system the hospice could not demonstrate that they actively participated in the development of the unified and integrated EPP. (Refer to E0042)”

“Based on document review, policy review, and interview, the Hospice Agency failed to ensure the patient or representatives signature was obtained that confirmed receipt of a copy of rights and responsibilities; failed to ensure immediate investigation of alleged violations and immediate action to prevent further potential violation; the hospice failed to ensure verified violations were reported within 5 working days to the state survey agency. The cumulative effects of the Hospices failure to ensure confirmation of receipt of patients rights by patients and their representatives, ensuring immediate investigation of alleged violations and timely required reporting, has the potential to place all patients at risk for lack of understanding of individual rights, for untimely investigation and intervention of concerns, and for potential violations of individual rights of patients and families. Findings Include: 1. The hospice Agency failed to ensure receipt of rights and responsibilities by patients and caregivers were confirmed by signature. (Refer to L504). 2. The hospice Agency failed to ensure alleged violations were immediately investigation to prevent further violations. (Refer to L509). 3. The hospice Agency failed to ensure verified violations were reported to the state survey agency within 5 working days. (Refer to L511).”

“Based on document review, policy review and interview, the Hospice governing body failed to ensure the hospice developed, implemented, and maintained an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program that reflected the complexity of its specific organization and services and failed to document indicators related to improved palliative outcomes and performance improvement specific to hospice. The cumulative effect of the hospice’s failure to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program, places all hospice patients at risk for substandard or unsafe quality of care, potential unmet care and service needs. Findings Include: 1. The hospices governing body failed to ensure the hospice completed an ongoing program for quality improvement and patient safety that was defined, implemented, maintained, and evaluated annually. (Refer to L574) 2. The hospices governing body failed to ensure the hospice-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness. (Refer to L575) 3. The hospices governing body failed to designate one or more individual(s) to be responsible for operating the quality assessment and performance improvement program. (Refer to L576)”

“Based on document review, policy review an interview, the Hospice failed to utilize Volunteers in defined roles under the supervision of a designated hospice employee. The cumulative affects to the hospices failure to utilize volunteers in day-to-day administrative and/or direct patient care roles, failure to document and demonstrate viable efforts to recruit and retain and document volunteer orientation and training places patients at risk for not receiving needed care and services through trained and qualified Volunteers. Findings Include: 1. The hospice failed to ensure volunteer orientation and training was provided, maintained, and documented, consistent with industry standards for patients. (Refer to L643) 2. The hospice failed to ensure volunteers were utilized in day-to-day administrative and/or direct patient care roles. (Refer to L644) 3. The hospice failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers. (Refer to L645) 4. The hospice failed to ensure that cost savings achieved through use of volunteers was documented. (Refer to L646)”

“Based review of the Emergency Preparedness Program and interview, the Hospice failed to review and update the emergency preparedness plan at least every 2 years. Failure to develop, maintain, review and update at least every 2 years places patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP failed to show a review or update to the Emergency Preparedness Program. During an interview on 12/19/23 between at 11:00 AM and 2:30 PM, the Administrator confirmed there was no revision date for the Emergency Preparedness Program.”

“Based on review of the Emergency Preparedness Program (EPP) the Hospice failed to develop and maintain an emergency preparedness plan that addressed patient population, the services the facility has the ability to provide in an emergency; and continuity of operations including the delegation of authority and succession plan. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP failed to show that the Patient Population was addressed the Emergency Preparedness Program. On 12/19/23 between at 11:00 AM and 2:30 PM, the Administrator confirmed that the Patient Population was not addressed within the Emergency Preparedness Program.”

“Based on review of the Emergency Preparedness Program (EPP) the Hospice failed to develop and maintain an emergency preparedness plan that includes a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP failed to show there was an included process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster for the Emergency Preparedness Program. On 12/19/23 between at 11:00 AM and 2:30 PM, the Administrator confirmed there was no included process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster for the Emergency Preparedness Program.”

“Based on review of the Emergency Preparedness Program (EPP) the Hospice failed to develop and implement policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section, that must be reviewed at least every 2 years. Findings Include: Review of the EPP failed to show there were no policies and procedures based on the Emergency Preparedness Program based on the risk assessment and communication plan. On 12/19/23 between at 11:00 AM and 2:30 PM, the Administrator confirmed there were no policies and procedures based on the EPP risk assessment and communication plan.”

“Based on review of the Emergency Preparedness Program (EPP) and interview the Hospice failed to develop a procedure to inform State and local emergency preparedness officials about homebound hospice patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. Failure to develop a procedure to inform State and local emergency preparedness officials about homebound hospice patients places them at risk for harm during an emergency. Findings Include: Review of the EPP failed to show a procedure to inform State and local emergency preparedness officials about homebound hospice patients in need of evacuation from their residences at any time due to an emergency situation. On 12/19/23 between at 11:00 AM and 2:30 PM, the Administrator confirmed there was no procedure to inform State and local emergency preparedness officials about homebound hospice patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment.”

“Based on the Emergency Preparedness Program (EPP) the Hospice failed to develop and implement policies and procedures which included the names and contact information for hospice employees, entities providing services under arrangement, patients’ physicians or other hospices. Findings Include: Review of the EPP failed to show policies and procedures for a communication plan that included names and contact information for the following: hospice employees, entities providing services under arrangement, patients’ physicians and other hospices for the EPP. On 12/19/23 between at 11:00 AM and 2:30 PM, the Administrator confirmed there were no policies and procedures for a communication plan that included hospice employees, entities providing services under arrangement, patients’ physicians and other Hospices.”

“Based on the Emergency Preparedness Program (EPP) the Hospice failed to develop an emergency officials contact list. Failure to have an emergency officials contact list during an emergency could lead to harm to both patients and staff if specific Federal, State, tribal, regional, and local emergency preparedness staff or other sources of assistance are not known if the need to contact them should arise. Findings Include: Review of the EPP failed to show emergency officials contact list for the Emergency Preparedness Program. On 12/19/23 between at 11:00 AM and 2:30 PM, the Administrator confirmed there was no emergency officials contact list for the Emergency Preparedness Program.”

“Based on the Emergency Preparedness Program (EPP) the Hospice failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, its risk assessment and the communication plan. Findings Include: Review of the EPP failed to show a training and testing program that is based on the emergency plan, its risk assessment and the communication plan for the Emergency Preparedness Program. On 12/19/23 between at 11:00 AM and 2:30 PM, the Administrator confirmed there was no training and testing program that is based on the emergency plan, its risk assessment and the communication plan for the Emergency Preparedness Program.”

“Based on the Emergency Preparedness Program (EPP) the Hospice failed to develop and maintain an EPP training and testing program that reflects the risks identified in the risk assessment, failed to provide annual training in emergency preparedness policies and procedures that are consistent with their roles in an emergency to all existing staff and individuals providing services under arrangement or any other individuals who provide services on an intermittent basis and would be expected to assist during an emergency. Findings Include: Review of the EPP failed to show there was a training and testing program for the Emergency Preparedness Program. On 12/19/23 between at 11:00 AM and 2:30 PM, the Administrator confirmed there was no training and testing program for the Emergency Preparedness Program.”

“Based on the Emergency Preparedness Program (EPP) and staff interview, it was determined that the Hospice is a part of an integrated healthcare system and could not demonstrate that the hospice and each separately certified facility within the system actively participated in the development of the unified and integrated EPP. Findings Include: Review of the EPP failed to show that each separately certified facility within the system actively participated in the development of the unified and integrated EPP. On 12/19/23 between at 11:00 AM and 2:30 PM, the Administrator confirmed the Hospice intended to be a part of an integrated health system, however, could not provide policies and procedures outlining the procedures for the Hospice.”

“Based on document review, policy review and interview, the Hospice failed to ensure a signature was documented that confirmed the patients receipt of rights and responsibilities for 14 (Patients 1-14) of 14 records reviewed. The hospice ‘s failure to ensure signatures to confirm receipt of patients rights have the potential to place all patients at risk for compromised understanding of and support of individual hospice patient rights. Findings Include: Review of hospice policy titled, “;Patient Rights”, undated, showed persons received care and services from the hospice shall receive a copy of the “;Patients Bill of Rights”, and an explanation of the same at the time of admission. “;The patient shall acknowledge the receipt in writing.” A review of admission documentation for Patients 1-14 showed documentation submitted with the patient or patient representatives signature on admission by the nurse was scanned and attached to the admission assessment for each patient in the electronic medical record. The admission documentation for Patients 1-14 did not contain documentation of the written statement of hospice patient rights attached nor documentation to support signature of acknowledgment of receipt of the patients rights at the time of admission. During an interview on 12/19/23 at 9:22 AM, Staff A, Administrator showed the surveyor the Patient Bill of Rights described in policy and confirmed the document was to be explained by the admitting nurse, signed by the patient on admission and scanned and attached to the admission assessment. The surveyor requested written documentation to support the hospice obtained signatures of receipt for each sampled patients rights. Staff A, Administrator stated she was concerned the nurses may not be scanning the patient rights in when signature is obtained on admission. No additional documentation was provided.”

“Based on document review, policy review and interview, the hospice failed to immediately investigate alleged complaints involving suspected medication diversion and tampering for 2 (Patient 9 and 11) of 2 patient allegations that required immediate investigation. The hospices failure to immediately investigate alleged complaints has the potential to place all patients at risk for compromised preservation of individual patient rights, compromised patient safety and inadequate symptom management of the hospice patient in the home. Findings Include: Review of Hospice policy titled “Suspected Abuse or Neglect”, undated, showed the hospice would function under the policy of (hospital system name) for suspected abuse or neglect of a child or adult. Review of Hospice policy (hospital system name) titled “;Abuse of Patients” states “;any employee who suspects abuse, neglect, or exploitation of patients or residents or believes a patient or resident is in need of protective services will contact the Kansas Protection Report Center to file the report. The Disclosure of Protected Health Information Form must be completed and taken to HIM. If the patient is in imminent danger notify the Atchison Police Department. Inform the supervisor, CNO, and Risk Manager if the police department has been notified.” Patient 11 Review of Patient 11 medical record showed Patient 11 was admitted to hospice services on 07/14/23 with diagnoses of malignant neoplasm of unspecified bronchus or lung. Review of the physician orders on 07/14/23 showed fentanyl (used to treat severe pain) patches, 50 micrograms(mcg), change every 3 days. On 07/25/23 the fentanyl patch dosage was increased to 75 mcg, change every 3 days. On 08/11/23 the Fentanyl patch dosage changed to 100 mcg, change every 3 days, with an effective date 07/31/23. Review of an RN visit note dated 07/28/23 showed there was noted concern stated by patient regarding “;Her daughter not listening to her and treating her like a child.” Review of an RN visit note dated 08/11/23 showed there was a noted concern stated by pharmacist due to early refill of 100mcg fentanyl patches as they were previously filled on 08/01/23. The stated reason for the early fill was that patient daughter stated, “;2 patches rolled up on patient back during the night.” Review of RN visit note dated 08/22/23 showed a conversation of making medications last the appropriate time before refill was had with patient daughter. RN visit note stated, “;fentanyl patches must last 15 days, Percocet tabs must last 1 week” and “;pt/caregiver in agreement with care plan.” On 08/28/23 Patient 11 live discharge note showed destruction of 2 patches of 100 mcg fentanyl during discharge visit. Review of receipt of prescription dated 07/15/23 show delivery of 50 mcg fentanyl patch quantity five. Receipt dated 07/24/23 showed delivery of 75 mcg fentanyl patch quantity five. Receipt dated 08/01/23 showed delivery of 100 mcg fentanyl patch quantity five. Receipt dated 08/11/23 showed delivery of 100 mcg fentanyl patch quantity five. Receipt dated 08/22/23 showed delivery of 100 mcg fentanyl patch quantity five. There was a total of 25 patches delivered over 45 days of hospice service. Based on time frame, note with a statement of 2 patches “;rolling up” on patient, and destruction of 2 patches at the discharge visit, only 19 patches are accounted for. During an interview on 12/19/23 at 8:45 AM, Staff A, Administrator, stated that there was a concern raised from the nurse about the daughter and suspected misuse of narcotic medication however when they attempted discussion with family regarding the concern patient daughter then revoked services and wanted to transfer. When asked about the process of documenting incident report or concerns within the medical record discussed and reporting it to proper authorities if legitimate concern exists. Staff member A, Administrator stated that the concern was brought to administration but not documented or reported beyond a verbal conversation as she was unaware that it needed to be reported to state agency or law enforcement if concern existed since the patient signed revocation of services. Patient 9 A review of Patient 9s “;Plan of Care Order”, dated 02/28/23 showed the patient was admitted with malignant neoplasm of the right and left bronchus and lung (lung cancer) who was cared for in her home by her daughter. She was unresponsive at the time of admission and required total care. A review of Patient 9s “;Written Certification”, dated 02/28/23-03/01/23 completed by Staff C, Registered Nurse (RN) and signed by the physician showed the patient resided in her home with her daughter staying to take care of her. Staff C documented the patient was being transferred from another hospice and she discussed patient status and care/medication needs by phone prior to arrival to the home for admission. Staff C, RN documented “;SN (skilled nurse) reviewed the comfort medications with the daughter; at this time, she gathered medications provided by the [transferring hospice] hospice to show the SN, to include 1 bottle of lorazepam intensol (used to treat anxiety) 2 mg/ml and 2 bottles of morphine (used to treat pain). When asked about the boxes with labels she presented 1 box and stated this is all she was given, box did not have a label with the patients name, medication, instructions, and dose. Daughter described the previous nurse from the transferring hospice coming into the home with medication bottles and mixing medications from bottles that he brought into the home. With medications being questionable SN informed daughter that the hospice would order a new set of comfort medications and bring them back to the home to replace the medications from the transferring hospice.” A review of Patient 9s Interdisciplinary Group (IDG) Physicians Order titled “;Discharge Summary”, dated 03/01/23, completed by Staff H, showed “;Patient had previous medications in the home from the transferring hospice that included about 10 ml of Lorazepam, 10 ml Morphine, and a completely full (overfilled) to the top of the bottle of Morphine. Medications in home from the transferring hospice did not have any patient labels/identifying or dosage information on them. The only box in the home was for Lorazepam-also with no patient identifying or dosage information. Patients daughter states that previous hospice nurse from (transferring) hospice would “;mix medications”, there were never any sealed medications” and she is concerned that they were being watered down by the previous hospice agencies nurse. Patients family did call the Sheriffs department while the SN was in the home to have the medications investigated and report their concerns. The Sherriff was in a meeting this morning and is going to call the family back after. Medications from the (transferring) hospice were left in the home so that law enforcement is able to investigate as needed. SN spoke with officers from the Sheriffs office regarding medication concerns found in the home left from the (transferring) hospice. The officers stated the medications will be collected from the patients home for investigation. SN also notified Clinical nurse manager of above concerns.” A review of the hospice incidents and complaints log dated 01/01/23 to the present date of survey failed to include the identified incident regarding unlabeled and mixed medications received in the home of Patient 9 from the transferring hospice. There was no documented investigation or outcome of the incident. During an interview on 12/19/23 at 8:32 AM, Staff A, Administrator confirmed the family notified the Sherriff about the medications the patient received from the nurse at the former hospice where the patient received services. She confirmed the hospice nurse discussed medication findings with the sheriffs office representatives and that the Sheriffs office had removed the medications from the transferring hospice, from the patients home and retained them for their investigation. Staff A, Administrator confirmed the Sherriffs office reported, the Kansas Bureau of Investigation had an ongoing criminal investigation into the former hospice and owner and felt that took care of the notification requirement. Staff A, Administrator confirmed she did not complete an investigation report nor report the incident to the state agency.”

“Based on document review, policy review and interview, the hospice failed to ensure verified allegations were reported with 5 working days to the state survey agency for 1 (Patient 9) of 1 patients who required reporting. The hospices failure to report verified violations has the potential to place all patients at risk for compromised preservation of individual rights and compromised health and safety of the hospice patient in the home. Findings Include: Review of Hospice policy titled “Suspected Abuse or Neglect”, undated, showed the hospice would function under the policy of (hospital system name) for suspected abuse or neglect of a child or adult. Review of Hospice policy (hospital system name) titled “;Abuse of Patients” states “;any employee who suspects abuse, neglect, or exploitation of patients or residents or believes a patient or resident is in need of protective services will contact the Kansas Protection Report Center to file the report. The Disclosure of Protected Health Information Form must be completed and taken to HIM. If the patient is in imminent danger notify the Atchison Police Department. Inform the supervisor, CNO, and Risk Manager if the police department has been notified.” Patient 9 A review of Patient 9s “;Plan of Care Order”, dated 02/28/23 showed the patient was admitted with Malignant neoplasm of the right and left bronchus and lung (lung cancer) who was cared for in her home by her daughter. She was unresponsive at the time of admission and required total care. A review of Patient 9s “;Written Certification”, dated 02/28/23-03/01/23 completed by Staff C, Registered Nurse (RN) and signed by the physician showed the patient resided in her home with her daughter staying to take care of her. Staff C documented the patient was being transferred from another hospice and she discussed patient status and care/medication needs by phone prior to arrival to the home for admission. Staff C, RN documented “;SN (skilled nurse) reviewed the comfort medications with the daughter; at this time, she gathered medications provided by the [transferring hospice] hospice to show the SN, to include 1 bottle of lorazepam intensol [used to treat anxiety] 2 mg/ml [milligrams/milliliter] and 2 bottles of morphine (used to treat pain). When asked about the boxes with labels she presented 1 box and stated this is all she was given, box did not have a label with the patients name, medication, instructions, and dose. Daughter described the previous nurse from the transferring hospice coming into the home with medication bottles and mixing medications from bottles that he brought into the home. With medications being questionable SN informed daughter that the hospice would order a new set of comfort medications and bring them back to the home to replace the medications from the transferring hospice.” Review of Patient 9s Interdisciplinary Group (IDG) Physicians Order titled “;Discharge Summary”, dated 03/01/23, completed by Staff H, showed “;Patient had previous medications in the home from the transferring hospice that included about 10 ml of Lorazepam, 10 ml Morphine, and a completely full (overfilled) to the top of the bottle of Morphine. Medications in home from the transferring hospice did not have any patient labels/identifying or dosage information on them. The only box in the home was for Lorazepam-also with no patient identifying or dosage information. Patients daughter states that previous hospice nurse from (transferring) hospice would “;mix medications”, there were never any sealed medications” and she is concerned that they were being watered down by the previous hospice agencies nurse. Patients family did call the Sheriffs department while the SN was in the home to have the medications investigated and report their concerns. The Sherriff was in a meeting this morning and is going to call the family back after. Medications from the (transferring) hospice were left in the home so that law enforcement is able to investigate as needed. SN spoke with officers from the Sheriffs office regarding medication concerns found in the home left from the (transferring) hospice. The officers stated the medications will be collected from the patients home for investigation. SN also notified Clinical nurse manager of above concerns.” Review of the hospice incidents and complaints log dated 01/01/23 to the present date of survey failed to include the identified incident regarding unlabeled and mixed medications received in the home of Patient 9 from the transferring hospice. There was no documentation to support the state agency was notified of the incident within 5 working days. During an interview on 12/19/23 at 8:32 AM, Staff A, Administrator confirmed the family notified the Sherriff about the medications the patient received from the nurse at the former hospice where the patient received services. She confirmed the hospice nurse discussed medication findings with the sheriffs office and that the Sheriffs office had removed the medications from the transferring hospice, from the patients home. Staff A, Administrator confirmed the Sherriffs office reported, the Kansas Bureau of Investigation had an ongoing criminal investigation into the former hospice and owner and felt that took care of the notification requirement. Staff A, Administrator confirmed she did not complete an investigation report, nor she did not report the incident to the state agency within 5 working days.”

“Based on record review, policy review, and staff interview the Hospice failed to ensure the interdisciplinary group (IDG) in collaboration with the patients attending physician updated the comprehensive assessment within the required 15-day time frame, the required members of the interdisciplinary group (IDG) were present during each meeting, and the discipline care frequencies were provided in accordance with the written plan of care for 1 (Patient 6) of 14 reviewed. Failure to regularly review and update the plan of care, frequency of visits, by all required members of the IDG does not allow for timely review of the patients response to care, progress towards desired goals, or adjust for the frequency of needs of the hospice patient. Findings Include: Review of hospice policy titled “;Physicians Plan of Care” showed “;A periodic review and updates will indicate the level of current problems, interventions, and goals and will be discussed by the interdisciplinary team at least every 2 weeks.” Review of hospice policy titled “;Care Plan” showed “;to provide quality and continuity of care, the care plan will be reviewed and or updated by the interdisciplinary team a minimum of every 2 weeks, and/or as the patient/familys condition warrants.” ... “;The primary hospice nurse, social worker, and any other team member will review and/or update the plan of care as needed, but at least once every 2 weeks at IDG meetings. After the meeting the IDG notes will include: 3. Changes in frequency of visits.” Patient 6 Review of Patient 6s record showed she was initially admitted on 07/22/20 with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Patient 6 was discharged on 05/12/23 from hospice to the hospital after a fall that resulted in a left hip fracture. Patient 6 was readmitted to hospice services on 05/26/23 with a primary diagnosis of chronic obstructive pulmonary disease. The record showed an IDG meeting occurred on 02/08/22 with no electronic documentation of physician attendance or signature on the plan of care note. The subsequent IDG meeting on 02/25/22 occurred 17 days later and had no electronic documentation of physician attendance or signature on the plan of care note. The IDG meeting documented on 05/10/23 had no electronic documentation of social worker attendance or signature of social worker on the plan of care note. Review of the IDG paper log sign in sheet showed the IDG dates occurring on 02/08/22 and 02/25/22 had no physician signature documented and confirmed a gap of 17 days between meetings. Review of the IDG paper log occurring on 05/10/23 had no social worker signature documented. Patient 6s initial readmission plan of care dated 05/26/23 showed the visit frequencies of the home health aide (HHA) was 3 times weekly. The aide care plan dated 05/26/23 showed the HHA visits to start on 05/30/23. The week of 05/28/23 through 06/03/23 showed 2 HHA visits were done on 05/30/23 and 06/02/23. There was no missed visit note to indicate why a third visit was not done. The plan of care showed the visit frequencies of medical social worker (MSW) to be 1 time weekly with no PRN (as needed) visits. There were no documented MSW visit or missed visit notes for the week of 07/02/23 through 07/08/23. Further review showed the MSW visit frequency changed on 07/19/23 decreasing the visits to 2-3 times monthly. This frequency remains unchanged throughout the rest of patient stay on hospice. The medical record showed MSW visits were made on 08/01/23, 08/08/23, 08/15/23, 08/22/23, and 08/29/23 without a frequency order change, addition of PRN visits, or plan of care update throughout this time frame. During an interview on 12/20/23 at 2:00 PM, Staff A, Administrator, stated that each IDG meeting occurs every 15 calendar days and at each meeting an electronic and paper log of the attendees should be obtained. Upon reviewing the paper log and electronic log for verification of 17-day gap and attendee signatures, Staff A was uncertain of why the meeting did not occur within the required 15-day time frame. Staff A stated that some meetings are attended in person and via teams meeting and each attendee should be signing the paper and electronic logs. She stated on some occasions the paper log has been missed by staff. When further discussing the review process for electronic charting Staff A, stated there is no current process for auditing visit frequencies, plan of care updates, or charts at this time. Staff A went on to state that the recent hiring of the new director of nursing and creation of new process and training regarding the auditing process will help with the plan of care review process.”

“Based on review of hospice Quality Assurance Performance Improvement documentation, policy review and interview, the hospices governing body failed to ensure the hospice completed an ongoing program for quality improvement and patient safety that was defined, implemented, maintained, and evaluated annually. This deficient practice has the potential for all patients to receive inadequate care and unmet needs. Findings Include: Review of a hospice policy titled, “Quality Assurance and Performance Improvement Plan-Department: Quality”, undated, showed the purpose of the Quality Program at (Hospital name) was to provide a comprehensive framework designed to ensure quality monitoring and improvement in the various departments of the hospital. The Quality Assurance and Performance Improvement (QAPI) Plan demonstrated (Hospital) commitment to improve the quality of care that is delivered. The policy showed quality monitoring was performed on a regular basis with each department creating a matrix of quality indicators for the year and presents data at monthly service line meetings. The policy showed the QAPI plan is assessed at least annually at multiple levels, including executive team, medical executive committee, and board of trustees to determine its effectiveness in achieving its goals and objectives. The policy listed examples of QAPI responsibilities and activities not limited to: Occurrence reporting and investigation, Quality and clinical record review, infection prevention, medication management. The surveyor requested hospice Quality Assurance Performance Improvement (QAPI) documentation, plan, and minutes. Documents labeled “;Health at Home” for the months of January 2023 through November 2023, were provided to the surveyor representing the Monthly Service line meetings held at the hospital with system departmental representatives, of which the hospice administrator attended. The documents reviewed the following areas each month by department: Talent Experience, Customer Experience, Operational & Financial Acumen, Strategic Growth, Community Impact, and included information from the hospices patient satisfaction surveys. Documentation provided did not include a hospice QAPI Plan, annual review/evaluation of the Hospice QAPI plan by the governing body, annual approval of the Hospice QAPI plan by the governing body nor documentation to support auditing activities to include measurement of quality indicators, adverse events, or monitoring of outcomes in compliance with activities outlined in the QAPI policy, such as monitoring of occurrences, infections, quality and clinical record reviews, and medication management. There was no documentation provided, specific to the hospice, to support the governing body ensured the hospice program scope reflected the complexity of the organization and services and designated individuals responsible for the program. There was no documentation to support the governing body documented, implemented, and monitored program data indicators related to improve quality of hospice patient care, palliative outcomes, patient safety and hospice performance improvement. There was no documentation to support that QAPI program activities included quality indicators and data collection of high risk, high volume, problem-prone areas, including adverse events. There was no documentation to support the hospice and governing body ensured the goals of the hospice performance improvement program were initiated, completed, evaluated and monitored. The governing body failed to ensure the QAPI program included documented actions taken in reports, minutes or annual agency evaluation. During an interview on 12/20/23 at 11:48 PM, Staff A, Administrator, reviewed the QAPI program with the surveyor and confirmed there was no documentation to support the governing body was responsible for the implementation of a hospice-wide Quality Assurance and Performance Improvement program that included overall quality of all facets of the hospice operations. She confirmed the hospice governing body did not develop, implement, maintain nor evaluate the hospices quality improvement and patient safety program.”

“Based on document review, policy review and interview, the governing body failed to ensure the hospice-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness. This deficient practice has the potential for all patients to receive inadequate care and unmet needs. Findings Include: Review of a hospice policy titled, “Quality Assurance and Performance Improvement Plan-Department: Quality”, undated, showed the purpose of the Quality Program at (Hospital name) was to provide a comprehensive framework designed to ensure quality monitoring and improvement in the various departments of the hospital. The Quality Assurance and Performance Improvement (QAPI) Plan demonstrated (Hospital) commitment to improve the quality of care that is delivered. The policy showed quality monitoring was performed on a regular basis with each department creating a matrix of quality indicators for the year and presents data at monthly service line meetings. The surveyor requested hospice Quality Assurance Performance Improvement (QAPI) documentation, plan, and minutes. Documents labeled “;Health at Home” for the months of January 2023 through November 2023, were provided to the surveyor representing the Monthly Service line meetings held at the hospital with system Departmental representatives, of which the hospice administrator attended. The documents reviewed the following areas each month by department: Talent Experience, Customer Experience, Operational & Financial Acumen, Strategic Growth, Community Impact, and included information from the hospices patient satisfaction surveys. Documentation provided did not confirm the hospices QAPI program priorities for quality of care and patient safety improvement actions were evaluated for effectiveness. There was no documentation provided, specific to the hospice, to support the governing body ensured the QAPI program priorities for quality of care and hospice patient safety including improvement actions, were evaluated for effectiveness. During an interview on 12/20/23 at 11:48 PM, Staff A, Administrator, reviewed the QAPI program with the surveyor and confirmed there was no documentation to support the governing body was responsible for the implementation of a hospice-wide Quality Assurance and Performance Improvement program that included overall quality of all facets of the hospice. She confirmed the hospice governing body did not address and annually evaluate all required priorities and actions for improved quality of care and patient safety, for the hospice’s quality assessment and performance improvement program.”

“Based on document review, policy review and interview, the governing body failed to designate one or more individual(s) to be responsible for operating the quality assessment and performance improvement program. This deficient practice has the potential for all patients to receive inadequate care and unmet needs. Findings Include: Review of a hospice policy titled, “Quality Assurance and Performance Improvement Plan-Department: Quality”, undated, showed the purpose of the Quality Program at (Hospital name) was to provide a comprehensive framework designed to ensure quality monitoring and improvement in the various departments of the hospital. The Quality Assurance and Performance Improvement (QAPI) Plan demonstrated (Hospital) commitment to improve the quality of care that is delivered. The policy showed quality monitoring was performed on a regular basis with each department creating a matrix of quality indicators for the year and presents data at monthly service line meetings. The policy showed the QAPI plan is assessed at least annually at multiple levels, including executive team, medical executive committee, and board of trustees to determine its effectiveness in achieving its goals and objectives. The policy listed examples of QAPI responsibilities and activities not limited to: Occurrence reporting and investigation, Quality and clinical record review, infection prevention, medication management. Review of a hospice policy titled, “;Administrative Staff”, undated, showed the administrator should oversee the implementation of the hospice quality improvement program. The surveyor requested hospice Quality Assurance Performance Improvement (QAPI) documentation, plan, and minutes. Documents labeled “;Health at Home” for the months of January 2023 through November 2023, were provided to the surveyor representing the Monthly Service line meetings held at the hospital with system Departmental representatives, of which the hospice administrator attended. The documents reviewed the following areas each month by department: Talent Experience, Customer Experience, Operational & Financial Acumen, Strategic Growth, Community Impact, and included information from the hospices patient satisfaction surveys. Documentation provided did not include verification the hospice administrator nor other individuals had been designated, by the governing body, the responsibility to oversee the hospice Quality Assurance Performance Improvement program. During an interview on 12/20/23 at 11:48 PM, Staff A, Administrator, reviewed the QAPI program with the surveyor and confirmed the hospice governing body did not designate in writing one or more individual(s) to be responsible for operating the hospice’s quality assessment and performance improvement program.”

“Based on document review, policy review and interview, the hospice failed to ensure the maintenance of a coordinated, agency wide program for surveillance, identification, prevention, and investigation of infections, that was integrated into the quality assessment and performance improvement program for patients. The hospices failure to maintain an infection control program has the potential to place patients, caregivers, and staff at risk for health and safety concerns. Findings Include: Review of hospice policy titled” Infection Control Program” showed the purpose was to improve patient health outcomes by identifying and reducing the risks of infections in patients and staff. Surveillance of continued data monitoring and collecting, to detect infections and changes in infection trends may be utilized; Infection Control Coordinator to keep current documentation of staff infections; symptoms suggestive of an infectious process should be noted on the patient infection control surveillance form; and written documentation will be maintained for reported infections, or signs/symptoms for suspected infections among employees and/or patients. The surveyor requested documentation of the hospices infection control program. A copy of the policy titled “;Infection Control Program” was provided. The documentation failed to include evidence to support the identification, surveillance and prevention of infections, nor the investigation of infections by the hospice. During an interview on 12/20/23 at 12:45 PM, Staff A, Administrator discussed employee infection control training, procedures, and controls in place for staff and patients in the home. Staff A, Administrator confirmed that the hospice was not routinely documenting and tracking staff and patient infections as part of an agency wide program for prevention and investigation of infections. She confirmed infection control data was not included in the hospices quality assessment and performance improvement program documentation.”

“Based on record review and staff interview the Hospice failed to ensure hospice aide supervisory visits were completed no less than every 14 days as required for 1 (Patient 6) of 14 patients reviewed. The failure to ensure supervision of hospice aide services every 14 days as required does not ensure that adequate quality of care is being provided and adjustment of the plan of care to meet the changing needs of the patient is being addressed in a timely manner. Findings Include: Review of Patient 6s record showed she was initially admitted on 07/22/20 with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Patient 6 was discharged on 05/12/23 from hospice to the hospital after a fall that resulted in a left hip fracture. Patient 6 was readmitted to hospice services on 05/26/23 with a primary diagnosis of chronic obstructive pulmonary disease. The record showed a home health aide supervisory visit (SV) dated 06/22/23 and subsequent SV on 07/13/23, 21-days between the supervisory visits. A home health aide SV dated 07/26/23 and subsequent supervisory visit dated 08/10/23, 15-days between supervisory visits. A home health aide supervisory visit was made on 09/19/23 and no additional supervisory visit were made. Patient 6 expired on 10/05/23. During an interview on 12/20/23 at 2:00 PM, Staff A, Administrator stated hospice aide supervisory visits are performed every 14 days and documented with a hospice aide supervisory visit note within the electronic record.”

“Based on document review, policy review and interview, the hospice failed to ensure volunteer orientation and training was provided, maintained, and documented, consistent with industry standards for patients. This deficient practice has the potential to affect quality and supervision of services for patients who request volunteer services. Findings Include: Review of the Hospice Policy titled, “Volunteer Services”, undated, showed the hospice would employ a volunteer services coordinator to be responsible for developing, implementing, and documenting a volunteer services program which meets both the operational needs of the program and provides patient/family service in accordance with the interdisciplinary plan of care. The surveyor requested and reviewed Volunteer program documentation on 12/20/23 at 3:05 PM, to support provision of volunteer services to hospice patients that included the training curriculum of volunteers. No documentation was provided. During an interview on 12/20/23 at 3:10 PM, Staff A, Administrator confirmed the hospice did not currently have available volunteers providing services in defined roles to patients, stating most left during COVID -19. During the same interview, Staff A confirmed the hospice recently employed a Social Worker who would be developing the volunteer program.”

“Based on review of hospice documentation, policy review and interview, the hospice failed to ensure volunteers were utilized in day-to-day administrative and/or direct patient care roles. This deficient practice has the potential to affect quality and supervision of services for patients who request volunteer services. Findings Include: Review of the Hospice Policy titled, “Volunteer Services”, undated, showed the hospice would employ a volunteer services coordinator to be responsible for developing, implementing, and documenting a volunteer services program which meets both the operational needs of the program and provides patient/family service in accordance with the interdisciplinary plan of care. The surveyor requested and reviewed Volunteer program documentation on 12/20/23 at 3:05 PM, to support provision of volunteer services to hospice patients in defined roles or position descriptions. No documentation of utilization of volunteers was received. During an interview on 12/20/23 at 3:10 PM, Staff A, Administrator confirmed the hospice did not currently have available volunteers providing services in defined roles to patients, stating most left during COVID -19. During the same interview, Staff A confirmed the hospice recently employed a Social Worker who would be developing the volunteer program.”

“Based on review of hospice documentation, policy review and interview, the hospice failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers. This deficient practice has the potential to affect quality and supervision of services for patients who request volunteer services. Findings Include: Review of the Hospice Policy titled, “Volunteer Services”, undated, showed the hospice would employ a volunteer services coordinator to be responsible for developing, implementing, and documenting a volunteer services program which meets both the operational needs of the program and provides patient/family service in accordance with the interdisciplinary plan of care. The policy showed there would be ongoing efforts to recruit and retain volunteers of all ages and ethnic backgrounds. The surveyor requested and reviewed Volunteer program documentation on 12/20/23 at 3:05 PM, to support provision of volunteer services to hospice patient that included Volunteer recruitment efforts. No documentation was provided. During an interview on 12/20/23 at 3:10 PM, Staff A, Administrator confirmed the hospice did not currently have available volunteers providing services in defined roles to patients, stating most left during COVID -19. During the same interview, Staff A confirmed the hospice recently employed a Social Worker who would be developing the volunteer program.”

“Based on document review, policy review and interview, the hospice failed to ensure a written agreements for physicians services confirmed those services were made routinely available on a 24-hour basis, 7 days a week. The hospices failure to ensure required language in written agreements has the potential to affect availability of physician services for all patients. Findings Include: Review of a hospice policy titled, “;Contracted Services and Coordination of Management”, undated, showed hospice will retain full management responsibility for all services provided, and will coordinate interdisciplinary care provided by hospice staff and contracted services, in accordance with local, state, and federal laws and regulations. Review of a hospice physicians services agreement titled “;Home Health and Hospice Medical Director Agreement, effective March 1, 2022, showed the written agreement lacked language to support hospice Medical Director services were made routinely available on a 24-hour basis, 7 days a week. During an interview on 11/20/23 at 12:15 PM, Staff A, Administrator confirmed the written agreement did not contain all required language about the 24-7 availability of the Medical Director for the hospice.”

“Based on document review, policy review and interview, the hospice failed to ensure a physician was designated to serve as medical director when the medical director was not available. The hospices failure to ensure an alternate physician is designated to serve in the absence of the medical director, has the potential to affect ability of the physician to assume the same responsibilities and obligations as the medical director, for all patients. Findings Include: Review of a hospice policy titled, “;Contracted Services and Coordination of Management”, undated, showed the hospice medical director assumed overall responsibility for the medical component of the patient care program. The surveyor requested and reviewed documentation related to the Medical Director(s) and the provision of physicians services, on 12/20/23 at 3:10 PM. Documentation was provided and taken into consideration. Review of a signed hospice physicians services agreement titled “;Home Health and Hospice Medical Director Agreement, effective March 1, 2022, showed the written agreement lacked language to ensure a physician was designated to fulfill medical director responsibilities when the medical director was not available. During an interview on 11/20/23 at 3:15 PM, Staff A, Administrator confirmed a physician was available in the absence of the Medical Director, but there was no written agreement that designated that physician to serve as medical director when the medical director was not available.”

“Based on record review and staff interview the Hospice failed to perform a face-to-face evaluation for 1 (Patient 6) of 14 patients prior to readmission and certification beyond the second benefit period. Failure to perform the face-to-face evaluation prior to readmission does not allow for the admitting physician to completely evaluate the medical condition or changes in the patient since discharge from hospice occurred. Without this initial comprehensive review, the patient physician plan of care may not address new needs or symptoms of the hospice patient. Findings Include: Patient 6 Review of Patient 6s record showed she was initially admitted on 07/22/20 with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Patient 6 was discharged on 05/12/23 from hospice to the hospital after a fall that resulted in a left hip fracture. Patient 6 was readmitted to hospice services on 05/26/23 with a primary diagnosis of chronic obstructive pulmonary disease. Review of Patient 6s medical record revealed a face-to-face recertification note dated 05/03/23 for benefit period of 05/08/23- 07/07/23. There was no documented evidence of a face-to-face evaluation at the time of readmission on 05/26/23. The next documented face to face evaluation occurred on 07/21/23, 56 days after readmission. During an interview on 12/18/23 at 4:20 PM, Staff A, Administrator stated that she was unaware that a new face to face needed to be performed before readmission to hospice services.”

“Based on record review, policy review, and interview with staff the Hospice failed to ensure physician orders were documented and updated in the plan of care for 2 (Patient 2 and 11) of 14 patients reviewed. Failure to ensure physician orders are documented and updated in the plan of care has the potential to place patients at risk for ineffective management of the patient and potentially unsafe outcomes. Findings Include: Review of Hospice policy titled “;Care Plan” states “;The primary hospice nurse, social worker, and any other team member will review and/or update the plan of care as needed, but at least once every 2 weeks at IDG meetings. After the meeting the IDG notes will include: 5. Additions or changes in medications.”Patient 2 Review of Patient 2s medical record showed Patient 2 was admitted to hospice services on 11/14/23 Alzheimers Disease and resided in a nursing facility to assist with activities of daily living and medication management. Review of the hospice Plan of Care Order, dated 11/14/23, showed Patient 2s current Medications ordered for pain included Tramadol Hydrochloride (HCL) Oral Tablet 50 milligrams (mg), 1 Tab twice daily for arthritis pain, Tramadol HCL Oral Tablet 50 mg 1 Tab daily at bedtime; Morphine Sulfate (Concentrate) Oral Solution 20 mg/Milliliter (ml), 0.5 ml, under the tongue every hour as needed for pain, cardiac pain, or respiratory distress. Review of the hospice Medication Order, dated 11/14/23, showed Patient 2s current Medications ordered for pain, Tramadol HCL Oral Tablet 50 mg, 1 Tab twice daily for arthritis pain, Tramadol HCL Oral Tablet 50 mg 1 Tab daily at bedtime; Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, 0.5 ml, under the tongue every hour as needed for pain, cardiac pain, or respiratory distress (opioid analgesic). During a home visit conducted at the nursing home on 12/20/23 at 10:00 AM, the surveyor requested facility documentation of Patient 2s current medications ordered and administered for the current month, including those ordered for pain management from the nursing home Assistant Director of Nursing. Review of the Nursing Home (NH) Order Review Report, dated12/18/23 showed Patient 2s Current Medications ordered for pain included: Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, 0.25 ml, by mouth every hour as needed for pain, cardiac pain, or respiratory distress ordered on 11/14/23 with a start date of 11/14/23. Further review of the nursing home orders dated 11/14/23 showed Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, 0.75 ml, by mouth every hour as needed for pain, cardiac pain, or respiratory distress. This dosage did not match the ordered dosage on the hospice Plan of Care Order and Medication Order of 20 mg/ml 0.5 ML every 1 hour as needed for pain, cardiac pain, respiratory distress). Additionally, the NH orders dated 11/14/23 showed an order for Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, 1.0 ml by mouth every hour as needed for pain, cardiac pain, or respiratory distress. These dosages did not match the ordered dosage on the hospice Plan of Care Orders and Medication Orders of 20 mg/ml, 0.5 ml every 1 hour as needed for pain, cardiac pain, respiratory distress. Also in the NH medications order review report was an order dated 11/21/23 with a start date of 11/23/23, for Morphine Sulfate (Concentrate) Oral Solution 20 mg/5ml, give 0.25 ml, by mouth every afternoon (scheduled dosage) for pain. The hospice Plan of Care Orders and Medication Orders did not include an order for a scheduled dose of Morphine every afternoon. The were no orders for Tramadol for Patient 2 on the Nursing home Order Review Report, nor documentation Tramadol had been administered by the nursing home. Review of the Nursing Home Medication Administration Record for Patient 2 for the month of December 2023 confirmed Patient 2 received the scheduled doses of Morphine .25 ml by mouth offered daily at 11:00 AM from the nursing home staff. No PRN (as needed) dosages were documented for the month of December 2023. Tramadol was not listed on the Medication Administration Record for the nursing home. There was no documentation to support the hospice updated Patient 2s Hospice Medication Orders and the Hospice Plan of Care to reflect the Morphine dosages ordered by nursing home for as needed pain management, effective 11/14/23. There was no documentation to support the hospice updated Patient 2s hospice Medication Orders and the hospice Plan of Care to reflect the scheduled Morphine dosage ordered by the nursing home on 11/21/23. There was no documentation to support the hospice updated the hospice Plan of Care and Medications Orders to reflect the Tramadol dosages were discontinued by the nursing facility. During an interview on 12/20/23 at 10:08 AM, Staff C, Registered Nurse (RN) and the nursing home Assistant Director of Nursing, Staff C, RN confirmed the hospice Plan of Care and hospice Medication Orders for Morphine, and Tramadol did not match what was being administered to the patient by the nursing home. Patient 11 Review of Patient 11 medical record showed Patient 11 was admitted to hospice services on 07/14/23 with diagnoses of malignant neoplasm of unspecified bronchus or lung. On 08/01/23 receipt of prescription signed by RN shows delivery of five 100 microgram (mcg) fentanyl (used to treat pain) patches. There was no physician order dated on 08/01/23 for the dosage change. Review of receipt of prescription on 08/22/23 showed a delivery of Percocet (used to treat pain) 10/325 milligrams (mg) 28 tablets (tabs). Review of an RN visit note dated 08/22/23 revealed delivery of 28 tabs of Percocet 10/325 and “;Percocet tabs must last 1 week.” Review of a missed RN visit form dated 08/25/23 noted “;Per the patients daughter, the patient is doing well, and the pain is being controlled with Percocet.” The record failed to show a written physician order for Percocet dated 08/22/23, notation of Percocet on the plan of care, or addition of Percocet to the medication regimen. During an interview on 12/19/23 at 8:45 AM, Staff A, Administrative Director stated, “;the nurse who receives the order is to write the order in the system upon receiving and then update the medication record and plan of care at that time.””

“Based on record review, policy review, and staff interview the hospice failed to ensure physician orders for pain medication were written timely for 1 (Patient 11) of 14 patients reviewed. Failure to ensure timely documentation of medication changes puts patients at an increased risk for negative outcomes and ineffective symptom management. Findings Include: Review of Hospice policy titled “;Care Plan” states “;The primary hospice nurse, social worker, and any other team member will review and/or update the plan of care as needed, but at least once every 2 weeks at IDG meetings. After the meeting the IDG notes will include: 5. Additions or changes in medications.” Patient 11 Review of Patient 11 medical record showed an admission date of 07/14/23 with diagnoses of malignant neoplasm of unspecified bronchus or lung. On 08/01/23 receipt of prescription signed by RN showed delivery of five fentanyl 100 microgram (mcg) patches. There was no documented physicians order dated on 08/01/23 for dosage change. Review of an RN visit note dated 08/11/23 showed there was a noted concern stated by pharmacist due to early refill of 100 mcg fentanyl patches as they were previously filled on 08/01/23. The stated reason for the early fill was that patient daughter stated, “;2 patches rolled up on patient back during the night.” Review of a physicians order dated 08/11/23 noted dosage change of fentanyl to 100 mcg every 3 days with initial start date of 07/31/23. Ten days after the fentanyl 100 microgram (mcg) patches were delivered. During an interview on 12/19/23 at 8:45 AM, Staff A, Administrator, stated “;the RN receiving the order is to write the order in the computer and sign it at the time the order was received and then send it for physician signature.””

“Based on document review, policy review and interview, the hospice failed to ensure changes in the hospice plan of care were discussed with the patient or representative, and SNF/NF representatives, and approved by the hospice before implementation for 1 (Patient 2) of 14 Patients reviewed. This deficient practice has the potential to place patients at risk for medication errors, and unmet needs and services. Findings Include: Review of hospice policy titled “;Care Plan”, undated, showed a care plan will be initiated and completed for each patient and family within three days of admission to the program. The primary hospice nurse, social worker and any other team member will review and/or update the care plan as needed, but at lese once every two weeks at IDG meetings. After meeting, the IDG notes will include new or discontinued treatments, resolved or new problems, goals and plans, and additions or changes in medications. Patient 2 Review of Patient 2s medical record showed patient was admitted to hospice services on 11/14/23 Alzheimers Disease and resided in a nursing facility to assist with activities of daily living and medication management. Review of the hospice Plan of Care Order, dated 11/14/23, showed Patient 2s current Medications ordered for pain included Tramadol Hydrochloride (HCL) Oral Tablet 50 milligrams (mg), 1 Tab twice daily for arthritis pain, Tramadol HCL Oral Tablet 50 mg 1 Tab daily at bedtime; Morphine Sulfate (Concentrate) Oral Solution 20 mg/Milliliter (ml), 0.5 ml, under the tongue every hour as needed for pain, cardiac pain, or respiratory distress. Review of the hospice Medication Order, dated 11/14/23, showed Patient 2s current Medications ordered for pain, Tramadol HCL Oral Tablet 50 mg, 1 Tab twice daily for arthritis pain, Tramadol HCL Oral Tablet 50 mg 1 Tab daily at bedtime; Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, 0.5 ml, under the tongue every hour as needed for pain, cardiac pain, or respiratory distress (opioid analgesic). Review of Skilled Nursing Visit completed on 12/14/23 by Staff H, RN showed (nursing home staff) did state that she has been “;holding the scheduled noon time Morphine due to (Patient 2) does not seem to be in pain and she lays down after lunch.” There was no documentation to support the hospice had identified the need for the patient to receive “;scheduled noon time Morphine” because of a change in pain status, identified by the hospice staff and Interdisciplinary group. There was no documentation to support the hospice plan of care and medication orders were changed to reflect the need for scheduled Morphine for pain control. There was no documentation to support the hospice authorized changes to the plan of care involving pain medication, prior to the change being made at the nursing facility. During a home visit conducted at the nursing home on 12/20/23 at 10:00 AM, the surveyor requested facility documentation of current medications ordered and administered for the current month, including those ordered pain management, for Patient 2, from the nursing home Assistant Director of Nursing. Review of the Nursing Home (NH) Order Review Report, dated12/18/23 showed Patient 2s Current Medications ordered for pain included: Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, 0.25 ml, by mouth every hour as needed for pain, cardiac pain, or respiratory distress ordered on 11/14/23 with a start date of 11/14/23. Further review of the nursing home orders dated 11/14/23 showed Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, 0.75 ml, by mouth every hour as needed for pain, cardiac pain, or respiratory distress. This dosage did not match the ordered dosage on the hospice Plan of Care Order and Medication Order of 20 mg/ml 0.5 ML every 1 hour as needed for pain, cardiac pain, respiratory distress). Additionally, the NH orders dated 11/14/23 showed an order for Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, 1.0 ml by mouth every hour as needed for pain, cardiac pain, or respiratory distress. These dosages did not match the ordered dosage on the hospice Plan of Care Orders and Medication Orders of 20 mg/ml, 0.5 ml every 1 hour as needed for pain, cardiac pain, respiratory distress. Also in the NH medications order review report was an order dated 11/21/23 with a start date of 11/23/23, for Morphine Sulfate (Concentrate) Oral Solution 20 mg/5ml, give 0.25 ml, by mouth every afternoon (scheduled dosage) for pain. The hospice Plan of Care Orders and Medication Orders did not include an order for a scheduled dose of Morphine every afternoon. The were no orders for Tramadol for Patient 2 on the Nursing home Order Review Report, nor documentation Tramadol had been administered by the nursing home. Review of the Nursing Home Medication Administration Record for Patient 2 for the month of December 2023 confirmed Patient 2 received the scheduled dosages of Morphine (.25 ml by mouth) offered daily at 11:00 AM from the nursing home staff. No PRN (as needed) dosages were documented for the month of December 2023. Tramadol was not listed on the Medication Administration Record for the nursing home. There was no documentation to support the hospice updated Patient 2s Hospice Medication Orders and the hospice Plan of Care to reflect the Morphine dosages ordered by nursing home staff for as needed pain management, effective 11/14/23. There was no documentation to support the hospice updated Patient 2s hospice Medication Orders and the hospice Plan of Care to reflect the scheduled Morphine dosage ordered by the nursing home staff on 11/21/23. There was no documentation to support the hospice updated the hospice Plan of Care and Medications Orders to reflect the Tramadol dosages were discontinued. There was no documentation to support the hospice authorized, communicated nor coordinated changes to the plan of care regarding Patient 2s medication regimen. During an interview on 12/20/23 at 10:08 AM with Staff C, Registered Nurse (RN) and the nursing home Assistant Director of Nursing regarding ordered morphine for Patient 2 and review of the nursing home Medication Administration Record, Staff C, RN confirmed the hospice Plan of Care and hospice Medication Orders for Morphine, and Tramadol did not match what was being administered to the patient by the facility. During an interview on 12/19/23 AM, Staff A, Administrator confirmed the nursing home utilized contract agency staff to cover shifts and had interim director. She confirmed hospice staff reported difficulty finding staff or staff who knew the patients, in order to coordinate care.”