Hand in Hand Hospice

“Based on review of the Emergency Preparedness Program (EPP) and staff interview, 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 in the hospice’s Emergency Preparedness Program. During an interview of the EPP on 07/03/24 between 9:30 AM and 12:30 PM, the Administrator confirmed that the Patient Population was not addressed within the Emergency Preparedness Program.”

“Based on policy review and staff interview, the hospice failed to develop and implement policies and procedures to track the location of on-duty staff and sheltered patients in the agencys care during an emergency. This deficient practice has the potential to place staff and patients at risk for harm during an emergency situation. Findings Include: Review of the hospice’s documents failed to show policies and procedures to track the location of on-duty staff and sheltered patients in the facilitys care during an emergency. During an interview on 07/03/24 between 9:30 AM and 12:30 PM, the Administrator stated that there were no policies and procedures to track the location of on-duty staff and sheltered patients in the agencys care during an emergency.”

“Based on observation, policy review, record review, and staff interview, the hospice failed to update the comprehensive assessment to include medication changes for 1 (Patient 4) of 19 sample patients. Failure to ensure all medications changes are included in the comprehensive assessment places the patient at risk for potential adverse effects, medication interaction, duplication of medications, additional medication side effects, and ineffective patient management with the plan of care (POC). Review of the hospice policy titled, “;HIH Plan of Care,” showed, “;The care and services provided to patients and their families are in accordance with an individualized written plan of care established by the hospice ... The patients plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments ... the plan of care (POC) is reviewed and updated by the interdisciplinary group (IDG) every 15 days or more frequently... Revisions to the plan are based on information from the patients updated comprehensive assessment”. Review of the hospice policy titled, “;HIH Medication – Management,” showed, “;A Medication Profile is maintained for every patient and includes a listing of the current medication orders for each patient ... The Medication Profile includes all prescription medications, over the counter drugs, vitamins, and herbal and alternative supplements. ... The hospice monitors the medications dispensed to and used by the patient.” Review of the hospice policy titled, “;HIH Hospice Care for Nursing Facility Residents-Hospice Plan of Care,” showed, “;A written plan of care is established and maintained for each hospice patient who resides in a facility ... The hospice nurse assigned to the facility patient is responsible for coordinating and implementing the patients plan of care in collaboration ... with representatives from the facility. ... All care provided to the facility patient must be in accordance with the written plan of care that includes the patients current medical ... needs. ... Any changes to the plan of care are discussed among all caregivers and must be approved by the hospice before implementation.” Review of Patient 4s record showed an admission date of 12/01/23 with a primary diagnosis of Parkinsons disease without dyskinesia (a movement disorder that often appears as uncontrolled shakes, tics, or tremors) and without mental fluctuations (a progressive neurological disorder causing movement problems). Other pertinent diagnoses are neurocognitive disorder with Lewy bodies (a progressive memory disease) and dysphagia (difficulty swallowing food or drink). Further review of Patient 4s record found that the POC and medication profile showed, “;levothyroxine 44 mcg (0.044mg)/mL oral solution; take 1 tab(s) orally once a day for hypothyroid.” Review of Patient 4s hospice medication profile showed “;levothyroxine 50 mcg PO ... take one tablet by mouth once daily.” Further review of Patient 4s record found that the POC and medication profile showed, “;MiraLax oral powder for reconstitution; Administer 17 gm(s) orally once a day for constipation”. Review of Patient 4s hospice medication profile showed “;polyethylene glycol (Miralax) 17g PO ... Mix 17g with 8 ounces of apple juice by mouth every other day for constipation. ... polyethylene glycol (Miralax) 17g PO PRN ... Mix 17g with 8 ounces of water by mouth twice daily as needed for constipation.” Further review of Patient 4s record found that the POC and medication profile showed, “;Melatonin 10 mg oral capsule; Take 1 cap(s) orally once a day (at bedtime) for insomnia” Review of Patient 4s hospice medication profile showed “;Melatonin 10 mg PO HS ... Take two tablets once a day at bedtime for insomnia.” Review of Patient 4s hospice medication profile showed, “;D-VI-SOL (cholecalciferol (vitamin D3)) 5 mL PO ... Take 5 mL by mouth daily. Review of Patient 4s record did not list this medication on the POC or medication profile. Further review of Patient 4s hospice medication profile showed, “;Estradiol 0.01% CRE PRA (Cenestin, Enjuvia, Estrace) 0.1mg/gm Urethra ... Apply pea-sized amount to urethra at night on Tuesday and Friday as instructed”. Review of Patient 4s record did not list this medication on the POC or medication profile. Further review of Patient 4s hospice medication profile showed, “;aluminum/magnesium/simethicone (Mylanta) 30ml PO PRN ... take 30ml by mouth every 4 hours as needed for heartburn/indigestion/stomach upset x 72 hours.” Review of Patient 4s record did not list this medication on the POC or medication profile. Further review of Patient 4s hospice medication profile showed, “;Childrens Tylenol Acetaminophen 160mg/5mL PO PRN ... give 15 mL every 4-6 hours as needed for pain or fever.” Review of Patient 4s record did not list this medication on the POC or medication profile. Further review of Patient 4s hospice medication profile showed, “;EQ pain reliver 500 mg each PO PRN ... Take 2 tablets by mouth every 8 hours **not to exceed a maximum of 3000mg per day of acetaminophen**”. Review of Patient 4s record did not list this medication on the POC or medication profile. Further review of Patient 4s hospice medication profile showed, “;Hydrocodone/Acetaminophen 5-325 mg PO PRN ... Take one tablet by mouth every 12 hours as needed for severe pain. **not to exceed a maximum of 3000mg per day of acetaminophen**”. Review of Patient 4s record did not list this medication on the POC or medication profile. Observation during Patient 4’s home visit on 07/02/24 at 10:15 AM with Staff E, Registered Nurse (RN), showed that the hospice medication profile for Patient 4 did not match the POC or medication profile when comparing the documents. During an interview on 07/02/24 at 10:15 AM, Staff E, Registered Nurse (RN) stated that she was unaware of the medication changes that had occurred for Patient 4. Staff E, RN, went on to state that the facility is supposed to call and fax any medication order changes or needs for the patient to hospice. Staff E, RN, stated that the charting system at the facility is electronic and hospice staff do not have electronic access to review the patient charts. During an interview on 07/02/24 at 11:45 AM, Staff A, Hospice Director, stated that facilities fax any new orders they receive from the primary care provider (PCP) to the hospice. Staff A went on to state that the medical director of the facility that Patient 4 resides at practices at the PCP office next to the facility and often new orders are sent via fax from the PCP office to the hospice directly. Staff A, stated that those orders are then updated in the hospice electronic record. The hospice failed to update the comprehensive assessment to include all new medication changes and accurately include all current medications for Patient 4.”

“Based on observation, policy review, record review, and staff interview, the hospice failed to ensure that the plan of care (POC) includes all drugs and treatment necessary to meet the needs of 1 (Patient 4) of 19 sample patients. Failure to ensure all medications are on the POC places the patient at risk for potential adverse effects, ineffective medication therapy, medication to medication interaction, medication duplication, and ineffective goal and symptom management. Review of the hospice policy titled, “;HIH Plan of Care,” showed, “;The care and services provided to patients and their families are in accordance with an individualized written plan of care established by the hospice ... The patients plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments ... the plan of care is reviewed and updated by the interdisciplinary group (IDG) every 15 days or more frequently... Revisions to the plan are based on information from the patients updated comprehensive assessment”. Review of the hospice policy titled, “;HIH Medication – Management,” showed, “;A Medication Profile is maintained for every patient and includes a listing of the current medication orders for each patient ... The Medication Profile includes all prescription medications, over the counter drugs, vitamins, and herbal and alternative supplements. ... The hospice monitors the medications dispensed to and used by the patient.” Review of the hospice policy titled, “;HIH Hospice Care for Nursing Facility Residents-Hospice Plan of Care,” showed, “;A written plan of care is established and maintained for each hospice patient who resides in a facility ... The hospice nurse assigned to the facility patient is responsible for coordinating and implementing the patients plan of care in collaboration ... with representatives from the facility. ... All care provided to the facility patient must be in accordance with the written plan of care that includes the patients current medical ... needs. ... Any changes to the plan of care are discussed among all caregivers and must be approved by the hospice before implementation.” Review of Patient 4s record showed an admission date of 12/01/23 with a primary diagnosis of Parkinsons disease without dyskinesia (a movement disorder that often appears as uncontrolled shakes, tics, or tremors) and without mental fluctuations (a progressive neurological disorder causing movement problems). Other pertinent diagnoses are neurocognitive disorder with Lewy bodies (a progressive memory disease) and dysphagia (difficulty swallowing food or drink). Further review of Patient 4s record found that the POC and medication profile showed, “;levothyroxine 44 mcg (0.044mg)/mL oral solution; take 1 tab(s) orally once a day for hypothyroid.” Review of Patient 4s hospice medication profile showed, “;levothyroxine 50 mcg PO ... take one tablet by mouth once daily.” Further review of Patient 4s record found that the POC and medication profile showed, “;MiraLax oral powder for reconstitution; Administer 17 gm(s) orally once a day for constipation”. Review of Patient 4s hospice medication profile showed, “;polyethylene glycol (Miralax) 17g PO ... Mix 17g with 8 ounces of apple juice by mouth every other day for constipation. ... polyethylene glycol (Miralax) 17g PO PRN ... Mix 17g with 8 ounces of water by mouth twice daily as needed for constipation.” Further review of Patient 4s record found that the POC and medication profile showed, “;Melatonin 10 mg oral capsule; Take 1 cap(s) orally once a day (at bedtime) for insomnia” Review of Patient 4s hospice medication profile showed, “;Melatonin 10 mg PO HS ... Take two tablets once a day at bedtime for insomnia.” Review of Patient 4s hospice medication profile showed, “;D-VI-SOL (cholecalciferol (vitamin D3)) 5 mL PO ... Take 5 mL by mouth daily. Review of Patient 4s record did not list this medication on the POC or medication profile. Further review of Patient 4s hospice medication profile showed, “;Estradiol 0.01% CRE PRA (Cenestin, Enjuvia, Estrace) 0.1mg/gm Urethra ... Apply pea-sized amount to urethra at night on Tuesday and Friday as instructed”. Review of Patient 4s record did not list this medication on the POC or medication profile. Further review of Patient 4s hospice medication profile showed, “;aluminum/magnesium/simethicone (Mylanta) 30ml PO PRN ... take 30ml by mouth every 4 hours as needed for heartburn/indigestion/stomach upset x 72 hours.” Review of Patient 4s record did not list this medication on the POC or medication profile. Further review of Patient 4s hospice medication profile showed, “;Childrens Tylenol Acetaminophen 160mg/5mL PO PRN ... give 15 mL every 4-6 hours as needed for pain or fever.” Review of Patient 4s record did not list this medication on the POC or medication profile. Further review of Patient 4s hospice medication profile showed, “;EQ pain reliver 500 mg each PO PRN ... Take 2 tablets by mouth every 8 hours **not to exceed a maximum of 3000mg per day of acetaminophen**”. Review of Patient 4s record did not list this medication on the POC or medication profile. Further review of Patient 4s hospice medication profile showed, “;Hydrocodone/Acetaminophen 5-325 mg PO PRN ... Take one tablet by mouth every 12 hours as needed for severe pain. **not to exceed a maximum of 3000mg per day of acetaminophen**”. Review of Patient 4s record did not list this medication on the POC or medication profile. Observation during Patient 4’s home visit on 07/02/24 at 10:15 AM with Staff E, Registered Nurse (RN), showed that the hospice medication profile for Patient 4 did not match the POC or medication profile when comparing the documents. During an interview on 07/02/24 at 10:15 AM, Staff E, Registered Nurse (RN) stated that she was unaware of the medication changes that had occurred for Patient 4. Staff E, RN, went on to state that the facility is supposed to call and fax any medication order changes or needs for the patient to hospice. Staff E, RN, stated that the charting system at the facility is electronic and hospice staff do not have electronic access to review the patient charts. During an interview on 07/02/24 at 11:45 AM, Staff A, Hospice Director, stated that facilities fax any new orders they receive from the primary care provider (PCP) to hospice. Staff A went on to state that the medical director of the facility that Patient 4 resides at practices at the PCP office next to the facility and often new orders are sent via fax from the PCP office to the hospice directly. Staff A, stated that those orders are then updated in the hospice electronic record. The hospice failed to accurately update the POC for Patient 4 for all previously existing and new medications.”

“Based on policy review, record review, observation, and staff interview, the hospice failed to maintain a system of communication to provide for ongoing sharing of information with other non-hospice healthcare providers furnishing services for 1 (Patient 4) of 19 sample patients. Failure to ensure ongoing communication with patient healthcare providers places the patient at risk for unmanaged symptoms and unmet care needs. Review of the hospice policy titled, “;HIH Hospice Care for Nursing Facility Residents-Hospice Plan of Care,” showed, “;A written plan of care is established and maintained for each hospice patient who resides in a facility ... The hospice nurse assigned to the facility patient is responsible for coordinating and implementing the patients plan of care in collaboration ... with representatives from the facility. ... All care provided to the facility patient must be in accordance with the written plan of care that includes the patients current medical ... needs. ... Any changes to the plan of care are discussed among all caregivers and must be approved by the hospice before implementation.” Review of the hospice policy titled, “;HIH Medication – Management,” showed “;A Medication Profile is maintained for every patient and includes a listing of the current medication orders for each patient ... The Medication Profile includes all prescription medications, over the counter drugs, vitamins, and herbal and alternative supplements. ... The hospice monitors the medications dispensed to and used by the patient. ... The hospice nurse case manager or designee provides and documents instruction to the patient/caregiver regarding the safe administration of medication”. Review of Patient 4s record showed an admission date of 12/01/23 with a primary diagnosis of Parkinsons disease without dyskinesia (a movement disorder that often appears as uncontrolled shakes, tics, or tremors) and without mental fluctuations (a progressive neurological disorder causing movement problems). Other pertinent diagnoses are neurocognitive disorder with Lewy bodies (a progressive memory disease) and dysphagia (difficulty swallowing food or drink). Further review of Patient 4s record showed the hospices plan of care (POC) and medication profile did not match the facility medication profile where Patient 4 is a resident. Observation during Patient 4’s home visit on 07/02/24 at 10:15 AM with Staff E, Registered Nurse (RN), showed that the hospice medication profile for Patient 4 did not match the POC or medication profile when comparing the documents. During an interview on 07/02/24 at 10:15 AM, Staff E, Registered Nurse (RN) stated that she was unaware of the medication changes that had occurred for Patient 4. Staff E, RN, went on to state that the facility is supposed to call and fax any medication order changes or needs for the patient to hospice. Staff E, RN, stated that the charting system at the facility is electronic and hospice staff do not have electronic access to review the patient charts. During an interview on 07/02/24 at 11:45 AM Staff A, Hospice Director, stated that facilities fax any new orders they receive from the primary care provider (PCP) to hospice. Staff A went on to state that the medical director of the facility that Patient 4 resides at, practices at the PCP office next to the facility and often new orders are sent via fax from the PCP office to hospice directly. Staff A stated that those orders are then updated in the hospice electronic record. The hospice failed to maintain an effective method of communication with the facility to ensure timely and accurate medication changes for Patient 4.”

“Based on observation, policy review, record review, and staff interview, the hospice failed to ensure that drugs labeled in accordance with currently accepted professional practice followed the written expiration date for 1 (Patient 2) of 19 sample patients. Failure to ensure a system to replace expired medications prior to use is being utilized, places the patient at risk for ineffective symptom management and increased risk for unknown side effects. Review of the hospice policy titled, “;HIH Medication – Management,” showed, “;The hospice monitors the medications dispensed to and used by the patient. ... The hospice nurse case manager or designee provides and documents instruction to the patient/caregiver regarding the safe administration of medications including ... proper storage, handling and preparation of medication. ... Medications that are no longer needed are disposed of in accordance with accepted standards of practice.” Review of Patient 2’s record showed an admission date of 05/09/24 with a primary diagnosis of chronic diastolic congestive heart failure (hardening of hearts pumping chamber causing ineffective filling and emptying of the chamber). Other pertinent diagnoses; bacteremia (bacteria in the blood stream), non-ST elevation myocardial infarction (heart attack), unspecified chronic kidney disease, essential hypertension (elevated blood pressure), major depressive disorder (persistent feeling of sadness). Observation during Patient 2’s home visit on 07/01/24 at 3:00 PM with Staff C, RN. Patient 2s daughter retrieved morphine from the patients bedroom with a label reading expiration date of 05/10/23. The daughter stated that she does not use the medication very often. During an interview on 07/02/24 at 11:45 AM, Staff A, Hospice Director, stated that a conversation was had with RN, Staff C regarding the expired morphine and she stated that if the medication was in the medication cabinet in the kitchen it may have been an old bottle as the daughter keeps expired medications in the cabinet in the kitchen. It was stated that the bottle came from Patient 2s bedroom and Staff A then stated that it was likely expired then. The hospice failed to dispose of Patient 2s expired bottle of morphine and replace it with a new bottle.”