Heart of Hospice

“Based on interviews and record reviews, the Hospice agency failed to meet the Condition of Participation of Patients Rights as evidenced by failure to ensure: 1. PRN SN Visits and alterations in treatment were completed following changes in condition for 5 (#1, #2, #3, #5, and #6) of 6 (#1, #2, #3, #4, #5, and #6). See findings in L517; and2. An effective system was in place to ensure communication and intervention when agency staff were notified S5RN missed PRN SNV for 4 (#1, #2, #3, and #5) of 6 (#1, #2, #3, #4, #5, and #6) patients in the final sample. See findings in L517. Patient #1 On 12/13/2024 at 11:22 p.m., S5RN was assigned to conduct an On-call SN Visit for Patient #1 after an unwitnessed fall with visible displacement of the left leg. S5RN failed to conduct the in person visit and contacted the NH via telephone around midnight to give verbal orders for increased pain control and an XR. Another On-Call SN visit was assigned to S5RN on 12/14/2024 at 10:30 a.m., when the NH contacted the Hospice agency with the results of the XR, which revealed a fractured femur, and to report uncontrolled pain. S5RN failed to conduct the visit or address Patient #1s uncontrolled pain on 12/14/2024. Patient #1 was transported via ambulance to the emergency room on 12/14/2025 at 1:19 p.m. for uncontrolled pain. S5RN arrived to the NH on 12/15/2024 around lunch time to assess Patient #1 and at that time contacted the physician for the first time to communicate the fall and fracture. The Physician provided orders to transfer the patient to inpatient hospice for aggressive IV treatment of uncontrolled pain where she expired on 12/19/2024. Hospice administration was unaware S5RN failed to conduct PRN SN Visits for Resident #1. S5RN also failed to conduct a total of 9 required PRN SN Visits for Patients #1, #2, #3, #5, and #6 from 12/13/2024 through 01/21/2025. An Immediate Jeopardy situation was identified and S1ED was notified of the Immediate Jeopardy on 02/05/2025 at 4:30 p.m. Onsite verification was conducted through observations, interviews and record reviews to ensure the agency had implemented an acceptable Plan of Removal: 02/06/2025 - 100% of Hospice staff present for Daily Standup call. Discussed all after hours triage calls, new admits, need of any follow-up visits, discussion of state surveyor findings.Executive Director and Director of Corporate Operations confirmed 100% of staff were present with verification by responding “I understand the education” in the chat in Teams application. Training acknowledgement of meeting held on 02/06/2025, along with the follow up training for discipline specific education, will be placed in Human Resources file. Executive Director instructed 100% of staff that mandatory meetings will be held by 02/14/2025 with an additional mandatory staff meeting held on 02/20/2025 to review with staff the complete state survey findings and plan of correction. In depth in-person follow up training will require 100% completion prior to being released to see patients. 02/06/2025 - 100% of Hospice staff received education and training related to failure of staff to perform prn visit. Immediately all prn visits must be completed on any patient with reported pain and any reports of patient falls. Executive Director or trained designee will verify completion of prn visits pertaining to pain or falls by a phone call to the patient/caregiver or nursing facility by 10:00 a.m. on the following day after the prn visit. Executive Director or trained designee will also audit 2 completed visits per day verifying completion and signature of patient or caregiver. Utilizing the agent visit summary report, capturing completed visits from prior day. A minimum of 2 completed visits per day will be audited verifying signature obtained on completion of visits by patient or caregiver. Selection will be rotated by clinician and physician team. This will be monitored for 3 consecutive months and until 100% compliant. 02/06/2025 - 100% of Hospice staff received education regarding Policy 3.031-Patient Fall Reduction Program. All staff educated on procedure on reporting patient falls. Education included the following expectations: The Fall Risk assessment will be completed by all nursing staff on admission, recertification, post fall and any change in condition or location as per Policy 3.031. Post Fall visits with suspected injury will be scheduled to receive a Skilled nurse visit within 24 hours post fall or reported fall. All other disciplines will report any falls to nurse case manager and complete a clinical coordination note in Home Care Home Base EHR system. Nurse Case Manager will enter fall occurrence in the Home Care Home Base EHR system. Executive Director or trained designee will enter fall occurrence into the Risk Management system within 72 hours. Executive Director or trained designee will provide additional in person education and policy review with signed copy of policy by 02/14/2025. Manager on-call will be notified of any after-hours falls via Care XM messaging system. Executive Director or trained designee will verify completion of prn visits pertaining to pain or falls by a phone call to the patient/caregiver or nursing facility within 2 hours of the prn visit and documented into patient ‘s medical record. Executive Director or trained designee will monitor compliance for 3 consecutive months and or 100% compliance to completed visits. 02/06/2025 - 100% of Hospice staff received education regarding Pain assessment policy 3.005. and Physician orders Policy 3.009. Education included the following expectations: When hospice agency is notified, a patient has pain above pain goal, an in-person visit is initiated by a nurse to assess for pain. A phone call will be made by nurse within 2 hours of completion of in-person visit to ensure interventions were effective. If interventions are not effective, a nurse will make an in-person return visit and continue the 2-hour monitoring plan until pain is controlled. Executive Director instructed 100% of staff that all patients with pain score above pain goal will receive an additional in-person follow-up visit within 24 hours of pain assessment. Executive Director instructed 100% of staff on Policy 3.009 Physician Orders. Executive Director instructed staff to obtain verbal orders as needed per patient. Any orders obtained will be entered into Home Care Home Base EHR system within 24 hours. All instruction given by nurse without physician verbal orders will be in violation of their scope of practice. All staff have a direct line to contact any of the hospice physicians. All patients reporting pain will be discussed on daily stand-up call and visits scheduled as needed. Executive Director or trained designee will verify completion of prn visits pertaining to pain by a phone call to the patient/caregiver or nursing facility within 2 hours of the prn visit and documented into patients medical record. Executive Director or trained designee will monitor for 3 consecutive months and until 100% compliant. 100% of all staff will be scheduled the ITrain course Pain Management at End of Life by 02/07/2025 with completion of course by 02/14/2025. Executive Director will review completion for all staff. If not completed by 02/14/2025, staff will not be allowed to see patients.Executive Director or trained designee will provide additional in-person education and policy review with signed copy of policy by 02/14/2025. 02/06/2025 - 100% of Hospice staff received education and instruction regarding procedure for missed visits, along with Hospice Standards of Behavior. Education included the following expectations: Executive Director instructed 100% of staff that before missing any visit a manager would need to be notified with the reason for a missed visit. Executive Director or trained designee will review missed visit report daily. If any visit missed was documented, Executive Director or trained designee will call staff to verify reason of missed visit and reeducate on missed visit procedure as needed. Executive Director or trained designee will also call patient /caregiver or nursing facility to verify staff reason is accurate. Executive Director or trained designee will monitor compliance for at least 3 consecutive months and until 100% compliance is achieved. 02/06/2025 - 100% of Hospice staff received education and instruction regarding procedure for RN aide supervisory visit and Policy 8.007 Hospice Aide Supervision. Education included the following expectations: RN Aide Supervisory visits must be completed, and documented in the electronic medical record, at least every 14 days. Executive Director instructed 100% of RN staff that mandatory meeting will be held by 02/14/2025 and copy of policy will be given and signed with copy filed in Administration binder with plan of correction. Executive Director or trained designee will perform at least one ride-along visit weekly, with RN to patient receiving aide services, to assure aide supervisory questions are asked and patient or caregiver is satisfied with the hospice aide services. Ride-along visits will be scheduled and completed with all RN staff by 02/28/2025, and continued until 100% compliance met for each RN. Current RN staff includes 11 full-time and 2 PRN with a patient census of 127. If PRN staff does not have a scheduled workday prior to 02/28/2025, PRN staff will have a ride along at next scheduled workday. 02/06/2025 - 100% of Hospice staff received education and instruction regarding procedure for afterhours calls regarding visits not made and addressing patient needs. Education included the following expectations: Expectation that any after-hours phone call received for uncontrolled symptoms and/or patient fall, will require an in-person visit from a Nurse. Executive Director or designee will monitor on call report daily via Morning Stand-Up call, including use of the Morning Stand-Up Call documentation tool. 02/06/2025 - 100% of Triage team was educated on process of notifying manager on-call of reported visits not made via Care XM messaging system. Education was provided by Care XM supervisor on 02/06/2025. Monitoring will be ongoing per Care XM triage report daily. All future education provided will include review of Hospice specific policies and procedures and will include a sign in sheet to document attendance and understanding of information provided. For staff who attend or receive education virtually, the staff member name and date of attendance will be documented on the sign in sheet by the Executive Director or designee. The QAPI Coordinator, Executive Director and or trained designee will review data collected monthly for compliance to plan of correction. Updates to plan of correction will be done monthly as compliance percentages are assessed. S5RN was terminated effective immediately on 02/05/2025 and was reported to the Louisiana State Board of Nursing. The RN SNV, dated 12/14/2024, for Patient #1 was marked unbillable as of 02/05/2025. The Immediate Jeopardy was lifted on 02/07/2025 at 11:00 a.m. prior to the survey exit and deficient practice remained at a condition level. The deficient practice had the potential to cause harm to the current agency patients and any future admits. See findings in L517. See findings in L517.”

“Based on interviews and record reviews, the Hospice Agency failed to meet the Condition of Participation for Organization and Administration of Services. This deficient practice was evidenced by failure to administer resources to provide hospice care and services to patients necessary for the palliation and management of the terminal illness and related conditions. The Hospice Agency failed to ensure positive palliative outcomes, patient safety and quality of care as evidenced by failure to have a system in place to:1. Prevent patient neglect through services provided in a manner consistent with accepted standards of practice for 5 (#1, #2, #3, #5, and #6) of 6 (#1, #2, #3, #4, #5, and #6) patients in the sample (See findings in L651); 2. Ensure documentation in each patients clinical record was performed in a manner consistent with accepted standards of practice for 5 (#1, #2, #3, #5, and #6) of 6 (#1, #2, #3, #4, #5, and #6) patients in the sample (See findings in L651); 3. Ensure drugs were ordered by a physician or nurse practitioner for 3 (#1, #3 and #5) of 6 (#1, #2, #3, #4, #5, and #6) patients in the sample (See findings in L651); and4. Manage a continuous QAPI Program to correct identified quality deficiencies for 4 (#1, #2, #3, and #5) of 6 (#1, #2, #3, #4, #5, and #6) patients reviewed in the sample (See findings in L651). The deficient practice had the potential to cause harm to the all of the 126 current patients and any future admissions to the agency. See findings in L651.”

“Based on record review and interview the Hospice agency failed to meet the Condition of Participation of Clinical Record Accuracy as evidenced by failure to ensure: 1. SN visits were performed as documented for 2 (#1 and #5) of 6 (#1, #2, #3, #4, #5, and #6) patients in the final sample; 2. Accuracy of Physicians Orders in the EHR for 4 (#1, #2, #3 and #5) of 6 (#1, #2, #3, #4, #5, and #6) patients in the final sample; 3. All action taken by the on-call nurse was documented for 4 (#1, #2, #3 and #6) of 6 (#1, #2, #3, #4, #5, and #6) patients in the final sample; and 4. Missed Visits were documented accurately for 1 (#1) of 6 (#1, #2, #3, #4, #5, and #6) patients in the final sample. See findings in L672. See findings in L672.”

“Based on interviews and record reviews, the Hospice agency failed to have a system in place to prevent patient neglect by ensuring services were delivered as ordered. The Hospice agency failed to ensure:1. PRN SN Visits and alterations in treatment were completed following changes in condition for 5 (#1, #2, #3, #5, and #6) of 6 (#1, #2, #3, #4, #5, and #6) sampled patients; and2. An effective system was in place to ensure communication and intervention when agency staff were notified S5RN missed PRN SNV for 4 (#1, #2, #3, and #5) of 6 (#1, #2, #3, #4, #5, and #6) patients in the final sample. This deficient practice resulted in an Immediate Jeopardy situation for Patient #1 on 12/13/2024 at 11:22 p.m. when S5RN was assigned to conduct an On-call SN Visit for Patient #1 after an unwitnessed fall with visible displacement of the left leg. S5RN failed to conduct the in person visit and contacted the NH via telephone around midnight to give verbal orders for increased pain control and an XR. Another On-Call SN visit was assigned to S5RN on 12/14/2024 at 10:30 a.m., when the NH contacted the Hospice agency with the results of the XR, which revealed a fractured femur, and to report uncontrolled pain. S5RN failed to conduct the visit or address Patient #1s uncontrolled pain on 12/14/2024. Patient #1 was transported via ambulance to the emergency room on 12/14/2025 at 1:19 p.m. for uncontrolled pain. S5RN arrived to the NH on 12/15/2024 around lunch time to assess Patient #1 and at that time contacted the physician for the first time to communicate the fall and fracture. The Physician provided orders to transfer the patient to inpatient hospice for aggressive IV treatment of uncontrolled pain. The patient expired in the inpatient hospice on 12/19/2024. Hospice administration was unaware S5RN failed to conduct PRN SN Visits for Patient #1. S5RN failed to conduct a total of 9 required PRN SN Visits for Patients #1, #2, #3, #5, and #6 from 12/13/2024 through 01/21/2025. S1ED was notified of the Immediate Jeopardy on 02/05/2025 at 4:30 p.m. The Immediate Jeopardy was lifted on 02/07/2025 at 11:00 a.m. prior to the survey exit and deficient practice remained at a Condition level. The deficient practice had the potential to cause harm to the current agency patients and any future admits. Cross Reference: L500, L568, L648, L651, L670, L672, L686, and L690. 1. Failed to ensure PRN SN Visits and alterations in treatment were completed following changes in condition Patient #1 Review of Patient #1s Clinical Record revealed she was admitted to the Hospice agency on 09/05/2024 with diagnoses, which included, in part, Alzheimers Disease and Dementia. Further review revealed she was a resident of a local NH facility. Review of Patient #1s POC for the Certification Period of 12/04/2024 through 12/19/2024, revealed she was to receive a SNV once a week for 13 weeks and as needed. Further review revealed, in part, the following: Problem: PainGoal: Patient pain will be reduced as evidenced by reduction in pain score to 5 or less at each SN visit. Review of Patient #1s Triage Coordination Notes, dated 12/13/2024 through 12/15/2024, revealed, in part, the following: 12/13/2024 at 11:16 p.m. - NH stated Patient #1 had an unwitnessed fall with complaints of left leg pain and visible displacement noted, with raised, hard area to outside of left knee. Requested orders for further pain control. PRN SNV requested. 12/13/2024 at 11:22 p.m. - S5RN was assigned.12/14/2024 at 10:24 a.m. - NH stated Patient #1s in-house X-Ray indicated a broken femur. Patient #1s pain remains uncontrolled. Patient #1 only ordered Tylenol for pain. PRN SNV requested. 12/14/2024 at 10:31 a.m. - S5RN was assigned.12/15/2024 at 8:16 a.m. - NH stated S5RN never came to the NH on 12/14/2024 to assess Patient #1. Patient #1 went to ED overnight for uncontrolled pain. NH requested PRN SNV ASAP for continued uncontrolled pain. 12/15/2024 at 9:24 a.m. - S5RN was assigned. Review of Patient #1s PRN SNV Notes, dated 12/13/2024 through 12/15/2024, revealed, in part, the following:12/13/2024 - No PRN SNV Notes documented by S5RN. 12/14/2024 at 2:45 p.m. by S5RN - Patient #1 in bed, stable, and responded “;no” to being in pain. Patient #1s NH nurse educated on the use of Dilaudid to control pain. Patient #1s POC, medication regimen and effectiveness, use of comfort kit, and pharmacologic and non-pharmacologic measures reviewed with her NH nurse. Patient #1s NH nurse verbalized understanding. The SNV began at 3:30 p.m. and ended at 5:14 p.m. The total in-home time was 1.73 hours. 12/15/2024 - No PRN SNV Notes documented by S5RN. Review of Patient #1s Nurse Coordination Notes, dated 12/13/2024 through 12/15/2024, revealed, in part, the following:12/13/2024 - No PRN SNV Notes documented by S5RN. 12/15/2024 - No PRN SNV Notes documented by S5RN. Review of Patient #1s Nurse Notes from the NH, dated 12/13/2024 through 12/14/2024, revealed, in part, the following: 12/14/2024 at 12:21 a.m. - Late entry following fall on 12/13/2024 at 11:00 p.m. Patient #1 was found on floor with both legs underneath her. A raised area was noted to her left knee laterally and medially. Patient #1was complaining of pain. Hospice agency was notified. S5RN called to give verbal orders to discontinue PRN Dilaudid and Lorazepam and change to scheduled every 4 hours and have an in-house XR of left leg the next morning. 12/14/2024 at 11:08 a.m. - In-house XR indicated left femur fracture. Awaiting return call from S5RN. 12/14/2024 at 12:25 p.m. - S5RN returned call at 11:30 a.m. S5RN stated due to Patient #1s age and comorbidities, it was very unlikely surgery would be performed. S5RN gave verbal orders to continue Dilaudid and Lorazepam every 4 hours to manage pain. S5RN stated she was over an hour away.12/14/2024 at 12:54 p.m. – Spoke with Patient #1s daughter about her XR results and the Hospice medication orders currently available to treat her pain. Patient #1s daughter requested her mother be sent to the local ED to achieve better pain control. Local EMS contacted and enroute for transport. 12/15/2024 at 9:45 a.m. – Received call from S5RN who stated Patient #1 needed inpatient Hospice so she could receive IV pain meds. 12/15/2024 at 10:58 a.m. – Patient #1 still crying out in pain, groaning, guarding and grimacing when touched the slightest. Dilaudid and Lorazepam given in ED yesterday and every 4 hours since order was received to do so. Local EMS stated high call volume and would transport to inpatient hospice ASAP. 12/15/2024 at 6:30 p.m. – Patient #1 remained unchanged. Transferred via local EMS to inpatient Hospice. Review of Patient #1s Run Reports from the local EMS, dated 12/14/2024, revealed, in part, the following: Run #1 - Transport from NH to local ED:Date/Time On Scene at NH: 12/14/2024 at 1:04 p.m.; Departed NH: 12/14/2024 at 1:19 p.m.Signs/Symptoms: Extremity pain to Left Hip/Leg following fall from bed on 12/13/2024.Vital Signs: Pulse-114; Respirations-18.Narrative: Complaints of uncontrolled pain to left lower extremity. Left lower extremity looks shortened and rotated with complaints of increased pain upon movement. Run #2 - Transport from local ED to NH: Date/Time of Arrival to NH: 12/14/2024 at 6:21 p.m.Further review revealed no documented evidence to indicate S5RN was present during either transport. Review of Patient #1s Medical Record from a local ED, dated 12/14/2024, revealed, in part, the following: Admit Date/Time: 12/14/2024 at 1:26 p.m. History of Present Illness: Uncontrolled pain to lower left extremity following fall on 12/13/2024. Current Pain: 7/10, worse on movement.XR Femur, Left x2 views - Impression: Distal femoral diaphyseal fracture roughly 4 cm above femoral component with mild posterior distraction of the dorsal lymph nodes. Plan: Administered Dilaudud 0.5 mg IV now for pain. Discharge Date/Time: 12/14/2024 at 6:00 p.m.Further review revealed no documented evidence to indicate S5RN was present during visit. Review of Patient #1s December 2024 MAR from her NH revealed, in part, the following: Dilaudid Tab 2mg. Administer via G-Tube PRN every 4 hours for pain. Start Date: 12/01/2024 at 11:15 a.m.Administered: 12/14/2024 at 10:51 a.m. - Pain: 7/10.Dilaudid Tab 2mg. Administer via G-Tube every 4 hours for pain. Start Date: 12/14/2024 at 4:00 p.m.Not Administered: 12/14/2024 at 8:00 p.m. - Patient received in ED with pain assessed as 9/10.Administered: 12/15/2024 at 12:00 a.m. - Pain: 8/10.12/15/2024 at 4:00 a.m. - Pain: 8/10, 12/15/2024 at 8:00 a.m. - Pain: 5/10, 12/15/2024 at 12:00 p.m. - Pain: 7/10, 12/15/2024 at 4:00 p.m. - Pain: 5/10.Lorazepam Tab 2mg. Administer via G-Tube PRN every 4 hours for Restlessness and Agitation. Start Date: 11/04/2024 at 12:00 a.m.Administered: 12/14/2024 at 10:52 a.m. - Pain: 7/10.Lorazepam Tab 2mg. Administer via G-Tube every 4 hours for pain. Start Date: 12/14/2024 at 4:00 pm 12/14/2024 at 8:00 p.m. - Patient received in ED with pain assessed as 9/10.Administered: 12/15/2024 at 12:00 a.m. 12/15/2024 at 4:00 a.m. 12/15/2024 at 8:00 a.m. 12/15/2024 at 12:00 p.m. 12/15/2024 at 4:00 p.m.Document Pain Scale Every Shift: 12/13/2024 PM Shift: 5/10, documented prior to patients fall. 12/14/2024 AM Shift: 7/10.12/14/2024 PM Shift: 6/10.12/15/2024 AM Shift: 3/10. An interview was conducted on 02/03/2025 at 2:30 p.m. with S5RN. S5RN confirmed she did not visit Patient #1 in the ED on 02/14/2024 and was unaware the NH sent her to the ED on 02/14/2024 for treatment of uncontrolled pain. S5RN stated she assessed Patient #1 in the NH on 02/14/2024 at the time documented in her PRN SNV note. S5RN stated she documented the PRN SNV note while in the NH with Patient #1. An interview was conducted on 02/04/2025 at 1:12 p.m. with Patient #1s daughter. She confirmed she was Patient #1s roommate in the NH. She confirmed she remained in their room from the time of Patient #1s fall on 12/13/2024 until Patient #1 went inpatient Hospice on 12/15/2024. She confirmed her mother began moaning and groaning in pain starting early morning and into the day on 12/14/2024. She confirmed when her mothers pain was not resolving and S5RN had not shown up by lunchtime on 12/14/2024, she requested for the NH to send her mother to the ED to get her pain under control. She stated the ED gave her pain medication which helped tremendously. She stated the problem was when the medication wore off, the NH didnt have medications to get her pain under control again. She confirmed her mothers pain returned late in the night on 12/14/2024 and she continued to moan and groan in pain until S3MD gave an order to transfer her to an inpatient Hospice unit on the evening of 12/15/2024 for aggressive treatment of pain with IV medications. She stated it broke her heart to have to sit there and listen to her mother suffer for days, while they waited for S5RN to show up and do something. She confirmed S5RN did not come to their room at any time on 12/13/2024 or 12/14/2024. She confirmed her mother was not present in the NH from lunchtime on 12/14/2024 until after supper the same day because she requested the NH send her to the ED for treatment of uncontrolled pain. She confirmed it was 12/15/2024 around lunchtime before S5RN came to assess her mother. An interview was conducted on 02/04/2025 at 12:55 p.m. with Patient #1s night shift nurse at the NH where she resided. She confirmed Patient #1s daughter was her roommate and was cognitively intact. She confirmed she worked 6:00 p.m. to 6:00 a.m. She confirmed she was Patient #1s nurse on 12/13/2024 through 12/15/20024. She confirmed she contacted the Hospice agency on 12/13/2024 immediately following Patient #1s fall to report the incident, her suspected injury and uncontrolled pain. She confirmed she informed the Hospice triage nurse Patient #1s left leg showed signs of fracture and possible displacement with pain to the site. She stated she received a call from S5RN who asked if there was bruising to Patient #1s left leg. She stated she informed S5RN there was not yet bruising, but there were signs of displacement. She stated S5RN informed her if there was no immediate bruising, Patient #1s leg could not possibly be broken, and she would not be making a visit to assess Patient #1 tonight. She stated S5RN then gave her verbal orders to discontinue her PRN Dilaudid and Lorazepam and change it to scheduled every 4 hours and to have an in-house XR done in the morning. She confirmed she gave Patient #1 the medication per the directions of S5RN and it worked for a little while, but early the next morning, it was no longer controlling her pain. She confirmed Patient #1 was at the ED when she started her shift on 12/14/2024 and came back with no signs of pain. She stated once the medication the ED gave her wore off, they were unable to get her pain under control with the ordered pain regimen. She confirmed S5RN, nor anyone from the Hospice agency came to the NH during her shift on 12/13/2024 or 12/14/2024. She stated when S5RN returned phone calls, she would remind the NH staff she lived over an hour away and frequently requested photos be texted to her so she would not have to drive to the NH. She stated S5RN would then give verbal telephone orders to pacify the patients needs until the next nurse came on shift to handle whatever was going on. An interview was conducted on 02/05/2025 at 9:44 a.m. with Patient #1s day shift nurse at the NH where she resided. She confirmed Patient #1s daughter was her roommate and she was cognitively intact. She confirmed she was Patient #1s nurse on 12/14/2024 from 6:00 a.m. until after 7:00 p.m. and again on 12/15/2024 from 6:00 a.m. to 6:00 p.m. She confirmed she contacted the Hospice agency with the results immediately when Patient #1s XR indicated a left femur fracture on 12/14/2024 around 11:00 a.m. She confirmed she requested a PRN SNV immediately in order to obtain orders for pain medication as the current orders were not effective. She stated S5RN called and told her she was 30 minutes south of Alexandria and would not be coming to the NH at that time. She stated she requested S5RN obtain new orders for more sufficient pain control but did not receive any. She stated S5RN stated she would attempt to locate a pharmacy to fill new pain medication orders and would bring them to the NH later on 12/14/2024. She confirmed S5RN failed to report to the NH nor did she call back with new pain medication orders on 12/14/2024. She confirmed Patient #1s pain remained uncontrolled until Patient #1s daughter requested for her to be sent to the ED for pain control on 12/14/2024 around lunch and did not return until just prior to the end of her shift. She stated if someone from the Hospice agency had come to assess Patient #1 on 12/14/2024, they would have had to ask her or Patient #1s daughter where the patient was. She confirmed she contacted the Hospice Triage Nurse on 12/15/2024 at 8:16 a.m. and informed the Triage Nurse Patient #1s pain remained uncontrolled and requested a PRN SNV immediately for additional pain medication orders. She stated she received a return call from S5RN on 12/15/2024 at 9:45 a.m. informing her Patient #1 needed to be transferred to inpatient hospice for aggressive IV pain control. She confirmed the first time S5RN arrived to the NH to physically assess Patient #1 was around lunch time on 12/15/2024 when they were preparing her for transfer to inpatient hospice. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed he was not contacted by S5RN or anyone with the Hospice agency until S5RN contacted him on 12/15/2024 to request Patient #1 be transferred to inpatient Hospice for uncontrolled pain. S3MD confirmed he would have expected S5RN to make a visit to physically assess Patient #1 immediately on 12/13/2024. S3MD confirmed he would have then expected S5RN to contact him immediately when Patient #1 was experiencing pain uncontrolled with her current pain regimen. S3MD confirmed he would have expected S5RN to continue to contact him for orders to obtain appropriate pain control for Patient #1 each time she was contacted by the NH and told Patient #1s pain remained uncontrolled. S3MD confirmed a fall with suspected injury and uncontrolled pain warranted an immediate PRN SNV. S3MD confirmed when a patients pain was uncontrolled, he would expect a Hospice nurse to make an immediate PRN SNV to assess the patient, then contact him to report the assessment findings and obtain further orders. S3MD confirmed any Hospice discipline not performing visits as they should was neglecting the needs of the patient. S3MD confirmed S5RN led to Patient #1 suffering needlessly, which was neglect. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed if Patient #1 was not present in the NH at the time S5RN documented she performed a visit in the NH, the visit could not have been performed as documented. S2DON confirmed she would have expected S5RN to immediately report to the NH on 12/13/2024 to assess Patient #1 then contact S3MD to notify him of the injury and uncontrolled pain in order to receive orders for treatment and she did not. S2DON confirmed when Patient #1s pain remained uncontrolled with her current medication regimen, she would have expected S5RN to continue making PRN SNVs to assess her and continue contacting S3MD for new orders until her pain level could be controlled and she did not. S2DON confirmed she would expect a PRN SNV to be performed immediately following report of a patient fall, especially if there were suspected injury and/or pain. S2DON confirmed she would expect a PRN SNV to be performed when requested and with reports of uncontrolled pain and/or other symptoms. S2DON confirmed leaving a Hospice patient with uncontrolled pain for any extended period of time was neglect and should not have occurred. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed if Patient #1 was not present in the NH at the time S5RN documented she performed a visit in the NH, the visit could not have been performed as documented. S1ED confirmed she would have expected S5RN to immediately report to the NH on 12/13/2024 to assess Patient #1 then contact S3MD to notify him of the injury and uncontrolled pain in order to receive orders for treatment and she did not. S1ED confirmed when Patient #1s pain remained uncontrolled with her current medication regimen, she would have expected S5RN to continue making PRN SNVs to assess her and continue contacting S3MD for new orders until her pain level could be controlled and she did not. S1ED confirmed she would expect a PRN SNV to be performed immediately following report of a patient fall, especially if there were suspected injury and/or pain. S1ED confirmed she would expect a PRN SNV to be performed when requested and with reports of uncontrolled pain and/or other symptoms. S1ED confirmed leaving a Hospice patient with uncontrolled pain for any extended period of time was neglect and should not have occurred. Patient #3 Review of Patient #3s Clinical Record revealed she was admitted to the Hospice agency on 04/18/2024 with diagnoses, which included, in part, Cerebrovascular Disease and History of Cerebral Infarction. Further review revealed she was a resident of a local ALF. Review of Patient #3s POC, for the Certification Periods of 09/10/2024 through 12/13/2024 and 12/14/2025 through 02/11/2025, revealed, in part, he was ordered to receive a SNV once weekly for nine weeks and as needed. Further review revealed, in part, Goals: Patient pain will be reduced as evidenced by reduction in pain score to 5 or less within 24 hours. Review of Patient #3s Triage Coordination Visit Notes, dated 12/15/2024 through 12/17/2024, revealed, in part, the following: 12/15/2024 at 11:40 p.m. – ALF stated Patient #3 fell and was now having dizziness. Blood Pressure was 182/88. Hospice Case Manager to follow up tomorrow.12/16/2024 at 3:23 a.m. – ALF stated Patient #3 had a fall earlier, dizziness now increased, pain reported and patient no longer able to stand on her own. ALF stated Patient #3 was normally independent. Second call for the night. Per protocol, PRN SNV to be performed. 12/16/2024 at 3:36 a.m. – S5RN was assigned. Review of Patient #3s PRN SNV Notes, dated 12/15/2024 through 12/17/2024, revealed, in part, the following: 12/15/2024 – No PRN SNV Notes documented by S5RN.12/16/2024 – No PRN SNV Notes documented by S5RN. Review of Patient #3s Nurse Coordination Visit Notes, dated 12/15/2024 through 12/17/2024, revealed, in part, the following: 12/15/2024 – No Nurse Coordination Notes documented by S5RN.12/16/2024 - No Nurse Coordination Notes documented by S5RN. Review of Patient #3s Physician Orders, dated 12/15/2024 through 12/16/2024, revealed, in part, the following: 12/15/2024 – No physician orders written per S5RN.12/16/2024 – No physician orders written per S5RN.12/16/2024 at 11:46 a.m. – Tylenol 325mg 1 tab by mouth every 4 hours as needed for fever or pain. 12/16/2024 at 11:46 a.m. – Tramadol 50mg 1 tab by mouth three times daily as needed for pain. An interview was conducted on 02/10/2025 at 10:40 a.m. with Patient #3s nurse at the ALF. She confirmed she was caring for Patient #3 when she fell and had a change in status on 12/15/2024 through 12/16/2024. She confirmed the ALF contacted the Hospice agency immediately to notify them of Patient #3s fall and the dizziness. She confirmed no one from the Hospice agency came to the ALF to assess Patient #3. She confirmed no new orders were received when S5RN contacted the ALF via telephone following the first call. She confirmed the ALF contacted the Hospice agency again when Patient #3 began complaining of uncontrolled pain, increased dizziness and was no longer able to stand on her own. She confirmed no one from the Hospice agency came to the ALF to assess Patient #3. She stated S5RN told her via telephone Patient #3s regular nurse would see her tomorrow during normal hours and said she was sending a prescription to the pharmacy for Tramadol 50mg three times daily as needed for pain. She confirmed the pain medication S5RN claimed to order never arrived from the pharmacy. She stated she also informed S5RN the ALF could not locate any pain medications to administer Patient #3 while they were waiting on the new prescription to arrive. She stated S5RN told her she could not help them and her regular nurse would have to sort it out when she came the next day. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed she was Patient #3s regular nurse at the time of her fall on 12/15/2024. S8RN confirmed S5RN was the nurse on-call when Patient #3 fell and later began experiencing a change of status on 12/15/2024. S8RN confirmed when she arrived to Patient #3s ALF on 12/16/2024 around lunch time, she was informed she was the first person from Hospice to assess Patient #3 since her fall on 12/15/2024 because S5RN had not shown up. S8RN confirmed when she arrived to the ALF, she obtained an order for Tramadol and entered it into the EHR because S5RN had not followed through with the verbal orders she gave the ALF while on-call. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed S5RN should have performed a PRN SNV on 12/15/2024 to assess Patient #3 following her fall and to obtain orders to prevent any further progression of symptoms and she did not. S2DON confirmed S5RN should have also performed a PRN SNV on 12/16/2024 to assess Patient #3 following the second call received by the ALF reporting changes in condition following a fall and to obtain orders to prevent any further progression of symptoms and she did not. S2DON confirmed S5RN should have made an effort with the ALF to sort out the confusion with Patient #3s pain medications to ensure her pain was controlled and she did not. S2DON confirmed leaving a Hospice patient with uncontrolled pain for any extended period of time was neglect and should not have occurred. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed S5RN should have performed a PRN SNV on 12/15/2024 to assess Patient #3 following her fall and to obtain orders to prevent any further progression of symptoms and she did not. S1ED confirmed S5RN should have also performed a PRN SNV on 12/16/2024 to assess Patient #3 following the second call received by the ALF reporting changes in condition following a fall and to obtain orders to prevent any further progression of symptoms and she did not. S1ED confirmed S5RN should have made an effort with the ALF to sort out the confusion with Patient #3s pain medications to ensure her pain was controlled and she did not. S1ED confirmed leaving a Hospice patient with uncontrolled pain for any extended period of time was neglect and should not have occurred. Patient #6 Review of Patient #6s Clinical Record revealed he was admitted to the Hospice agency on 12/06/2024 with diagnoses, which included, Acute on Chronic Congestive Heart Failure and Chronic Kidney Disease with history of dependence on hemodialysis. Review of Patient #6s POC, for a Certification Period of 12/06/2024 through 03/05/2025, revealed, in part, he was ordered to receive one SNV twice weekly for one week, seven SNVs weekly for twelve weeks, four SNVs weekly for one week and visits as needed for symptom management. Review of Patient #6s Clinical Triage Coordination Notes, dated 12/26/2024, revealed, in part, the following: 12/26/2024 at 2:12 a.m. – Patient #6s daughter requested a PRN SNV immediately due to uncontrolled symptoms. 12/26/2024 at 2:33 a.m. – S5RN was assigned. Review of Patient #6s Nurse Coordination Notes, dated 12/26/2024, revealed, in part, the following: 12/26/2024 – No Nurse Coordination Notes documented by S5RN. Review of Patient #6s PRN SNV Notes, dated 12/26/2024, revealed, in part, the following: 12/26/2024 – No PRN SNV Notes documented by S5RN. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed she would have expected S5RN to immediately conduct a PRN SNV as requested by the family to ensure Patient #6s symptoms were being properly managed. S2DON confirmed she would expect a PRN SNV to be conducted immediately following report of a patient fall, especially if there were suspected injury and/or pain. S2DON confirmed she would expect a PRN SNV to be conducted when requested, and when pain or other symptoms were uncontrolled with the current medication regimen. S2DON confirmed not performing visits when necessary was neglect and should never happen. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed she would have expected S5RN to immediately conduct a PRN SNV as requested by the family to ensure Patient #6s symptoms were being properly managed. S1ED confirmed she would expect a PRN SNV to be conducted immediately following report of a patient fall, especially if there were suspected injury and/or pain. S1ED confirmed she would expect a PRN SNV to be conducted when requested and when pain or other symptoms were uncontrolled with the current medication regimen. S1ED confirmed not performing visits when necessary was neglect and should never happen. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed a fall with suspected injury, uncontrolled pain or other symptoms warranted an immediate PRN SNV, along with notification made to him as soon as the patient was assessed to obtain further orders. S3MD confirmed he would expect all Hospice staff to take uncontrolled pain and other symptoms seriously, and to contact him immediately to address them. S3MD confirmed he did not utilize standing orders, so nurses should contact him with any needs or questions to obtain orders from him. S3MD confirmed any Hospice discipline not performing visits as they should was neglecting the needs of the patient. S3MD stated if staff were not performing their visits as they should, the agency was not meeting the needs of their patients appropriately. Patient #5Review of Patient #5s Clinical Record revealed he was admitted to the agency on 12/16/2024 with diagnoses, which included, in part, Pressure Ulcer Stage 4 to the Sacral Region, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region, and Pressure Ulcer of Unidentified Site with Unidentified Staging. Further review revealed Patient #5 resided at a local NH and was a patient of S4MD. Review of Patient #5s POC, for the Certification Period of 12/16/2024 through 01/25/2025, revealed, in part, he was ordered to receive two SNVs weekly for eight weeks, two SNVs weekly for one week and as needed. Review of Patient #5s Triage Coordination Note, dated 01/12/2024, revealed, in part, the following: 01/12/2025 at 3:28 p.m. – NH stated Patient #5 started new Fentanyl patch dose on 01/09/2025 with increased confusion since that time. NH stated a new Fentanyl patch was due tonight. NH requested PRN SNV to address family concerns and discuss dose changes to pain medication regimen. 01/12/2025 at 3:48 p.m. – S5RN was assigned. Review of Patient #5s PRN SNV Narrative Notes, dated 01/12/2025, revealed, in part, the following: 01/12/2025 at 5:41 p.m. by S5RN – Patient #5 was lying in hospital bed, drowsy, lethargic and reportedly sleeping more. Patient #5s son requested pain patch (Fentanyl) be reduced and resumed at a lower dose. Verbal order given to discontinue current Fentanyl patch. Will confer with S4MD regarding dosage change by S8RN. The visit began at 5:41 p.m. and ended at 6:21 p.m. The total time in-home was 0.5 hours. Review of Patient #5s Physician Orders, dated 01/12/2025, revealed, in part, the following:01/12/2025 5:51 p.m. – Verbal Order entered by S5RN - Discontinue Fentanyl patch now. 01/13/2025 2:59 p.m. – Verbal Order entered by S8RN - Resume Fentanyl patch 100mg/hour. 1 patch topically every 72 hours for pain. An interview was conducted on 02/05/2025 at 12:00 p.m. with the DON for Patient #5s NH. She reviewed Patient #5s Nurse Notes and confirmed there was a note written on 01/12/2025 at 11:46 a.m., which stated Patient #5 was experiencing increased confusion and agitation so Hospice on-call was notified. She stated the note indicated S5RN informed the NH she would not be coming on 01/12/2025 because his regular nurse would come the following day during normal business hours. She stated the note also indicated S5RN gave a verbal order to discontinue Patient #5s Fentanyl patch at this time. An interview was conducted on 02/05/2025 at 1:16 p.m. with the Administrator for Patient #5s NH. She reviewed Patient #5s Nurse Notes and confirmed there was a note written on 01/12/2025 at 11:46 a.m., which stated Patient #5 was experiencing increased confusion and agitation so Hospice on-call was notified. She stated the note indicated S5RN informed the NH she would not be coming on 01/12/2025 because his regular nurse would come the following day during normal business hours. She stated the note also indicated S5RN gave a verbal order to discontinue Patient #5s Fentanyl patch at this time. She confirmed she reviewed Patient #5s hard chart, Hospice chart and EHR and no documentation was present to indicate S5RN performed an in-person visit on 01/12/2025. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed she was Patient #5s regular nurse on 01/12/2025 and 01/13/2025. S8RN confirmed S5RN was the nurse on-call when the NH called about Patient #5s pain medication. S8RN confirmed when she went to see Patient #5 on 01/13/2025, the NH told her S5RN did not come out but had given them a telephone order to discontinue Patient #5s Fentanyl patch. S8RN stated she was shocked because they had such a time getting Patient #5s pain down to a comfortable level for him. S8RN confirmed when she contacted S4MD, he was not aware the medication had been discontinued and ordered for it to be resumed immediately to prevent breakthrough pain. An interview was conducted on 02/11/2025 at 9:33 a.m. with S4MD. S4MD confirmed S5RN did not contact him on 01/12/2025 regarding Patient #5 and he di d not give an order for S5RN to discontinue Patient #5s Fentanyl patch. S4MD confirmed Patient #5 had been experiencing on-going difficulties with getting his pain managed and under control. S4MD confirmed he would not have given an order to discontinue the medication that had finally helped achieve Patient #5s pain goal. S4MD confirmed he would have expected 5RN to contact him before making any changes to a patients medication regimen, especially in regards to a controlled substance for pain control, and she had not. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed she would have expected S5RN to make an in-person visit to assess Patient #5 on 01/12/2025 after being assigned by the Triage Nurse. S2DON confirmed S5RN had not performed an in-person visit as she documented and had actually handled the call over the phone and she should not have. S2DON confirmed S5RN discontinuing a controlled substance for pain control without a physicians order put Patient #5 at risk for experiencing uncontrolled breakthrough pain. S2DON confirmed she would have expected S5RN to contact S4MD to inform him of the situation and allow him to provide her with orders he felt were appropriate for his patient and she did not. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed she would have expected S5RN to make an in-person visit to assess Patient #5 on 01/12/2025 after being assigned by the Triage Nurse. S1ED confirmed S5RN had not performed an in-person visit as she documented and had actually handled the call over the phone and she should not have. S1ED confirmed S5RN discontinuing a controlled substance for pain control without a physicians order put Patient #5 at risk for experiencing uncontrolled breakthrough pain. S1ED confirmed she would have expected S5RN to contact S4MD to inform him of the situation and allow him to provide her with orders he felt were appropriate for his patient and she did not. Patient #2 Review of Patient #2s Clinical Record revealed he was admitted to the Hospice agency on 11/15/2022 with diagnoses, which included, in part, Chronic Systolic Heart Failure, Cardiomyopathy, Angina Pectoris, and Weakness. Further review revealed he was a resident of a local NH facility. Review of Patient #2s POC, for the Certification Period of 12/09/2024 through 01/24/2025, revealed in part, he was ordered to receive one SNV twice weekly and as needed. Review of Patient #2s Triage Coordination Notes, dated 01/20/2025 through 01/21/2025, revealed, in part, the following: 01/20/2025 at 11:54 p.m. - NH stated Patient #2 had an unwitnessed fall due to increased agitation. 01/21/2025 at 1:00 a.m. - S5RN was assigned. 01/21/2025 at 4:54 a.m. - NH stated Patient #2 had another unwitnessed fall due to increased agitation uncontrolled by current medication regimen. NH stated Patient #2 had increased confusion and kept trying to get out of bed.01/21/2025 at 5:04 a.m. - S5RN was assigned. Review of Patient #2s PRN SNV Notes, dated 01/20/2025 through 01/21/2025, revealed, in part, the following:01/20/2025 - No PRN SNV Notes documented by S5RN.01/21/2025 - No PRN SNV Notes documented by S5RN. Review of Patient #2s Nurse Coordination Notes, dated 01/20/2025 through 01/21/2025, revealed, in part, the following:01/20/2025 - No Nurse Coordination Notes documented by S5RN. 01/21/2025 - No Nurse Coordination Notes documented by S5RN. An interview was conducted on 02/10/2025 at 1:00 p.m. with the DON for Patient #2s NH. She confirmed she was familiar with Patient #2 and his falls on 01/20/2025 and 01/21/2025. She reviewed Patient #2s incident reports and nurse notes for 01/20/2025 through 01/21/2025. She confirmed the NH contacted the Hospice agency just before midnight on 01/20/2025 to request a PRN SNV due to uncontrolled agitation. The DON stated no one came or called back with any instructions or new orders for Patient #2. She confirmed just before 5:00 a.m. on 01/21/2025, Patient #2 had another fall when his agitation remained uncontrolled and the NH contacted the hospice agency again to request a SNV. The DON stated no one came or called back with any instructions or new orders for Patient #2. She confirmed a Hospice nurse should have assessed Patient #2 then spoken with his physician to obtain orders for medications to decrease his agitation and keep him comfortable. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed S5RN did not perform a PRN SNV on 01/20/2025 and 01/21/2025 and she did not obtain new orders to manage his agitation. S1ED stated when the triage nurse was notified Patient #2 fell the first time due to late stage agitation, she would have expected S5RN to report to the facility immediately to assess Patient #2 and obtain orders to treat his agitation and she did not. S1ED confirmed there was no documentation in Patient #2s Clinical Record to indicate S5RN responded to or conducted a PRN SNV following the triage calls regarding falls and increased agitation for Patient #2 and there should be. S1ED confirmed Patient #2 sustained a second fall a few hours later, which could have been prevented if S5RN had reported to the facility to assess the patient as she should have. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed he was the Medical Director for the Hospice agency and they did not utilize standing orders. S3MD confirmed nurses were expected to contact the patients physician to obtain all orders, especially when dealing with a controlled substance; including changing frequency, discontinuation of a medication, etc. S3MD confirmed a nurse giving orders without a physician put patients at serious risk of uncontrolled symptoms and many other potential issues. S3MD confirmed he would expect all Hospice staff to take uncontrolled pain and other symptoms seriously and to contact the patients physician immediately to address them. S3MD confirmed it was unacceptable for a Hospice patients symptoms to remain untreated for any reason and to do so would constitute patient neglect. 2. Failed to ensure an effective system was in place to ensure communication and intervention when agency staff were notified S5RN missed PRN SNVs. Patient #1 Review of Patient #1s Triage Coordination Notes, dated 12/13/2024 through 12/15/2024, revealed, in part, the following: 12/15/2024 8:16 a.m. – NH called to report S5RN was supposed to perform a PRN SNV for Patient #1 on 12/14/2024 and never showed up. Advised caller care team would be notified to follow up.Further review revealed no documented evidence of this information being reported to anyone within the Hospice agency. Review of documentation from the agency to indicate the aforementioned concern had been reported, investigated, and/or handled was attempted throughout the course of the survey with no documented evidence produced for review. An interview was conducted on 02/05/2025 at 9:44 a.m. with Patient #1s day shift nurse at the NH on 12/14/2024 and 12/15/2024. She confirmed she contacted the Hospice agencys on-call number on 12/15/2024 to inform them S5RN failed to report to the NH on 12/14/2024 to assess Patient #1. She confirmed the triage nurse informed her she would make administration aware of the issue but no one from the Hospice agency reached out to ask her any questions. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed she was unaware S5RN failed to perform her required visits for Patient #1 on the weekend of 12/13/2024 through 12/15/2024. S2DON confirmed the agencys triage nurse should have contacted her or S2DON immediately when they were told S5RN failed to report for Patient #1s PRN SNV on 12/14/2024. S2DON confirmed the agency did not currently have a system in place to ensure the triage nurses reported this type of information or a system to ensure the information was being investigated/handled once administration was made aware. S2DON confirmed the agency did not currently have a system in place to double check and verify staff were performing their visits. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed she was unaware S5RN failed to perform her required visits for Patient #1 on the weekend of 12/13/2024 through 12/15/2024 and she should have been. S1ED confirmed the agencys triage nurse should have contacted someone with administration immediately when they were told S5RN did not show up for Patient #1s PRN SNV on 12/14/2024. S1ED confirmed the agency did not currently have a system in place to ensure the triage nurses reported this type of information or a system to ensure the information was being investigated/handled once administration was made aware. S1ED confirmed the agency did not currently have a system in place to double check and verify staff were performing their visits. Patient #3 Review of Patient #3s Triage Coordination Visit Notes, dated 12/15/2024 through 12/17/2024, revealed, in part, the following: 12/15/2024 at 11:40 p.m. – ALF stated Patient #3 fell and was now having dizziness. Blood Pressure was 182/88. Hospice Case Manager to follow up tomorrow.12/16/2024 at 3:23 a.m. – ALF stated Patient #3 had a fall earlier, dizziness now increased, pain reported and patient no longer able to stand on her own. ALF stated Patient #3 was normally independent. Second call for the night. Per protocol, PRN SNV to be performed. 12/16/2024 at 3:36 a.m. – S5RN was assigned. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed when she arrived to Patient #3s ALF on 12/16/2024 around lunch time, she was informed she was the first person from Hospice to assess Patient #3 since her fall on 12/15/2024 because S5RN had not shown up. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed Patient #3s ALF made her and S1ED aware on 12/17/2024 of the incident involving Patient #3 on 12/15/2024. S2DON confirmed after being made aware, she and S1ED educated S5RN on the importance of performing visits as required and confirmed there was no documented evidence of the education provided. S2DON confirmed S5RN was not written up nor did she receive any disciplinary action for not performing visits as required. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed Patient #3s ALF made her and S2DON aware on 12/17/2024 of the incident involving Patient #3 on 12/15/2024. S1ED confirmed she and S2DON provided information education to S5RN on the importance of performing visits as required and confirmed there was no documented evidence of the education provided. S1ED confirmed S5RN was not written up nor did she receive any disciplinary action for not performing visits as required. Review of the Hospice agencys Complaint Intake Report regarding Patient #3, created 12/17/2024 at 3:24 p.m., revealed, in part, the following: Created by: S1EDDescription: While in a meeting with S2DON and the nurse at Patient #3s ALF, the Hospice agency was informed Patient #3 experienced a change of status on 12/15/2024 followed by a fall on the morning of 12/16/2024. ALF staff reported this information to the triage nurse who then assigned S5RN. ALF staff asked S5RN about Patient #3s pain medication due to complaints of pain following her fall because they were unable to locate it. ALF staff stated S5RN responded I dont know what you want me to do about it. S5RN did not perform a PRN SNV to assess Patient #3 or address the concerns the ALF voiced with being unable to locate her pain medication for administration. The concerns regarding Patient #3 were addressed when her regular Hospice nurse came on shift later in the day. Interventions: Educated S5RN on customer service. Patient #5 Review of Patient #5s Triage Coordination Note, dated 01/12/2024, revealed, in part, the following: 01/12/2025 at 3:28 p.m. – NH stated Patient #5 started new Fentanyl patch dose on 01/09/2025 with increased confusion since that time. NH stated a new Fentanyl patch was due tonight. NH requested PRN SNV to address family concerns and discuss dose changes to pain medication regimen. 01/12/2025 at 3:48 p.m. – S5RN was assigned. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed she was Patient #5s regular nurse on 01/12/2025 and 01/13/2025. S8RN confirmed S5RN was the nurse on-call on 01/12/2025 when the NH called about Patient #5s pain medication. S8RN confirmed when she went to see Patient #5 on 01/13/2025, the NH told her S5RN did not come to the NH on 01/12/2025 but had given them a telephone order to discontinue Patient #5s Fentanyl patch. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed the information received from Patient #5s NH and S8RN indicated S5RN had not performed an in-person visit and she should have. S2DON confirmed S8RN did not make her aware S5RN did not perform a visit for Patient #5 on 01/12/2025 and should have. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed the information received from Patient #5s NH and S8RN indicated S5RN had not performed an in-person and she should have. S1ED confirmed S8RN did not make her aware S5RN did not perform a visit for Patient #5 on 01/12/2025 and should have. Patient #2 Review of Patient #2s Triage Coordination Notes, dated 01/20/2025 through 01/21/2025, revealed, in part, the following: 01/20/2025 at 11:54 p.m. - NH stated Patient #2 had an unwitnessed fall due to increased agitation. 01/21/2025 at 1:00 a.m. - S5RN was assigned. 01/21/2025 at 4:54 a.m. - NH stated Patient #2 had another unwitnessed fall due to increased agitation uncontrolled by current medication regimen. NH stated Patient #2 had increased confusion and kept trying to get out of bed.01/21/2025 at 5:04 a.m. - S5RN was assigned. An interview was conducted on 02/10/2025 at 1:00 p.m. with the DON for Patient #2s NH. She confirmed just before 5:00 a.m. on 01/21/2025, Patient #2 had another fall when his agitation remained uncontrolled and the NH contacted the hospice agency again to request a PRN SNV. The DON stated no one came or called back with any new orders for Patient #2. She confirmed a few days after Patient #2s falls, she made S1ED and S2DON aware of the NHs dissatisfaction with the way S5RN handled Patient #2s uncontrolled symptoms. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed a few days after Patient #2s fall, the NH DON made her aware S5RN did not perform a PRN SNV on 01/20/2025 and 01/21/2025 and she did not obtain new orders to manage his agitation. S2DON confirmed after being made aware, she and S1ED spoke with S5RN and provided informal education on the importance of performing visits as required and confirmed there was no documented evidence of the conversation or education provided. S2DON confirmed S5RN was not written up nor did she receive any disciplinary action for not performing visits as required. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed a few days after Patient #2s fall, the NH DON made her aware S5RN did not perform a PRN SNV on 01/20/2025 and 01/21/2025 and she did not obtain new orders to manage his agitation. S1ED confirmed after being made aware, she and S2DON spoke with S5RN and provided informal education on the importance of performing visits as required and confirmed there was no documented evidence of the conversation or education provided. S1ED confirmed S5RN was not written up nor did she receive any disciplinary action for not performing visits as required. Onsite verification was conducted through review of plan of removal and observations, interviews and record reviews to ensure the Hospice agency had implemented an acceptable Plan of Removal. After conducting plan of removal review, observations, interviews and record reviews to verify the POR was carried out, the plan was accepted and Immediacy removed on 02/07/2025 at 11:00 a.m. The deficient practice remained at Condition level. 02/06/2025 - 100% of Hospice staff present for Daily Standup call. Discussed all after hours triage calls, new admits, need of any follow-up visits, discussion of state surveyor findings.Executive Director and Director of Corporate Operations confirmed 100% of staff were present with verification by responding “I understand the education” in the chat in Teams application. Training acknowledgement of meeting held on 02/06/2025, along with the follow up training for discipline specific education, will be placed in Human Resources file. Executive Director instructed 100% of staff that mandatory meetings will be held by 02/14/2025 with an additional mandatory staff meeting held on 02/20/2025 to review with staff the complete state survey findings and plan of correction. In depth in-person follow up training will require 100% completion prior to being released to see patients. 02/06/2025 - 100% of Hospice staff received education and training related to failure of staff to perform prn visit. Immediately all prn visits must be completed on any patient with reported pain and any reports of patient falls. Executive Director or trained designee will verify completion of prn visits pertaining to pain or falls by a phone call to the patient/caregiver or nursing facility by 10:00 a.m. on the following day after the prn visit. Executive Director or trained designee will also audit 2 completed visits per day verifying completion and signature of patient or caregiver. Utilizing the agent visit summary report, capturing completed visits from prior day. A minimum of 2 completed visits per day will be audited verifying signature obtained on completion of visits by patient or caregiver. Selection will be rotated by clinician and physician team. This will be monitored for 3 consecutive months and until 100% compliant. 02/06/2025 - 100% of Hospice staff received education regarding Policy 3.031-Patient Fall Reduction Program. All staff educated on procedure on reporting patient falls. Education included the following expectations: The Fall Risk assessment will be completed by all nursing staff on admission, recertification, post fall and any change in condition or location as per Policy 3.031. Post Fall visits with suspected injury will be scheduled to receive a Skilled nurse visit within 24 hours post fall or reported fall. All other disciplines will report any falls to nurse case manager and complete a clinical coordination note in Home Care Home Base EHR system. Nurse Case Manager will enter fall occurrence in the Home Care Home Base EHR system. Executive Director or trained designee will enter fall occurrence into the Risk Management system within 72 hours. Executive Director or trained designee will provide additional in person education and policy review with signed copy of policy by 02/14/2025. Manager on-call will be notified of any after-hours falls via Care XM messaging system. Executive Director or trained designee will verify completion of prn visits pertaining to pain or falls by a phone call to the patient/caregiver or nursing facility within 2 hours of the prn visit and documented into patient ‘s medical record. Executive Director or trained designee will monitor compliance for 3 consecutive months and or 100% compliance to completed visits. 02/06/2025 - 100% of Hospice staff received education regarding Pain assessment policy 3.005. and Physician orders Policy 3.009. Education included the following expectations: When hospice agency is notified, a patient has pain above pain goal, an in-person visit is initiated by a nurse to assess for pain. A phone call will be made by nurse within 2 hours of completion of in-person visit to ensure interventions were effective. If interventions are not effective, a nurse will make an in-person return visit and continue the 2-hour monitoring plan until pain is controlled. Executive Director instructed 100% of staff that all patients with pain score above pain goal will receive an additional in-person follow-up visit within 24 hours of pain assessment. Executive Director instructed 100% of staff on Policy 3.009 Physician Orders. Executive Director instructed staff to obtain verbal orders as needed per patient. Any orders obtained will be entered into Home Care Home Base EHR system within 24 hours. All instruction given by nurse without physician verbal orders will be in violation of their scope of practice. All staff have a direct line to contact any of the hospice physicians. All patients reporting pain will be discussed on daily stand-up call and visits scheduled as needed. Executive Director or trained designee will verify completion of prn visits pertaining to pain by a phone call to the patient/caregiver or nursing facility within 2 hours of the prn visit and documented into patients medical record. Executive Director or trained designee will monitor for 3 consecutive months and until 100% compliant. 100% of all staff will be scheduled the ITrain course Pain Management at End of Life by 02/07/2025 with completion of course by 02/14/2025. Executive Director will review completion for all staff. If not completed by 02/14/2025, staff will not be allowed to see patients.Executive Director or trained designee will provide additional in-person education and policy review with signed copy of policy by 02/14/2025. 02/06/2025 - 100% of Hospice staff received education and instruction regarding procedure for missed visits, along with Hospice Standards of Behavior. Education included the following expectations: Executive Director instructed 100% of staff that before missing any visit a manager would need to be notified with the reason for a missed visit. Executive Director or trained designee will review missed visit report daily. If any visit missed was documented, Executive Director or trained designee will call staff to verify reason of missed visit and reeducate on missed visit procedure as needed. Executive Director or trained designee will also call patient /caregiver or nursing facility to verify staff reason is accurate. Executive Director or trained designee will monitor compliance for at least 3 consecutive months and until 100% compliance is achieved. 02/06/2025 - 100% of Hospice staff received education and instruction regarding procedure for RN aide supervisory visit and Policy 8.007 Hospice Aide Supervision. Education included the following expectations: RN Aide Supervisory visits must be completed, and documented in the electronic medical record, at least every 14 days. Executive Director instructed 100% of RN staff that mandatory meeting will be held by 02/14/2025 and copy of policy will be given and signed with copy filed in Administration binder with plan of correction. Executive Director or trained designee will perform at least one ride-along visit weekly, with RN to patient receiving aide services, to assure aide supervisory questions are asked and patient or caregiver is satisfied with the hospice aide services. Ride-along visits will be scheduled and completed with all RN staff by 02/28/2025, and continued until 100% compliance met for each RN. Current RN staff includes 11 full-time and 2 PRN with a patient census of 127. If PRN staff does not have a scheduled workday prior to 02/28/2025, PRN staff will have a ride along at next scheduled workday. 02/06/2025 - 100% of Hospice staff received education and instruction regarding procedure for afterhours calls regarding visits not made and addressing patient needs. Education included the following expectations: Expectation that any after-hours phone call received for uncontrolled symptoms and/or patient fall, will require an in-person visit from a Nurse. Executive Director or designee will monitor on call report daily via Morning Stand-Up call, including use of the Morning Stand-Up Call documentation tool. 02/06/2025 - 100% of Triage team was educated on process of notifying manager on-call of reported visits not made via Care XM messaging system. Education was provided by Care XM supervisor on 02/06/2025. Monitoring will be ongoing per Care XM triage report daily. All future education provided will include review of Hospice specific policies and procedures and will include a sign in sheet to document attendance and understanding of information provided. For staff who attend or receive education virtually, the staff member name and date of attendance will be documented on the sign in sheet by the Executive Director or designee. The QAPI Coordinator, Executive Director and or trained designee will review data collected monthly for compliance to plan of correction. Updates to plan of correction will be done monthly as compliance percentages are assessed. S5RN was terminated effective immediately on 02/05/2025 and was reported to the Louisiana State Board of Nursing. The RN SNV, dated 12/14/2024, for Patient #1 was marked unbillable as of 02/05/2025.”

“Based on interviews and record reviews, the Hospice agency failed to follow an individualized POC established by the Hospice IDG in collaboration with the Attending Physician in accordance with the patients needs and preferences for 1 (#1) of 6 (#1, #2, #3, #4, #5, and #6) patients in the final sample. The Hospice agency failed to ensure HA Visits were conducted in accordance with Patient #1s preference for her visit time. Review of Patient #1s Clinical Record revealed she was admitted to the Hospice agency on 09/05/2024 and was a resident of a local NH facility. Review of Patient #1s POC, for the Certification Periods of 09/05/2024 through 12/03/2024 and 12/04/2024 through 12/19/2024, revealed she was to receive HA Visits three times weekly. Review of Patient #1s Visit Calendar and Client Coordination Notes, dated 11/01/2024 through 12/19/2024, revealed, in part, the following: 11/01/2024 – HA Missed Visit - Caregiver/Patient Refused. 11/20/2024 – HA Missed Visit - Caregiver/Patient Refused. 11/22/2024 – HA Missed Visit - Caregiver/Patient Refused. 11/25/2024 – HA Missed Visit - Caregiver/Patient Refused. 11/27/2024 – HA Missed Visit - Caregiver/Patient Refused.12/03/2024 – HA Missed Visit - Caregiver/Patient Refused.12/11/2024 – HA Missed Visit - Caregiver/Patient Refused. 12/16/2024 – HA Missed Visit - Caregiver/Patient Refused. 12/18/2024 – HA Missed Visit - Caregiver/Patient Refused. An interview was conducted on 02/04/2025 at 1:12 p.m. with Patient #1s daughter who confirmed she was her roommate at the NH. She confirmed she, nor her mother refused care from any of the Hospice employees. She stated the HA was supposed to see Patient #1 in the mornings three times a week but they were lucky if she completed one visit a week. She stated she was not aware she should have filed a complaint with the Hospice agency about Patient #1 not receiving her services because she believed the agency must already be aware S6HA was not coming to do her job. An interview was conducted on 02/06/2025 at 11:30 a.m. with S6HA. S6HA confirmed she was Patient #1s regular HA. S6HA confirmed Patient #1 lived with her daughter in a local NH. S6HA confirmed neither Patient #1 nor her daughter ever refused a HA Visit. S6HA stated the issue with Patient #1 not receiving her visits as ordered was because her daily patient assignment was very spread out. S6HA stated she could not always make it to Patient #1s NH in time to provide care when Patient #1 wanted to have it performed, so Patient #1s daughter would ask the NH aide to do it before she arrived. S6HA confirmed she made S7RN aware every time she missed a visit and why. S6HA confirmed she made S1ED and S2DON aware she not always able to perform Patient #1s visits as scheduled due to her current patient assignment and nothing changed. An interview was conducted on 02/06/2025 at 11:55 a.m. with S7RN. S7RN confirmed she was Patient #1s regular nurse. S7RN confirmed Patient #1 lived with her daughter in a local NH. S7RN confirmed she did not recall Patient #1 or her daughter ever refusing visits from her or S6HA. S7RN confirmed S6HA informed her any time she missed a visit with Patient #1. S7RN stated when S6HA missed a visit for Patient #1 it was because she was unable to make the visit in the morning per Patient #1 and her daughters preference. S7RN confirmed S6HA made her aware she was not always able to make it to Patient #1 in the mornings due to her other patient assignment locations. S7RN confirmed she had discussed Patient #1s missed visits and why they occurred during IDG in the past. S7RN stated to her knowledge, HA schedules and assignments were not altered to accommodate Patient #1s timing preference for her care in order to prevent further missed HA Visits. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed she would expect HA Visits to be performed as ordered, and at a time that best met the needs of the patient. S2DON confirmed S6HA missing Patient #1s visits due to her patient assignment was not acceptable and should not have happened. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed she would expect HA Visits to be performed as ordered, and at a time that best met the needs of the patient. S1ED confirmed S6HA missing Patient #1s visits due to her patient assignment was not acceptable and should not have happened. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed he was the Medical Director for the Hospice agency. S3MD confirmed visit frequencies were carefully determined based on the needs of each individual patient and he would expect visits to be performed as ordered.”

“Based on interviews and record reviews, the Hospice agencys QAPI Program failed to correct identified quality deficiencies to ensure positive palliative outcomes, patient safety and quality of care for 4 (#1, #2, #3, and #5) of 6 (#1, #2, #3, #4, #5, and #6) patients reviewed in the sample. The deficient practice had the potential to affect any of the Hospice agencys 126 current patients and any future admissions. Patient #1 Review of Patient #1s Clinical Record revealed she was admitted to the Hospice agency on 09/05/2024 and was a resident of a local NH facility. Review of Patient #1s Triage Coordination Notes, dated 12/13/2024 through 12/15/2024, revealed, in part, the following: 12/15/2024 8:16 a.m. – NH called to report S5RN was supposed to perform a PRN SNV for Patient #1 on 12/14/2024 and never showed up. Advised caller care team would be notified to follow-up. Review attempted of documentation from the agency to indicate the aforementioned concern/incident had been reported, investigated, monitored, and/or handled via PIP for QAPI throughout the course of the survey with no documented evidence produced for review. An interview was conducted on 02/03/2025 at 3:20 p.m. with the DON at Patient #1s NH. She confirmed during a phone call the first week of January 2025 with S1ED, she made S1ED aware the NH was dissatisfied with the Hospice agencys services for Patient #1 on the weekend of her fall. She stated a few days later, S1ED came to the NH and she again made S1ED aware of their dissatisfaction with the way S5RN handled the entire situation in the days following Patient #1s injury. An interview was conducted on 02/05/2025 at 9:44 a.m. with Patient #1s day shift nurse at the NH on 12/14/2024 and 12/15/2024. She confirmed she contacted the Hospice agencys on-call number on 12/15/2024 to inform them S5RN failed to report to the NH on 12/14/2024 to assess Patient #1. She confirmed the Triage Nurse informed her she would make Administration aware of the issue with S5RN but no one from the Hospice agency reached out to ask her any questions. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed the Triage Nurse did not inform her S5RN failed to perform her required visits for Patient #1 on the weekend of 12/13/2024 through 12/15/2024 and should have. S2DON confirmed the agency did not currently have a system in place to ensure the Triage Nurses reported this type of information or a system to ensure the information was being investigated/handled once administration was made aware. S2DON confirmed the agency did not currently have a system in place to double check and verify staff were performing their visits. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed the Triage Nurse did not inform her S5RN failed to perform her required visits for Patient #1 on the weekend of 12/13/2024 through 12/15/2024 and she should have. S1ED confirmed the agencys Triage Nurse should have contacted someone with administration immediately when they were told S5RN did not show up for Patient #1s PRN SNV on 12/14/2024. S1ED confirmed the agency did not currently have a system in place to ensure the triage nurses reported this type of information or a system to ensure the information was being investigated/handled once administration was made aware. S1ED confirmed the agency did not currently have a system in place to double check and verify staff were performing their visits. S1ED confirmed at the beginning of January 2025, she was made the NH was very upset with the Hospice agencys services for Patient #1 on 12/13/2024 through 12/15/2024. S1ED stated the NHs DON did not make her aware why they were unhappy with the way S5RN handled the situation. S1ED confirmed she did not open a PIP for QAPI nor investigate and monitor the situation or S5RN any further. S1ED confirmed Patient #1 expired on 12/19/2024. Patient #3 Review of Patient #3s Clinical Record revealed she was admitted to the Hospice agency on 04/18/2024 with diagnoses, which included, in part, Cerebrovascular Disease and History of Cerebral Infarction. Further review revealed she was a resident of a local ALF. Review of Patient #3s Triage Coordination Visit Notes, dated 12/15/2024 through 12/17/2024, revealed, in part, the following: 12/15/2024 at 11:40 p.m. – ALF stated Patient #3 fell and was now having dizziness. Blood Pressure was 182/88. Hospice Case Manager to follow up tomorrow.12/16/2024 at 3:23 a.m. – ALF stated Patient #3 had a fall earlier, dizziness now increased, pain reported and patient no longer able to stand on her own. ALF stated Patient #3 was normally independent. Second call for the night. Per protocol, PRN SNV to be performed. 12/16/2024 at 3:36 a.m. – S5RN was assigned. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed when she arrived to Patient #3s ALF on 12/16/2024 around lunch time, she was informed she was the first person from Hospice to assess Patient #3 since her fall on 12/15/2024 because S5RN had not shown up. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed Patient #3s ALF contacted the Hospice agency to file a complaint on 12/17/2024, at which point she made her and S1ED aware of the above incident involving S5RN and Patient #3 on 12/15/2024. S2DON confirmed after being made aware, she and S1ED provided informal education to S5RN on the importance of performing visits as required and confirmed there was no documented evidence of the education provided. S2DON confirmed S5RN was not written up nor did she receive any disciplinary action with monitoring for not performing visits as required. Review of the Hospice agencys Complaint Intake Report (CIR) regarding Patient #3, created 12/17/2024 at 3:24 p.m., revealed, in part, the following: Created by: S1EDDescription: While in a meeting with S2DON and the nurse at Patient #3s ALF, the Hospice agency was informed Patient #3 experienced a change of status on 12/15/2024 followed by a fall on the morning of 12/16/2024. ALF staff reported this information to the triage nurse who then assigned S5RN. ALF staff asked S5RN about Patient #3s pain medication due to complaints of pain following her fall because they were unable to locate it. ALF staff stated S5RN responded I dont know what you want me to do about it. S5RN did not perform a PRN SNV to assess Patient #3 or address the concerns the ALF voiced with being unable to locate her pain medication for administration. The concerns regarding Patient #3 were addressed when her regular Hospice nurse came on shift later in the day. Interventions: Educated S5RN on customer service. Review was attempted of documentation from the agency to indicate the aforementioned complaint had been investigated, monitored and/or handled via PIP for QAPI throughout the course of the survey with no documented evidence produced for review. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed Patient #3s ALF made her and S2DON aware on 12/17/2024 of the incident involving Patient #3 on 12/15/2024. S1ED confirmed after she became aware, she created the above CIR. S1ED confirmed she and S2DON provided informal education to S5RN on the importance of performing visits as required and confirmed there was no additional documented evidence of the education provided aside from what was documented on the above CIR. S1ED confirmed S5RN was not written up nor did she receive any disciplinary action with monitoring for not performing visits as required. S1ED confirmed she did not open a PIP for QAPI nor investigate and monitor any further than documented in the aforementioned CIR. Patient #5 Review of Patient #5s Clinical Record revealed he was admitted to the agency on 12/16/2024 and was a resident at a local NH facility. Review of Patient #5s Triage Coordination Note, dated 01/12/2024, revealed, in part, the following: 01/12/2025 at 3:28 p.m. – NH stated Patient #5 started new Fentanyl patch dose on 01/09/2025 with increased confusion since that time. NH stated a new Fentanyl patch was due tonight. NH requested PRN SNV to address family concerns and discuss dose changes to pain medication regimen. 01/12/2025 at 3:48 p.m. – S5RN was assigned. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed she was Patient #5s regular nurse on 01/12/2025 and 01/13/2025. S8RN confirmed S5RN was the nurse on-call on 01/12/2025 when the NH called about Patient #5s pain medication. S8RN confirmed when she went to see Patient #5 on 01/13/2025, the NH told her S5RN did not come to the NH on 01/12/2025 but had given them a telephone order to discontinue Patient #5s Fentanyl patch. Review was attempted of documentation from the agency to indicate the aforementioned concern had been reported, investigated, monitored, and/or handled via PIP for QAPI throughout the course of the survey with no documented evidence produced for review. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed the information received from Patient #5s NH and S8RN indicated S5RN had not performed an in-person PRN SNV and she should have. S2DON confirmed S8RN did not make her aware S5RN did not perform a PRN SNV for Patient #5 on 01/12/2025 and should have. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed the information received from Patient #5s NH and S8RN indicated S5RN had not performed an in-person PRN SNV and she should have. S1ED confirmed S8RN did not make her aware S5RN did not perform a PRN SNV for Patient #5 on 01/12/2025 and should have. Patient #2 Review of Patient #2s Clinical Record revealed he was admitted to the Hospice agency on 11/15/2022 and was a resident of a local NH facility. Review of Patient #1s Triage Coordination Notes, dated 01/20/2025 through 01/21/2025, revealed, in part, the following: 01/20/2025 at 11:54 p.m. - NH stated Patient #2 had an unwitnessed fall due to increased agitation. 01/21/2025 at 1:00 a.m. - S5RN was assigned. 01/21/2025 at 4:54 a.m. - NH stated Patient #2 had another unwitnessed fall due to increased agitation uncontrolled by current medication regimen. NH stated Patient #2 had increased confusion and kept trying to get out of bed.01/21/2025 at 5:04 a.m. - S5RN was assigned. An interview was conducted on 02/10/2025 at 1:00 p.m. with the DON for Patient #2s NH. She confirmed just before 5:00 a.m. on 01/21/2025, Patient #2 had another fall when his agitation remained uncontrolled and the NH contacted the hospice agency again to request a PRN SNV. The DON stated no one came or called back with any new orders for Patient #2. She confirmed a few days after Patient #2s falls, she made S1ED and S2DON aware of the NHs dissatisfaction with the way S5RN handled Patient #2s uncontrolled symptoms. Review was attempted of documentation from the agency to indicate the aforementioned concern had been investigated, monitored, and/or handled via PIP for QAPI throughout the course of the survey with no documented evidence produced for review. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed a few days after Patient #2s fall, the NH DON made her aware S5RN did not perform a PRN SNV on 01/20/2025 and 01/21/2025 and she did not obtain new orders to manage his agitation. S2DON confirmed after being made aware, she and S1ED spoke with S5RN and provided informal education on the importance of performing visits as required and confirmed there was no documented evidence of the conversation or education provided. S2DON confirmed S5RN was not written up nor did she receive any disciplinary action with monitoring for not performing visits as required. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED stated she reviewed the Triage Call Reports every morning from all calls received the previous day. S1ED confirmed she did not review reports or hold daily stand-up meetings during weekends, holidays, and/or office closures but would review and discuss them on the following business day. S1ED stated when she reviewed the Triage Call Reports for 01/20/2025 through 01/23/2025, she noted Patient #2 had a fall on 01/20/2025 and another on 01/21/2025. S1ED stated she reviewed Patient #2s chart to see how the situation was handled and realized no PRN SNVs had been documented by S5RN nor was there any documentation of S5RNs actions following the on-call assignments. S1ED stated she called S5RN who confirmed she did not make visits but handled the situation by phone. S1ED confirmed the NHs DON also made her aware S5RN had not performed any PRN SNVs following Patient #2s falls on 01/20/2025 and 01/21/2025 nor did she obtain new orders to manage his agitation. S1ED confirmed after speaking with the NHs DON, S5RN received a phone call for informal education making her aware of the importance of performing visits as required, the importance of contacting the physician to obtain orders when symptoms were uncontrolled and the importance of documenting her actions in response to an on-call assignment. S1ED confirmed there was no documented evidence of the conversation or education provided to S5RN. S1ED confirmed S5RN was not written up nor did she receive any disciplinary action with monitoring for not performing visits as required. S1ED stated she did not go further with the incident because she did not recall the previous incidents and thought this was the first time any potential issues involving S5RN had come up. S1ED confirmed following notification of S5RNs lack of response to Patient #2 on 01/20/2025 and 01/21/2025, she did not file a CIR, open a QAPI or investigate the situation or S5RN any further. S1ED confirmed the Hospice agency failed to perform further investigation and monitoring or open a PIP for QAPI following any of the aforementioned incidents involving S5RN and Patient #1, #2, #3 and #5. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed he was the Medical Director for the Hospice agency. S3MD confirmed if S1ED, S2DON and/or anyone employed by the Hospice agency became aware a nurse was not performing PRN SNVs as required, he would expect them to investigate the situation further and correct the issue in order to ensure it did not recur moving forward.”

“Based on interviews and record reviews, the Hospice agency failed to ensure the RN conducted an on-site HA Supervisory Visit at least every 14 days to assess the quality of care and services provided by the hospice aide for 1 (#1) of 6 (#1, #2, #3, #4, #5, and #6) patients in the sample. The Hospice agency failed to ensure the RN was assessing the frequency of services provided by the HA. Review of Patient #1s Clinical Record revealed she was admitted to the Hospice agency on 09/05/2024 and was a resident of a local NH facility. Review of Patient #1s POC, for the Certification Periods of 09/05/2024 through 12/03/2024 and 12/04/2024 through 12/19/2024, revealed she was to receive HA Visits three times weekly. Review of Patient #1s Visit Calendar and Client Coordination Notes, dated 11/01/2024 through 12/19/2024, revealed, in part, the following: 11/01/2024 – HA Missed Visit - Caregiver/Patient Refused. 11/20/2024 – HA Missed Visit - Caregiver/Patient Refused. 11/22/2024 – HA Missed Visit - Caregiver/Patient Refused. 11/25/2024 – HA Missed Visit - Caregiver/Patient Refused. 11/27/2024 – HA Missed Visit - Caregiver/Patient Refused.12/03/2024 – HA Missed Visit - Caregiver/Patient Refused.12/11/2024 – HA Missed Visit - Caregiver/Patient Refused. 12/16/2024 – HA Missed Visit - Caregiver/Patient Refused. 12/18/2024 – HA Missed Visit - Caregiver/Patient Refused. An interview was conducted on 02/04/2025 at 1:12 p.m. with Patient #1s daughter who confirmed she was her roommate at the NH. She confirmed she, nor her mother refused care from any of the Hospice employees. She stated the HA was supposed to see Patient #1 in the mornings three times a week but they were lucky if she completed one visit a week. She confirmed S7RN never asked if S6HA was reporting for her visits when she was supposed to or if Patient #1 was receiving the services she was supposed to receive. She stated she assumed the Hospice agency was aware S6HA wasnt showing up as scheduled. She stated if S7RN had asked, she would have told her S6HA was frequently missing visits. An interview was conducted on 02/06/2025 at 11:55 a.m. with S7RN. S7RN confirmed she was Patient #1s regular Hospice nurse. S7RN confirmed during Patient #1s HA Supervisory Visits, she had not asked Patient #1 or her daughter if S6HA was reporting for visits to perform the services Patient #1 should receive. S7RN stated she always assumed if there was a problem, the patient or their family would let her know. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed during the HA Supervisory Visit, she would expect the RN to thoroughly assess the quality of care and services provided by the HA by asking the patient or family member if the HA was reporting for visits to perform the services the patient should receive. S2DON confirmed when S7RN did not perform thorough assessments, they could not ensure the services ordered by the hospice IDG were meeting all of the patients needs. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed during the HA Supervisory Visit, she would expect the RN to thoroughly assess the quality of care and services provided by the HA by asking the patient or family member if the HA was reporting for visits to perform the services the patient should receive. S1ED confirmed when S7RN did not perform thorough assessments, they could not ensure the services ordered by the hospice IDG were meeting all of the patients needs.”

“Based on interviews and record reviews, the Hospice agencys Governing Body and Administrator failed to ensure the quality provision of all Hospice services by managing and addressing Hospice operations, services and a continuous QAPI Program. The Hospice agency failed to have an effective system in place to: 1. Prevent patient neglect through services provided in a manner consistent with accepted standards of practice in management of suspected injury, pain, and/or altered mental status for, 5 (#1, #2, #3, #5, and #6) of 6 (#1, #2, #3, #4, #5, and #6) patients in the sample;2. Ensure documentation in each patients clinical record was performed in a manner consistent with accepted standards of practice for 5 (#1, #2, #3, #5, and #6) of 6 (#1, #2, #3, #4, #5, and #6) patients in the sample; 3. Ensure drugs were ordered by a physician or nurse practitioner for 3 (#1, #3 and #5) of 6 (#1, #2, #3, #4, #5, and #6) patients in the sample; and4. Manage a continuous QAPI Program to correct identified quality deficiencies for 4 (#1, #2, #3, and #5) of 6 (#1, #2, #3, #4, #5, and #6) patients reviewed in the sample. The deficient practice had the potential to cause harm to all of the 126 current patients and any future admissions to the agency. Cross reference: L500, L517, L543, L568, L629, L648, L670, L672, L686, and L690. 1. Failed to prevent patient neglect through services provided in a manner consistent with accepted standards of practice in management of suspected injury, pain, and/or altered mental status. Patient #1 Review of Patient #1s Clinical Record revealed she was admitted to the Hospice agency on 09/05/2024 and was a resident of a local NH facility. Further review revealed she was a patient of S3MD. Review of Patient #1s Triage Coordination Notes, dated 12/13/2024 through 12/15/2024, revealed, in part, the following: 12/13/2024 at 11:16 p.m. - NH stated Patient #1 had an unwitnessed fall with complaints of left leg pain and visible displacement noted, with raised, hard area to outside of left knee. Requested orders for further pain control. PRN SNV requested. 12/13/2024 at 11:22 p.m. - S5RN was assigned to the requested PRN SNV.12/14/2024 at 10:24 a.m. - NH stated Patient #1s in-house XR indicated broken femur. Patient #1s pain remains uncontrolled. Patient #1 only ordered Tylenol for pain. PRN SNV requested. 12/14/2024 at 10:31 a.m. - S5RN was assigned to the requested PRN SNV.12/15/2024 8:16 a.m. – NH called to report S5RN was supposed to perform a PRN SNV for Patient #1 on 12/14/2024 and never showed up. Patient #1 went to ED overnight for uncontrolled pain. NH requested PRN SNV ASAP for continued uncontrolled pain. Advised caller care team would be notified to follow up. Review attempted of documentation from the agency to indicate the aforementioned concern had been reported, investigated, and/or handled was attempted throughout the course of the survey with no documented evidence produced for review to indicate the issue had been investigated by the Hospice agency. An interview was conducted on 02/04/2025 at 1:12 p.m. with Patient #1s daughter. She confirmed she was Patient #1s roommate in the NH. She confirmed she remained in their room from the time of Patient #1s fall on 12/13/2024 until Patient #1 went inpatient Hospice on 12/15/2024. She confirmed her mother began moaning and groaning in pain starting early morning and into the day on 12/14/2024. She confirmed when her mothers pain was not resolving and S5RN had not shown up by lunchtime on 12/14/2024, she requested for the NH to send her mother to the ED to get her pain under control. She stated the ED gave her pain medication which helped tremendously. She stated the problem was when the medication wore off, the NH didnt have medications to get her pain under control again. She confirmed her mothers pain returned later in the night on 12/14/2024 and she continued to moan and groan in pain until S5RN finally transferred her to an inpatient Hospice unit on the evening of 12/15/2024 for aggressive treatment of pain with IV medications. She confirmed S5RN did not come to their room at any time on 12/13/2024 or 12/14/2024. She confirmed her mother was not present in the NH from lunchtime on 12/14/2024 until after supper the same day because she requested the NH send her to the ED for treatment of uncontrolled pain. She confirmed it was 12/15/2024 around lunchtime before S5RN came to assess her mother. An interview was conducted on 02/04/2025 at 12:55 p.m. with Patient #1s night shift nurse at the NH where she resided. She confirmed Patient #1s daughter was her roommate and was cognitively intact. She confirmed she worked 6:00 p.m. to 6:00 a.m. She confirmed she was Patient #1s nurse on 12/13/2024 through 12/15/20024. She confirmed she contacted the Hospice agency on 12/13/2024 immediately following Patient #1s fall to report the incident, her suspected injury and uncontrolled pain. She confirmed she informed the Hospice triage nurse Patient #1s left leg showed signs of fracture and possible displacement with pain to the site. She stated she received a call from S5RN who asked if there was bruising to Patient #1s left leg. She stated she informed S5RN there was not yet bruising, but there were signs of displacement. She stated S5RN informed her if there was no immediate bruising, Patient #1s leg could not possibly be broken, and she would not be making a visit to assess Patient #1 tonight. She stated S5RN then gave her verbal orders to discontinue her PRN Dilaudid and Lorazepam and change it to scheduled every 4 hours and to have an in-house XR done in the morning. She confirmed she gave Patient #1 the medication per the directions of S5RN and it worked for a little while, but early the next morning, it was no longer controlling her pain. She confirmed Patient #1 was at the ED when she started her shift on 12/14/2024 and came back with no signs of pain. She stated once the medication the ED gave her wore off, they were unable to get her pain under control with the ordered pain regimen. She confirmed S5RN, nor anyone from the Hospice agency, came to the NH during her shift on 12/13/2024 or 12/14/2024. She stated when S5RN returned phone calls, she would remind the NH staff she lived over an hour away and frequently requested photos be texted to her so she would not have to drive to the NH. She stated S5RN would then give verbal telephone orders to pacify the patients needs until the next nurse came on shift to handle whatever was going on. An interview was conducted on 02/05/2025 at 9:44 a.m. with Patient #1s day shift nurse at the NH where she resided. She confirmed Patient #1s daughter was her roommate, and she was cognitively intact. She confirmed she was Patient #1s nurse on 12/14/2024 from 6:00 a.m. until after 7:00 p.m. and again on 12/15/2024 from 6:00 a.m. to 6:00 p.m. She confirmed she contacted the Hospice agency with the results immediately when Patient #1s XR indicated a left femur fracture on 12/14/2024 around 11:00 a.m. She confirmed she requested a PRN SNV immediately in order to obtain orders for pain medication as the current orders were not effective. She stated S5RN called and told her she was over an hour and a half away and would not be coming to the NH at that time. She stated she requested S5RN obtain new orders for more sufficient pain control but did not receive any. She stated S5RN stated she would attempt to locate a pharmacy to fill new pain medication orders and would bring them to the NH later on 12/14/2024. She confirmed S5RN failed to report to the NH nor did she call back with new pain medication orders on 12/14/2024. She confirmed Patient #1s pain remained uncontrolled until Patient #1s daughter requested for her to be sent to the ED for pain control on 12/14/2024 around lunch and did not return until just prior to the end of her shift. She confirmed she contacted the Hospice Triage Nurse on 12/15/2024 at 8:16 a.m. and informed the Triage Nurse Patient #1s pain remained uncontrolled and requested a PRN SNV immediately for additional pain medication orders. She confirmed she informed the Triage Nurse S5RN failed to report to the NH on 12/14/2024 to assess Patient #1. She confirmed the triage nurse informed her she would make administration aware of the issue but no one from the Hospice agency reached out to ask her any questions. She stated she received a return call from S5RN on 12/15/2024 at 9:45 a.m. informing her Patient #1 needed to be transferred to inpatient hospice for aggressive IV pain control. She confirmed the first time S5RN arrived to the NH to physically assess Patient #1 was around lunch time on 12/15/2024 when they were preparing her for transfer to inpatient hospice. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed he was not contacted by S5RN or anyone with the Hospice agency until S5RN contacted him on 12/15/2024 to request Patient #1 be transferred to inpatient Hospice for uncontrolled pain. S3MD confirmed he would have expected S5RN to make a visit to physically assess Patient #1 immediately on 12/13/2024. S3MD confirmed he would have then expected S5RN to contact him immediately when Patient #1 was experiencing pain uncontrolled with her current pain regimen. S3MD confirmed he would have expected S5RN to continue to contact him for orders to obtain appropriate pain control for Patient #1 each time she was contacted by the NH and told Patient #1s pain remained uncontrolled. S3MD confirmed a fall with suspected injury and uncontrolled pain warranted an immediate PRN SNV. S3MD confirmed when a patients pain was uncontrolled, he would expect a Hospice nurse to make an immediate PRN SNV to assess the patient, then contact him to report the assessment findings and obtain further orders. S3MD confirmed any Hospice discipline not performing visits as they should was neglecting the needs of the patient. S3MD confirmed S5RN led to Patient #1 suffering needlessly, which was neglect. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed she would have expected S5RN to immediately report to the NH on 12/13/2024 to assess Patient #1 then contact S3MD to notify him of the injury and uncontrolled pain in order to receive orders for treatment and she did not. S2DON confirmed when Patient #1s pain remained uncontrolled with her current medication regimen, she would have expected S5RN to continue making PRN SNVs to assess her and continue contacting S3MD for new orders until her pain level could be controlled and she did not. S2DON confirmed she would expect a PRN SNV to be performed immediately following report of a patient fall, especially if there were suspected injury and/or pain. S2DON confirmed she would expect a PRN SNV to be performed when requested and with reports of uncontrolled pain and/or other symptoms. S2DON confirmed leaving a Hospice patient with uncontrolled pain for any extended period of time was neglect and should not have occurred. S2DON confirmed she was unaware S5RN failed to perform her required visits for Patient #1 on the weekend of 12/13/2024 through 12/15/2024. S2DON confirmed the agencys triage nurse should have contacted her or S2DON immediately when they were told S5RN failed to report for Patient #1s PRN SNV on 12/14/2024. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed she would have expected S5RN to immediately report to the NH on 12/13/2024 to assess Patient #1 then contact S3MD to notify him of the injury and uncontrolled pain in order to receive orders for treatment and she did not. S1ED confirmed when Patient #1s pain remained uncontrolled with her current medication regimen, she would have expected S5RN to continue making PRN SNVs to assess her and continue contacting S3MD for new orders until her pain level could be controlled and she did not. S1ED confirmed she would expect a PRN SNV to be performed immediately following report of a patient fall, especially if there were suspected injury and/or pain. S1ED confirmed she would expect a PRN SNV to be performed when requested and with reports of uncontrolled pain and/or other symptoms. S1ED confirmed leaving a Hospice patient with uncontrolled pain for any extended period of time was neglect and should not have occurred. S1ED confirmed she was unaware S5RN failed to perform her required visits for Patient #1 on the weekend of 12/13/2024 through 12/15/2024 and she should have been. S1ED confirmed the agencys triage nurse should have contacted someone with administration immediately when they were told S5RN did not show up for Patient #1s PRN SNV on 12/14/2024. Patient #3 Review of Patient #3s Clinical Record revealed she was admitted to the Hospice agency on 04/18/2024 and was a resident of a local ALF. Review of Patient #3s Triage Coordination Visit Notes, dated 12/15/2024 through 12/17/2024, revealed, in part, the following: 12/15/2024 at 11:40 p.m. – ALF stated Patient #3 fell and was now having dizziness. Blood Pressure was 182/88. Hospice Case Manager to follow up tomorrow.12/16/2024 at 3:23 a.m. – ALF stated Patient #3 had a fall earlier, dizziness now increased, pain reported and patient no longer able to stand on her own. ALF stated Patient #3 was normally independent. Second call for the night. Per protocol, PRN SNV to be performed. 12/16/2024 at 3:36 a.m. – S5RN was assigned to the requested PRN SNV. Review of Patient #3s PRN SNV Notes and Nurse Coordination Visit Notes, dated 12/15/2024 through 12/17/2024, revealed, in part, the following: 12/15/2024 – No documentation by S5RN.12/16/2024 – No documentation by S5RN. Review of Patient #3s Physician Orders, dated 12/15/2024 through 12/16/2024, revealed, in part, the following: 12/15/2024 – No physician orders written per S5RN.12/16/2024 – No physician orders written per S5RN. An interview was conducted on 02/10/2025 at 10:40 a.m. with Patient #3s nurse at the ALF. She confirmed she was caring for Patient #3 when she fell and had a change in status on 12/15/2024 through 12/16/2024. She confirmed the ALF contacted the Hospice agency immediately to notify them of Patient #3s fall and the dizziness. She confirmed no one from the Hospice agency came to the ALF to assess Patient #3. She confirmed no new orders were received when S5RN contacted the ALF via telephone following the first call. She confirmed the ALF contacted the Hospice agency again when Patient #3 began complaining of uncontrolled pain, increased dizziness and was no longer able to stand on her own. She confirmed no one from the Hospice agency came to the ALF to assess Patient #3. She stated S5RN told her via telephone Patient #3s regular nurse would see her tomorrow during normal hours and said she was sending a prescription to the pharmacy for Tramadol 50mg three times daily as needed for pain. She confirmed the pain medication S5RN claimed to order never arrived from the pharmacy. She stated she also informed S5RN the ALF could not locate any pain medications to administer Patient #3 while they were waiting on the new prescription to arrive. She stated S5RN told her she could not help them and her regular nurse would have to sort it out when she came the next day. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed she was Patient #3s regular nurse at the time of her fall on 12/15/2024. S8RN confirmed S5RN was the nurse on-call when Patient #3 fell and later began experiencing a change of status on 12/15/2024. S8RN confirmed when she arrived to Patient #3s ALF on 12/16/2024 around lunch time, she was informed she was the first person from Hospice to assess Patient #3 since her fall on 12/15/2024 because S5RN had not shown up. S8RN confirmed when she arrived to the ALF, she obtained an order for Tramadol and entered it into the EHR because S5RN had not followed through with the verbal orders she gave the ALF while on-call. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed S5RN should have performed a PRN SNV on 12/15/2024 to assess Patient #3 following her fall and to obtain orders to prevent any further progression of symptoms and she did not. S2DON confirmed S5RN should have also performed a PRN SNV on 12/16/2024 to assess Patient #3 following the second call received by the ALF reporting changes in condition following a fall and to obtain orders to prevent any further progression of symptoms and she did not. S2DON confirmed S5RN should have made an effort with the ALF to sort out the confusion with Patient #3s pain medications to ensure her pain was controlled and she did not. S2DON confirmed leaving a Hospice patient with uncontrolled pain for any extended period of time was neglect and should not have occurred. S2DON confirmed Patient #3s ALF made her and S1ED aware on 12/17/2024 of the incident involving Patient #3 on 12/15/2024. S2DON confirmed after being made aware, she and S1ED educated S5RN on the importance of performing visits as required and confirmed there was no documented evidence of the education provided. S2DON confirmed S5RN was not written up nor did she receive any disciplinary action for not performing visits as required. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed S5RN should have performed a PRN SNV on 12/15/2024 to assess Patient #3 following her fall and to obtain orders to prevent any further progression of symptoms and she did not. S1ED confirmed S5RN should have also performed a PRN SNV on 12/16/2024 to assess Patient #3 following the second call received by the ALF reporting changes in condition following a fall and to obtain orders to prevent any further progression of symptoms and she did not. S1ED confirmed S5RN should have made an effort with the ALF to sort out the confusion with Patient #3s pain medications to ensure her pain was controlled and she did not. S1ED confirmed leaving a Hospice patient with uncontrolled pain for any extended period of time was neglect and should not have occurred. S1ED confirmed Patient #3s ALF made her and S2DON aware on 12/17/2024 of the incident involving Patient #3 on 12/15/2024. S1ED confirmed she and S2DON provided information education to S5RN on the importance of performing visits as required and confirmed there was no documented evidence of the education provided. S1ED confirmed S5RN was not written up nor did she receive any disciplinary action for not performing visits as required. Review of the Hospice agencys Complaint Intake Report (CIR) regarding Patient #3, created 12/17/2024 at 3:24 p.m., revealed, in part, the following: Created by: S1EDDescription: While in a meeting with S2DON and the nurse at Patient #3s ALF, the Hospice agency was informed Patient #3 experienced a change of status on 12/15/2024 followed by a fall on the morning of 12/16/2024. ALF staff reported this information to the triage nurse who then assigned S5RN. ALF staff asked S5RN about Patient #3s pain medication due to complaints of pain following her fall because they were unable to locate it. ALF staff stated S5RN responded I dont know what you want me to do about it. S5RN did not perform a PRN SNV to assess Patient #3 or address the concerns the ALF voiced with being unable to locate her pain medication for administration. The concerns regarding Patient #3 were addressed when her regular Hospice nurse came on shift later in the day. Interventions: Educated S5RN on customer service. Review attempted of documentation from the agency to indicate the aforementioned concern had been investigated and/or handled any further than the aforementioned CIR was attempted throughout the course of the survey with no documented evidence produced for review to indicate the issue had been investigated by the Hospice agency. Patient #6 Review of Patient #6s Clinical Record revealed he was admitted to the Hospice agency on 12/06/2024 with diagnoses, which included, Acute on Chronic Congestive Heart Failure and Chronic Kidney Disease with history of dependence on hemodialysis. Review of Patient #6s Clinical Triage Coordination Notes, dated 12/26/2024, revealed, in part, the following: 12/26/2024 at 2:12 a.m. – Patient #6s daughter requested a PRN SNV immediately due to uncontrolled symptoms; including elevated blood pressure and complaints of “;feeling like his heart was going to stop”.12/26/2024 at 2:33 a.m. – S5RN was assigned to the requested PRN SNV. Review of Patient #6s PRN SNV Notes and Nurse Coordination Notes, dated 12/26/2024, revealed, in part, the following: 12/26/2024 – No documentation by S5RN. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed she was unaware of the aforementioned situation with S5RN and Patient #6. S2DON confirmed she would have expected S5RN to immediately conduct a PRN SNV as requested by the family to ensure Patient #6s symptoms were being properly managed. S2DON confirmed she would expect a PRN SNV to be conducted immediately following report of a patient fall, especially if there were suspected injury and/or pain. S2DON confirmed she would expect a PRN SNV to be conducted when requested, and when pain or other symptoms were uncontrolled with the current medication regimen. S2DON confirmed not performing visits when necessary was patient neglect. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed she was unaware of the aforementioned situation with S5RN and Patient #6. S1ED confirmed she would have expected S5RN to immediately conduct a PRN SNV as requested by the family to ensure Patient #6s symptoms were being properly managed. S1ED confirmed she would expect a PRN SNV to be conducted immediately following report of a patient fall, especially if there were suspected injury and/or pain. S1ED confirmed she would expect a PRN SNV to be conducted when requested and when pain or other symptoms were uncontrolled with the current medication regimen. S1ED confirmed not performing visits when necessary was patient neglect and should never happen. Patient #5 Review of Patient #5s Clinical Record revealed he was admitted to the agency on 12/16/2024 and was resident at a local NH. Further review revealed he was a patient of S4MD. Review of Patient #5s Triage Coordination Note, dated 01/12/2024, revealed, in part, the following: 01/12/2025 at 3:28 p.m. – NH stated Patient #5 started new Fentanyl patch dose on 01/09/2025 with increased confusion since that time. NH stated a new Fentanyl patch was due tonight. NH requested PRN SNV to address family concerns and discuss dose changes to pain medication regimen. 01/12/2025 at 3:48 p.m. – S5RN was assigned to the requested PRN SNV. Review of Patient #5s Physician Orders, dated 01/12/2025, revealed, in part, the following:01/12/2025 5:51 p.m. – Verbal Order entered by S5RN - Discontinue Fentanyl patch now. 01/13/2025 2:59 p.m. – Verbal Order entered by S8RN - Resume Fentanyl patch 100mg/hour. 1 patch topically every 72 hours for pain. An interview was conducted on 02/05/2025 at 12:00 p.m. with the DON for Patient #5s NH. She reviewed Patient #3s Nurse Notes and confirmed there was a note written on 01/12/2025 at 11:46 a.m., which stated Patient #5 was experiencing increased confusion and agitation so Hospice on-call was notified. She stated the note indicated S5RN informed the NH she would not be coming on 01/12/2025 because his regular nurse would come the following day during normal business hours. She stated the note also indicated S5RN gave a verbal order to discontinue Patient #5s Fentanyl patch at this time. An interview was conducted on 02/05/2025 at 1:16 p.m. with the Administrator for Patient #5s NH. She confirmed the information provided in her DONs aforementioned interview. She confirmed she reviewed Patient #5s hard chart, Hospice chart and EHR and no documentation was present to indicate S5RN performed an in-person visit on 01/12/2025. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed she was Patient #5s regular nurse. S8RN confirmed when she went to see Patient #5 on 01/13/2025, the NH told her S5RN did not come out but had given them a telephone order to discontinue Patient #5s Fentanyl patch. S8RN stated she was shocked the order was discontinued by S5RN because they had such a time getting Patient #5s pain down to a comfortable level for him. S8RN confirmed when she contacted S4MD, he was not aware the medication had been discontinued and ordered for it to be resumed immediately to prevent breakthrough pain. An interview was conducted on 02/11/2025 at 9:33 a.m. with S4MD. S4MD confirmed S5RN did not contact him on 01/12/2025 regarding Patient #5 and he did not give an order for S5RN to discontinue Patient #5s Fentanyl patch. S4MD confirmed Patient #5 had been experiencing on-going difficulties with getting his pain managed and under control. S4MD confirmed he would not have given an order to discontinue the medication that had finally helped achieve Patient #5s pain goal. S4MD confirmed he would have expected 5RN to contact him before making any changes to a patients medication regimen, especially in regards to a controlled substance for pain control, and she had not. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed she would have expected S5RN to make an in-person visit to assess Patient #5 on 01/12/2025 after being assigned by the Triage Nurse. S2DON confirmed S5RN had not performed an in-person visit as she documented and had actually handled the call over the phone and she should not have. S2DON confirmed S5RN discontinuing a controlled substance for pain control without a physicians order put Patient #5 at risk for experiencing uncontrolled breakthrough pain. S2DON confirmed she would have expected S5RN to contact S4MD to inform him of the situation and allow him to provide her with orders he felt were appropriate for his patient and she did not. S2DON confirmed S8RN did not make her aware S5RN did not perform a visit for Patient #5 on 01/12/2025 and should have. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed she would have expected S5RN to make an in-person visit to assess Patient #5 on 01/12/2025 after being assigned by the Triage Nurse. S1ED confirmed S5RN had not performed an in-person visit as she documented and had actually handled the call over the phone and she should not have. S1ED confirmed S5RN discontinuing a controlled substance for pain control without a physicians order put Patient #5 at risk for experiencing uncontrolled breakthrough pain. S1ED confirmed she would have expected S5RN to contact S4MD to inform him of the situation and allow him to provide her with orders he felt were appropriate for his patient and she did not. S1ED confirmed S8RN did not make her aware S5RN did not perform a visit for Patient #5 on 01/12/2025 and should have. Patient #2 Review of Patient #2s Clinical Record revealed he was admitted to the Hospice agency on 11/15/2022 and was a resident of a local NH facility. Review of Patient #1s Triage Coordination Notes, dated 01/20/2025 through 01/21/2025, revealed, in part, the following: 01/20/2025 at 11:54 p.m. - NH stated Patient #2 had an unwitnessed fall due to increased agitation. 01/21/2025 at 1:00 a.m. - S5RN was assigned to the requested PRN SNV. 01/21/2025 at 4:54 a.m. - NH stated Patient #2 had another unwitnessed fall due to increased agitation uncontrolled by current medication regimen. NH stated Patient #2 had increased confusion and kept trying to get out of bed.01/21/2025 at 5:04 a.m. - S5RN was assigned to the requested PRN SNV. Review of Patient #2s PRN SNV Notes and Nurse Coordination Notes, dated 01/20/2025 through 01/21/2025, revealed, in part, the following:01/20/2025 - No documentation by S5RN.01/21/2025 - No documentation by S5RN. An interview was conducted on 02/10/2025 at 1:00 p.m. with the DON for Patient #2s NH. She confirmed she was familiar with Patient #2 and his falls on 01/20/2025 and 01/21/2025. She reviewed Patient #2s incident reports and nurse notes for 01/20/2025 through 01/21/2025. She confirmed the NH contacted the Hospice agency just before midnight on 01/20/2025 to request a PRN SNV due to uncontrolled agitation. The DON stated no one came or called back with any instructions or new orders for Patient #2. She confirmed just before 5:00 a.m. on 01/21/2025, Patient #2 had another fall when his agitation remained uncontrolled and the NH contacted the hospice agency again to request a SNV. The DON stated no one came or called back with any instructions or new orders for Patient #2. She confirmed a Hospice nurse should have assessed Patient #2 then spoken with his physician to obtain orders for medications to decrease his agitation and keep him comfortable and they did not. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed a few days after Patient #2s fall, the NH DON made her aware S5RN did not perform a PRN SNV on 01/20/2025 and 01/21/2025 and she did not obtain new orders to manage his agitation. S2DON confirmed after being made aware, she and S1ED spoke with S5RN and provided informal education on the importance of performing visits as required and confirmed there was no documented evidence of the conversation or education provided. S2DON confirmed S5RN was not written up nor did she receive any disciplinary action for not performing visits as required. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed S5RN did not perform a PRN SNV on 01/20/2025 and 01/21/2025 and she did not obtain new orders to manage his agitation and she should have. S1ED stated when the triage nurse was notified Patient #2 fell the first time due to late stage agitation, she would have expected S5RN to report to the facility immediately to assess Patient #2 and obtain orders to treat his agitation and she did not. S1ED confirmed Patient #2 sustained a second fall a few hours later, which could have been prevented if S5RN had reported to the facility to assess the patient as she should have. S1ED confirmed a few days after Patient #2s fall, the NH DON made her aware S5RN did not perform a PRN SNV on 01/20/2025 and 01/21/2025 and she did not obtain new orders to manage his agitation. S1ED confirmed after being made aware, she and S2DON spoke with S5RN and provided informal education on the importance of performing visits as required and confirmed there was no documented evidence of the conversation or education provided. S1ED confirmed S5RN was not written up nor did she receive any disciplinary action for not performing visits as required. Review attempted of documentation from the agency to indicate the aforementioned concern had been reported, investigated, and/or handled was attempted throughout the course of the survey with no documented evidence produced for review. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed he was the Medical Director for the Hospice agency and they did not utilize standing orders. S3MD confirmed a fall with suspected injury, uncontrolled pain or other symptoms warranted an immediate PRN SNV, along with notification made to him or S4MD as soon as the patient was assessed to obtain further orders. S3MD confirmed nurses were expected to contact the patients physician to obtain all orders, especially when dealing with a controlled substance; including changing frequency, discontinuation of a medication, etc. S3MD confirmed a nurse giving orders without a physician put pati ents at serious risk of uncontrolled symptoms and many other potential issues. S3MD confirmed he would expect all Hospice staff to take uncontrolled pain and other symptoms seriously and to contact the patients physician immediately to address them. S3MD confirmed any Hospice discipline not performing visits as they should was neglecting the needs of the patient. S3MD confirmed it was unacceptable for a Hospice patients symptoms to remain untreated for any reason and to do so would constitute patient neglect. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed the agency did not currently have a system in place to ensure the triage nurses reported this type of information or a system to ensure the information was being investigated/handled once administration was made aware. S2DON confirmed the agency did not currently have a system in place to double check and verify staff were performing their visits. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed the agency did not currently have a system in place to ensure the triage nurses reported this type of information or a system to ensure the information was being investigated/handled once administration was made aware. S1ED confirmed the agency did not currently have a system in place to double check and verify staff were performing their visits. Record review revealed S5RN failed to conduct a total of 9 required PRN SN Visits for Patient #1, #2, #3, #5, and #6 from 12/13/2024 through 01/21/2025. 2. Failed to ensure documentation in each patients clinical record was performed in a manner consistent with accepted standards of practice. Review of the agencys “;Hospice Medical Record” policy, last revised 10/01/2023, revealed, in part, the following: Purpose: To define the contents and requirements of the Hospice medical record. Procedure:2. The Hospice medical record shall contain the following: b. Any summaries of care, treatment, or services, including changes in patients condition.k. The patients response to care treatment and services. l. Documentation and communication with the patient, caregivers and physicians. m. Any assessment relevant to care, treatment and services. n. Physicians Orders.7. Entries in the Hospice record must be according to acceptable standards of practice. a. All entries recorded in the Hospice record must be accurate. Review of the agencys “;On-Call and Back-up Services” policy, last revised 10/01/2024, revealed, in part, the following: Purpose: To ensure essential services will be available to all Hospice patients at all times, 24 hours a day, 7 days a week.Policy: The agency will make all attempts to provide full services at the times, frequencies and level of care specified in the patients plan of care. The agency will have a plan for back-up on-call services when the regular staff cannot report to work and during times when the office is closed. Procedure: 5. Hospice patient/representative calls are handled in the following manner: a. If the patient/representative requests a visit, a visit should be made. b. On-call events will be documented by the on-call nurse. This documentation will detail the timeline of event notification and follow-up, reason for call; and actions taken to resolve concerns of patient/representative. 7. All on-call coordination notes will be maintained in the electronic medical record. Patient #1 Review of Patient #1s Clinical Record revealed she was admitted to the Hospice agency on 09/05/2024 and was a resident of a local NH facility. Review of Patient #1s Triage Coordination Notes, dated 12/13/2024 through 12/15/2024, revealed, in part, the following: 12/13/2024 at 11:16 p.m. - NH requested PRN SNV due to Patient #1s fall with obvious signs of injury.12/13/2024 at 11:22 p.m. - S5RN was assigned.12/14/2024 at 10:24 a.m. – NH requested PRN SNV. 12/14/2024 at 10:31 a.m. – S5RN was assigned.12/15/2024 at 8:16 a.m. - NH stated S5RN did not show up to assess Patient #1 on 12/14/2024. NH requested PRN SNV ASAP for continued uncontrolled pain. 12/15/2024 at 9:24 a.m. - S5RN was assigned to the requested PRN SNV. Review of Patient #1s PRN SNV Notes and Nurse Coordination Notes, dated 12/13/2024 through 12/15/2024, revealed, in part, the following:12/13/2024 – No documentation present by S5RN. 12/14/2024 at 2:45 p.m. by S5RN - Patient #1 in bed, stable, and responded “;no” to being in pain. Patient #1s NH nurse educated on the use of Dilaudid to control pain. Patient #1s POC, medication regimen and effectiveness, use of comfort kit, and pharmacologic and non-pharmacologic measures reviewed with her NH nurse. Patient #1s NH nurse verbalized understanding. S5RN documented her visit began at 3:30 p.m. and ended at 5:14 p.m. for a total in-home time of 1.73 hours. 12/14/2024 – No additional documentation present on this date by S5RN.12/15/2024 – No documentation present by S5RN. Review of Patient #1s Nurse Notes from her NH, dated 12/13/2024 through 12/15/2024, revealed, in part, the following: 12/14/2024 12:21 a.m. - Late entry following fall on 12/13/2024 at 11:00 p.m. S5RN called to say she would not be coming to the facility to assess Patient #1. S5RN provided verbal telephone orders to change the frequency of Patient #1s Dilaudid and Lorazepam from PRN to scheduled every 4 hours and to have an in-house XR performed of Patient #1s left leg in the morning. 12/14/2024 at 12:25 p.m. – S5RN called to say she was over an hour away and could not come at this time. S5RN was updated on Patient #1s status and gave verbal telephone orders to continue Patient #1s Dilaudid and Lorazepam scheduled every 4 hours to manage pain. 12/15/2024 at 9:45 a.m. – S5RN returned call and stated Patient #1 required transfer to inpatient Hospice and stated she would be in shortly to make arrangements. 12/15/2024 at 10:58 a.m. – S5RN called to state S3MD had given orders for Patient #1 to be transferred to inpatient Hospice at a local hospital. Review of Patient #1s Physician Orders, dated 12/13/2024 through 12/15/2024, revealed, in part, the following: 12/13/2024 – No Physician Orders entered by S5RN. 12/14/2024 – No Physician Orders entered by S5RN. 12/15/2024 at 5:47 a.m. – Change level of care from routine to inpatient entered by S5RN per S3MD. Review of Patient #1s Run Reports from the local EMS, dated 12/14/2024, revealed, in part, the following: Run #1: Transport from NH to local EDDate/Time On Scene at NH: 12/14/2024 at 1:04 p.m.; Departed NH: 12/14/2024 at 1:19 p.m.Run #2: Transport from local ED to NHDate/Time of Arrival to NH: 12/14/2024 at 6:21 p.m.Further review revealed no documented evidence to indicate S5RN was present during either transport. Review of Patient #1s Medical Record from the local ED, dated 12/14/2024, revealed, in part, the following: Admit Date/Time: 12/14/2024 1:26 p.m. Discharge Date/Time: 12/14/2024 6:00 p.m.Further review revealed no documented evidence to indicate S5RN was present during visit. An interview was conducted on 02/04/2025 at 1:12 p.m. with Patient #1s daughter who confirmed she was her roommate in the NH. She confirmed she remained in their room from the time Patient #1 fell on 12/13/2024 until Patient #1 went inpatient Hospice on 12/15/2024. She confirmed her mother was not present in the NH from lunchtime on 12/14/2024 until after supper the same day because she was at the ED. She confirmed S5RN did not come to their room at any time on 12/13/2024 or 12/14/2024. She confirmed S5RN arrived to assess her mother around lunch time on 12/15/2024, at which time she began arranging to have her mother transferred to inpatient hospice for better pain control. An interview was conducted on 02/04/2025 at 12:55 p.m. with Patient #1s night shift nurse at the NH. She confirmed Patient #1s daughter was her roommate and was cognitively intact. She confirmed she worked on 12/13/2024 and 12/14/2024 from 6:00 p.m. to 6:00 a.m. as Patient #1s nurse. She stated S5RN called the NH on 12/13/2024 after Patient #1 fell and gave verbal telephone orders to change the frequency of her Dilaudid and Lorazepam from PRN to scheduled every 4 hours and to have an in-house XR performed of Patient #1s left leg in the morning. She confirmed neither S5RN nor anyone from the Hospice agency came to the NH to see Patient #1 during her shift on 12/13/2024 or 12/14/2024. She confirmed Patient #1 was transferred to a local hospital per S5RN for inpatient Hospice on 12/15/2024 during her shift. An interview was conducted on 02/05/2025 at 9:44 a.m. with Patient #1s day shift nurse at the NH. She confirmed she worked on 12/14/2024 from 6:00 a.m. until after 7:00 p.m. and 12/15/2024 from 6:00 a.m. to 6:00 p.m. as Patient #1s nurse. She confirmed she and S5RN had multiple phone calls throughout the morning on 12/14/2024 regarding Patient #1s status and care. She confirmed she contacted the Hospice agency immediately on the morning of 12/14/2024 to request a PRN SNV immediately. She stated when S5RN called her back, she informed S5RN Patient #1s pain remained uncontrolled. She stated S5RN told her she was going to try to locate a pharmacy to fill and deliver new pain medications to the NH. She stated she spoke with S5RN on the phone again after Patient #1s in-house XR confirmed a left femur fracture, at which point S5RN told her not to send her out because nothing could be done. She stated S5RN told her she would not be coming to the NH at that time and to continue giving Lorazepam and Dilaudid every 4 hours. She confirmed neither S5RN nor anyone from the Hospice agency came to the NH to see Patient #1 during her shift on 12/14/2024. She confirmed Patient #1 was sent to the ED via ambulance per family request around lunchtime on 12/14/2024 and did not return until just prior to the end of her shift. She stated if someone from Hospice had come to assess Patient #1 during that timeframe, they would have had to ask her or Patient #1s daughter where the patient was and no one did. She confirmed she contacted the Hospice Triage Nurse on 12/15/2024 at 8:16 a.m. to make them aware S5RN had not shown up to assess Patient #1 since her fall on 12/13/2024. She confirmed she informed the Triage Nurse Patient #1s pain remained uncontrolled and requested a PRN SNV immediately for additional pain medication orders. She stated she received a return call from S5RN on 12/15/2024 at 9:45 a.m. informing her Patient #1 needed to be transferred to inpatient hospice for aggressive IV pain control. She confirmed the first time S5RN arrived to the NH to physically assess Patient #1 was around lunch time on 12/15/2024 when they were preparing her for transfer to inpatient hospice. An interview was conducted on 02/03/2025 at 2:30 p.m. with S5RN. S5RN confirmed she was not aware the NH sent Patient #1 out on 12/14/2024. S5RN stated she assessed Patient #1 in the NH on 12/14/2024 and did not see her in the ED. S5RN confirmed the visit date/time on 12/14/2024 was accurate because she documented the PRN SNV note during her visit with Patient #1. S5RN confirmed when she was assigned to a patients on-call request, if the situation was handled by telephone, she did not document what the conversation entailed or what instructions she provided. S5RN confirmed if the assignment required her to contact a physician for notification of a situation or to obtain new orders, she did not document her communication with the physician or any orders/instructions received. S5RN stated she did not consider the verbal order she provided to Patient #1s NH nurse to discontinue PRN Dilaudid and Lorazepam and change to scheduled every 4 hours or the verbal order to obtain an XR of the left leg to require a documented note or new orders to be entered into her EHR. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed S5RN had not contacted him regarding Patient #1 at any time on 12/13/2024 or 12/14/2024. S3MD confirmed if Patient #1 was not present in the NH on 12/14/2024 at the time S5RN documented a visit was performed for her in the NH, there was no way the documented visit could be accurate. S3MD confirmed a Hospice employee should never falsely document a visit they did not actually perform. S3MD confirmed he was contacted by S5RN on 12/15/2024 to request Patient #1 be transferred to a local hospital for inpatient Hospice due to uncontrolled pain following a fall on 12/13/2024 resulting in left femur fracture. S3MD confirmed a nurse not documenting the care they provided or the care they instructed caregivers to provide should never occur. S3MD stated he would expect all steps taken by a nurse regarding the status and care of a patient to have been documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed if Patient #1 was not present in the NH on 12/14/2024 at the time S5RN documented a visit was performed for her in the NH, there was no way the documented visit could be accurate S2DON confirmed a Hospice employee should never falsely document a visit they did not actually perform. S2DON confirmed Patient #1s Physicians Orders did not accurately reflect the verbal orders S5RN gave the NH on 12/13/2024 and 12/14/2024 for Patient #1 and should. S2DON confirmed if S5RN received a verbal medication order from S3MD for Patient #1, she would expect an electronic order to be entered into the EHR as soon as possible to protect the accuracy of the record. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed if Patient #1 was not present in the NH on 12/14/2024 at the time S5RN documented a visit was performed for her in the NH, there was no way the documented visit could be accurate S1ED confirmed a Hospice employee should never falsely document a visit they did not actually perform. S1ED confirmed Patient #1s Physicians Orders did not accurately reflect the verbal orders S5RN gave the NH on 12/13/2024 and 12/14/2024 for Patient #1 and should. S1ED confirmed if S5RN received a verbal medication order from S3MD for Patient #1, she would expect an electronic order to be entered into the EHR as soon as possible to protect the accuracy of the record. Patient #2 Review of Patient #2s Clinical Record revealed he was admitted to the Hospice agency on 11/15/2022 and was a resident of a local NH facility. Review of Patient #2s Triage Coordination Notes, dated 01/20/2025 through 01/25/2025, revealed in part, the following: 01/21/2025 at 12:54 a.m. – NH called to report an unwitnessed fall out of bed. 01/21/2025 at 1:00 a.m. – S5RN was assigned to the requested PRN SNV. 01/21/2025 at 4:54 a.m. – NH called to report a second unwitnessed fall with scrapes present to elbows and forehead. Patient fell again, scraped his elbows with scrape to forehead, unclear if he hit his head. Denies pain. Patient #2 remains confused and attempting to get out of bed. Receiving medications as instructed following first fall but it is ineffective at this time. 01/21/2025 at 5:09 a.m. – S5RN was assigned to the requested PRN SNV. Review of Patient #2s PRN SNV Notes and Nurse Coordination Notes, dated 01/21/2025 through 01/22/2025, revealed, in part, the following:01/21/2025 – No documentation present by S5RN. Review of the agencys Client Occurrence Report, dated 01/21/2025, revealed, in part, the following: Date/Time of Occurrence: 01/21/2025 at 5:04 a.m.Client Involved: Patient #2Person Preparing Report: S5RNLocation: Patient #2s NHNature of Occurrence: Unattended FallDescription: S3MD gave a new verbal order to increase Patient #2s Morphine Concentrate to 0.75mLs. Review of Patient #2s Physician Orders, dated 01/21/2025, revealed in part, the following: 01/21/2025 – No Physician Order entered by S5RN. An interview was conducted on 02/10/2025 at 1:00 p.m. with the DON of the NH where Patient #2 resided. She confirmed S5RN contacted Patient #2s NH nurse by telephone on 01/21/2025 following his first fall and told them to administer his agitation medications as frequently as they could per his orders, to increase safety rounds and to call back with any changes. She confirmed Patient #2 fell again a few hours later due to continued agitation. She confirmed Patient #2s NH nurse contacted the Triage Nurse to report the second fall with continued uncontrolled agitation. She confirmed S5RN contacted Patient #2s NH nurse by telephone following his second fall on 01/21/2025 and told them to make sure they were administering his agitation medications as frequently as his orders would allow, to continue the increased safety rounds and to call back with any additional changes. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed she would expect all steps taken by a nurse regarding the status and care of Patient #2 to be documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained and S5RN had not. S2DON confirmed Patient #2s Physicians Orders did not accurately reflect the verbal orders S5RN documented she received from S3MD on 01/21/2025 and should. S2DON confirmed if S5RN received a verbal medication order from S3MD for Patient #2, she would expect an electronic order to be entered into the EHR as soon as possible to protect the accuracy of the record. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed she would expect all steps taken by a nurse regarding the status and care of Patient #2 to be documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained and S5RN had not. S1ED confirmed Patient #2s Physicians Orders did not accurately reflect the verbal orders S5RN documented she received from S3MD on 01/21/2025 and should. S1ED confirmed if S5RN received a verbal medication order from S3MD for Patient #2, she would expect an electronic order to be entered into the EHR as possible to protect the accuracy of the record. Patient #3 Review of Patient #3s Clinical Record revealed she was admitted to the Hospice agency on 04/18/2024 and was a resident of a local ALF. Review of Patient #3s Triage Coordination Notes, dated 12/15/2024 through 12/17/2024, revealed, in part, the following: 12/15/2024 11:40 p.m. – ALF reported Patient #3 fell and was having dizziness when she stood up. Blood pressure was 182/88. 12/16/2024 at 3:23 a.m. – ALF reported Patient #3 with increased dizziness and no longer able to stand independently. 2nd call for the night. Per protocol patient requires PRN SNV. 12/16/2024 at 3:36 a.m. – S5RN was assigned to the requested PRN SNV. Review of Patient #3s PRN SNV Notes and Nurse Coordination Notes, dated 12/15/2024 through 12/16/2024, revealed, in part, the following:12/15/2024 – No documentation present by S5RN. 12/16/2024 – No documentation present by S5RN. Review of Patient #3s Physician Orders, dated 12/15/2024 through 12/16/2024, revealed, in part, the following:12/15/2024 – No physician orders entered by S5RN. 12/16/2024 – No physician orders entered by S5RN. 12/16/2024 at 11:46 a.m. – Tylenol 325mg 1 tab by mouth every 4 hours as needed for fever or pain entered by S8RN per S4MD.12/16/2024 at 11:46 a.m. – Tramadol 50mg 1 tab by mouth three times daily as needed for pain entered by S8RN per S4MD. An interview was conducted on 02/10/2025 at 10:40 a.m. Patient #3s nurse at the ALF on 12/15/2024 through 12/16/2024. She confirmed Patient #3 had a change of condition followed by a fall on 12/15/2024 a little before midnight so she contacted the Hospice Triage Nurse to report it. She confirmed around 4:00 a.m. on 12/16/2024, Patient #3s condition declined further and she began complaining of pain so she contacted the Hospice Triage Nurse again and requested a PRN SNV. She reviewed her nurse notes, dated 12/15/2024 and 12/16/2024, and confirmed she received a phone call on 12/16/2024 around 4:00 a.m. from S5RN with a verbal telephone order for Tramadol 50mg three times daily as needed for pain and stated she was sending the prescription to the pharmacy now. She confirmed the pain medication S5RN ordered on 12/16/2024 never arrived from the pharmacy. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed she was Patient #3s regular nurse on 12/16/2024. S8RN confirmed around lunchtime on 12/16/2024 she obtained an order from S4MD for Tramadol when she realized S5RN had not followed through with the verbal order the ALF reported she gave them while on-call. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed she would expect all steps taken by a nurse regarding the status and care of Patient #3 to be documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained and S5RN had not. S2DON confirmed Patient #3s Physicians Orders did not accurately reflect the verbal orders given to the ALF by S5RN on 12/16/2024 and should. S2DON confirmed if S5RN gave a verbal medication order for Patient #3, she would expect an electronic order to be entered into the EHR as soon as possible to protect the accuracy of the record. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed she would expect all steps taken by a nurse regarding the status and care of Patient #3 to be documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained and S5RN had not. S1ED confirmed Patient #3s Physicians Orders did not accurately reflect the verbal orders S5RN gave the ALF on 12/16/2024 and should. S1ED confirmed if an order was given verbally for a patient, she would expect an electronic order to be entered into the patients EHR as soon as possible to protect the accuracy of the record. Patient #6 Review of Patient #6s Clinical Record revealed he was admitted to the Hospice agency on 12/06/2024 and lived at home with family. Review of Patient #6s Clinical Triage Coordination Notes, dated 12/26/2024, revealed, in part, the following: 12/26/2024 at 2:12 a.m. – Patient #6s daughter requested a PRN SNV immediately due to uncontrolled symptoms. 12/26/2024 at 2:33 a.m. – S5RN was assigned to the requested PRN SNV. Review of Patient #6s PRN SNV Notes and Nurse Coordination Notes, dated 12/26/2024, revealed, in part, the following: 12/26/2024 – No documentation by S5RN. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON reviewed the lack of documentation for Patient #6 by S5RN and confirmed she would have expected S5RN to document whatever actions she took following her assignment to Patient #6s request for a PRN SNV and she did not. S2DON confirmed she would expect any steps taken by S5RN regarding the status and care of Patient #3 to be documented; including all contact with the caregiver, any contact with their physician and any follow up contact made to ensure relief was obtained and S5RN had not. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED reviewed the lack of documentation for Patient #6 by S5RN and confirmed she would have expected S5RN to document whatever actions she took following her assignment to Patient #6s request for a PRN SNV and she did not. S1ED confirmed she would expect any steps taken by S5RN regarding the status and care of Patient #3 to be documented; including all contact with the caregiver, any contact with their physician and any follow up contact made to ensure relief was obtained and S5RN had not. Patient #5 Review of Patient #5s Clinical Record revealed he was admitted to the agency on 12/16/2024 and was a resident of a local NH facility. Review of Patient #5s Triage Coordination Notes, dated 01/12/2024, revealed, in part, the following: 01/12/2025 at 3:28 p.m. – NH requested PRN SNV. 01/12/2025 at 3:48 p.m. – S5RN assigned to the requested PRN SNV. Review of Patient #5s PRN SNV Notes and Nurse Coordination Notes, dated 01/12/2025, revealed, in part, the following: 01/12/2025 at 5:41 p.m. by S5RN – Verbal order given to NH nurse to discontinue current Fentanyl patch. Will confer with S4MD per S8RN regarding change. S5RN documented her visit began at 5:41 p.m. and ended at 6:21 p.m. for a total in-home time of 0.5 hours. Review of Patient #5s Physician Orders, dated 01/12/2025, revealed, in part, the following order:01/12/2025 at 5:51 p.m. – Entered by S5RN per verbal order of S4MD - Discontinue Fentanyl patch. An interview was conducted on 02/05/2025 at 12:00 p.m. with the DON for Patient #5s NH. She reviewed Patient #5s Nurse Notes at the NH and confirmed there was a note written on 01/12/2025 at 11:46 a.m. which indicated a PRN SNV was requested for Patient #5. She stated the note indicated S5RN informed the NH she would not be coming today because his regular nurse would come the following day during normal business hours then gave a verbal order to discontinue Patient #5s Fentanyl patch at this time. An interview was conducted on 02/05/2025 at 1:16 p.m. with the Administrator for Patient #5s NH. She confirmed the information provided in her DONs aforementioned interview. She confirmed she reviewed Patient #5s hard chart, Hospice chart and EHR and no documentation was present to indicate S5RN performed an in-person visit on 01/12/2025. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed she was Patient #5s regular nurse. S8RN confirmed when she went to see Patient #5 on 01/13/2025, the NH told her S5RN did not come out but had given them a telephone order to discontinue Patient #5s Fentanyl patch. An interview was conducted on 02/11/2025 at 9:33 a.m. with S4MD. S4MD confirmed he was Patient #5s physician and was familiar with his care during January 2025. S4MD confirmed the information received from Patient #5s NH indicated S5RN did not perform an in-person visit on 01/12/2024 as she documented and her visit documentation was inaccurate. S4MD confirmed a Hospice employee should never falsely document a visit they did not actually perform. S4MD confirmed he was not contacted by S5RN to obtain orders for Patient #5 on 01/12/2025 and had not given S5RN verbal orders to discontinue Patient #5s Fentanyl patch. S4MD stated if there was an order in Patient #5s EHR to discontinue his Fentanyl patch, the order was inaccurate. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed the information received from Patient #5s NH indicated S5RN did not perform an in-person visit as she documented on 01/12/2024 and her visit documentation was inaccurate. S2DON confirmed S5RN entering a false Physicians Order into Patient #5s EHR was inaccurate documentation and should not have occurred. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed the information received from Patient #5s NH indicated S5RN did not perform an in-person visit on 01/12/2024 as she documented and her visit documentation was inaccurate. S1ED confirmed S5RN entering a false Physicians Order into Patient #5s EHR was inaccurate documentation and should not have occurred. An interview was conducted on 02/03/2025 at 2:30 p.m. with S5RN. S5RN confirmed when she was assigned to a patients on-call request, if the situation was handled by telephone, she did not document what the conversation entailed or what instructions she provided. S5RN confirmed if the assignment required her to contact a physician for notification of a situation or to obtain new orders, she did not document her communication with the physician or any orders/instructions received. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed a Hospice employee should never falsely document a visit they did not actually perform. S2DON confirmed she would expect all steps taken by a nurse regarding the status and care of a patient to have been documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained. S2DON confirmed the agency did not currently have a system in place to double check and verify the accuracy of staff documentation. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed a Hospice employee should never falsely document a visit they did not actually perform. S1ED confirmed she would expect all steps taken by a nurse regarding the status and care of a patient to have been documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained. S1ED confirmed the agency did not currently have a system in place to double check and verify the accuracy of staff documentation. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed a Hospice employee should never falsely document a visit they did not actually perform. S3MD confirmed a nurse not documenting the care they provided or the care they instructed caregivers to provide should never occur. S3MD stated he would expect all steps taken by a nurse regarding the status and care of a patient to have been documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained. S3MD confirmed a nurse not documenting physician orders they received should never occur. S3MD confirmed if a verbal order was given to a nurse by a physician, he would expect the nurse receiving the order to enter it into the patients EHR as soon as possible to protect the accuracy of the record. 3. Faile d to ensure drugs were ordered by a physician or nurse practitioner. Patient #1 Review of Patient #1s Nurse Notes from Patient #1s NH, dated 12/13/2024 through 12/14/2024, revealed, in part, the following: 12/14/2024 12:21 a.m. - Late entry following fall on 12/13/2024 at 11:00 p.m. S5RN provided verbal telephone orders to change Patient #1s Dilaudid and Lorazepam from PRN to scheduled every 4 hours, and to have an in-house XR performed of Patient #1s left leg first thing this morning. 12/14/2024 at 12:25 p.m. – S5RN gave verbal telephone orders to continue Patient #1s Dilaudid and Lorazepam every 4 hours to manage pain. An interview was conducted on 02/04/2025 at 12:55 p.m. with Patient #1s night shift nurse at the NH on 12/13/2024 when she fell. She confirmed S5RN called the NH on 12/13/2024 just before midnight and gave verbal orders to discontinue Patient #1s PRN Dilaudid and Lorazepam and change them both to scheduled administration every 4 hours. She confirmed S5RN also gave her a verbal order for an in-house XR of Patient #1s left leg first thing in the morning. An interview was conducted on 02/05/2025 at 9:44 a.m. with Patient #1s day shift nurse at the NH on 12/14/2024. She confirmed S5RN called the NH on 12/14/2024 around lunchtime and gave verbal orders to continue administering Patient #1s Dilaudid and Lorazepam scheduled every 4 hours. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed he was the Medical Director of the Hospice agency and the Hospice agency did not utilize standing orders. S3MD confirmed he was Patient #1s physician and was familiar with her care during December 2024. S3MD confirmed he was working and available on 12/13/2024 and 12/14/2024 and no other physician would have been taking calls for him during that time. S3MD reviewed his call log, text messages and emails for 12/13/2024 and 12/14/2024 and confirmed he was not contacted by S5RN at any time regarding orders for Patient #1. S3MD confirmed he had not given S5RN verbal orders to change the administration frequency for Patient #1s Dilaudid and Lorazepam. S3MD confirmed a frequency change for a controlled substance required a physicians order and he would have expected S5RN to contact him in order to receive an order and she did not. S3MD confirmed he had not given S5RN a verbal order to perform an in-house XR of Patient #1s left leg. S3MD confirmed an order for imaging required a physicians order and he would have expected S5RN to contact him to request an order and she did not. S3MD confirmed when S5RN did not contact him to obtain the above orders, she performed actions outside of her scope of practice as a Registered Nurse which was very dangerous for patients. Patient #3 An interview was conducted on 02/10/2025 at 10:40 a.m. with Patient #3s nurse at the ALF on 12/16/2024. She reviewed her nurse notes, dated 12/16/2024, and confirmed she received a phone call around 4:00 a.m. from S5RN with a verbal telephone order for Tramadol 50mg three times daily as needed for pain. An interview was conducted on 02/11/2025 at 9:33 a.m. with S4MD. S4MD confirmed he was the one of the physicians for the Hospice agency and confirmed the Hospice agency did not utilize standing orders. S4MD confirmed he was Patient #3s physician and was familiar with her care during December 2024. S4MD reviewed his call and text logs for 12/16/2024 and confirmed he was not contacted by S5RN to obtain orders for Patient #3. S4MD confirmed he had not given S5RN verbal orders for Tramadol for Patient #3. S4MD confirmed a controlled substance required a physicians order and he would have expected S5RN to contact him to request an order and she did not. S4MD stated when S5RN did not contact him to obtain the above order for Patient #3, she performed actions outside of her scope of practice as a Registered Nurse which was very dangerous for patients. Patient #5 Review of Patient #5s Physician Orders, dated 01/12/2025, revealed, in part, the following order:01/12/2025 at 5:51 p.m. – Entered by S5RN per verbal order of S4MD - Discontinue Fentanyl patch. An interview was conducted on 02/11/2025 at 9:33 a.m. with S4MD. S4MD confirmed he was Patient #5s physician and was familiar with his care during January 2025. S4MD reviewed his call and text logs for 01/12/2025 and confirmed he was not contacted by S5RN to obtain orders for Patient #5. S4MD confirmed he had not given S5RN verbal orders to discontinue Patient #5s Fentanyl patch. S4MD confirmed he would not have approved an order to discontinue Patient #5s Fentanyl patch because his pain had been difficult to get down to a comfortable level. S4MD confirmed the discontinuation of a controlled substance required a physicians order and he would have expected S5RN to contact him in order to receive an order and she did not. S4MD stated when S5RN did not contact him to obtain the above order for Patient #5, she performed actions outside of her scope of practice as a Registered Nurse which was very dangerous for patients. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed an RN writing and/or giving prescriptions without a physicians order was considered operating outside of their scope of practice and should not occur. S2DON confirmed S5RN was employed by the Hospice agency as a RN and would not be authorized to write prescriptions for Patient #1, #3 and #5, only S3MD and S4MD were able to do so. S2DON confirmed all of their nurses were aware S3MD and S4MD did not utilize standing orders and were expected to contact S3MD and S4MD to obtain orders for their patients. S2DON reviewed the aforementioned information for Patient #1, #3 and #5 and confirmed S5RN was practicing outside of her scope by giving orders without a physician and should not have. S2DON confirmed the agency did not currently have a system in place to verify their nurses were following the procedure for obtaining a physicians order. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed an RN writing and/or giving prescriptions without a physicians order was considered operating outside of their scope of practice and should not occur. S1ED confirmed S5RN was employed by the Hospice agency as a RN and would not be authorized to write prescriptions for Patient #1, #3 and #5, only S3MD and S4MD were able to do so. S1ED confirmed all of their nurses were aware they were expected to contact either S3MD or S4MD to obtain orders for their patients and all of the staff had been provided with their contact information. S1ED reviewed the aforementioned information for Patient #1, #3 and #5 and confirmed S5RN was practicing outside of her scope by giving orders without a physician and should not have. 4. Failed to manage a continuous QAPI Program to correct identified quality deficiencies. Patient #1 Review of Patient #1s Triage Coordination Notes, dated 12/13/2024 through 12/15/2024, revealed, in part, the following: 12/15/2024 8:16 a.m. – NH called to report S5RN was supposed to perform a PRN SNV for Patient #1 on 12/14/2024 and never showed up. Advised caller care team would be notified to follow-up. Review of documentation from the agency to indicate the aforementioned concern/incident had been reported, investigated, monitored, and/or handled was attempted throughout the course of the survey with no documented evidence produced for review. An interview was conducted on 02/03/2025 at 3:20 p.m. with the DON at Patient #1s NH. She confirmed during a phone call the first week of January 2025 with S1ED, she made S1ED aware the NH was dissatisfied with the Hospice agencys services for Patient #1 on the weekend of her fall. She stated a few days later, S1ED came to the NH and she again made S1ED aware of their dissatisfaction with the way S5RN handled the entire situation in the days following Patient #1s injury. An interview was conducted on 02/05/2025 at 9:44 a.m. with Patient #1s day shift nurse at the NH on 12/14/2024 and 12/15/2024. She confirmed she contacted the Hospice agencys on-call number on 12/15/2024 to inform them S5RN failed to report to the NH on 12/14/2024 to assess Patient #1. She confirmed the Triage Nurse informed her she would make Administration aware of the issue with S5RN but no one from the Hospice agency reached out to ask her any questions. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed the Triage Nurse did not inform her S5RN failed to perform her required visits for Patient #1 on the weekend of 12/13/2024 through 12/15/2024 and should have. S2DON confirmed the agency did not currently have a system in place to ensure the Triage Nurses reported this type of information or a system to ensure the information was being investigated/handled once administration was made aware. S2DON confirmed the agency did not currently have a system in place to double check and verify staff were performing their visits. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed the Triage Nurse did not inform her S5RN failed to perform her required visits for Patient #1 on the weekend of 12/13/2024 through 12/15/2024 and she should have. S1ED confirmed the agencys Triage Nurse should have contacted someone with administration immediately when they were told S5RN did not show up for Patient #1s PRN SNV on 12/14/2024. S1ED confirmed the agency did not currently have a system in place to ensure the triage nurses reported this type of information or a system to ensure the information was being investigated/handled once administration was made aware. S1ED confirmed the agency did not currently have a system in place to double check and verify staff were performing their visits. S1ED confirmed at the beginning of January 2025, she was made the NH was very upset with the Hospice agencys services for Patient #1 on 12/13/2024 through 12/15/2024. S1ED stated the NHs DON did not make her aware why they were unhappy with the way S5RN handled the situation. S1ED confirmed she did not open a QAPI nor investigate and monitor the situation or S5RN any further. S1ED confirmed Patient #1 expired on 12/19/2024. Patient #3 Review of Patient #3s Triage Coordination Visit Notes, dated 12/15/2024 through 12/17/2024, revealed, in part, the following: 12/16/2024 at 3:23 a.m. – ALF stated Patient #3 had a fall earlier, dizziness now increased, pain reported and patient no longer able to stand on her own. ALF stated Patient #3 was normally independent. Second call for the night. Per protocol, PRN SNV to be performed. 12/16/2024 at 3:36 a.m. – S5RN was assigned to the requested PRN SNV. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed when she arrived to Patient #3s ALF on 12/16/2024 around lunch time, she was informed she was the first person from Hospice to assess Patient #3 since her fall on 12/15/2024 because S5RN had not shown up. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed Patient #3s ALF contacted the Hospice agency to file a complaint on 12/17/2024, at which point the DON made her and S1ED aware of the above incident involving S5RN and Patient #3 on 12/15/2024. S2DON confirmed after being made aware, she and S1ED provided informal education to S5RN on the importance of performing visits as required and confirmed there was no documented evidence of the education provided. S2DON confirmed S5RN was not written up nor did she receive any disciplinary action with monitoring for not performing visits as required. Review of the Hospice agencys Complaint Intake Report (CIR) regarding Patient #3, created 12/17/2024 at 3:24 p.m., revealed, in part, the following: Created by: S1EDDescription: While in a meeting with S2DON and the nurse at Patient #3s ALF, the Hospice agency was informed Patient #3 experienced a change of status on 12/15/2024 followed by a fall on the morning of 12/16/2024. ALF staff reported this information to the triage nurse who then assigned S5RN. ALF staff asked S5RN about Patient #3s pain medication due to complaints of pain following her fall because they were unable to locate it. ALF staff stated S5RN responded I dont know what you want me to do about it. S5RN did not perform a PRN SNV to assess Patient #3 or address the concerns the ALF voiced with being unable to locate her pain medication for administration. The concerns regarding Patient #3 were addressed when her regular Hospice nurse came on shift later in the day. Interventions: Educated S5RN on customer service. Review of documentation from the agency to indicate the aforementioned complaint had been investigated and monitored was attempted throughout the course of the survey with no documented evidence produced for review to indicate the issue was investigated by the Hospice agency. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed Patient #3s ALF made her and S2DON aware on 12/17/2024 of the incident involving Patient #3 on 12/15/2024. S1ED confirmed after she became aware, she created the above CIR. S1ED confirmed she and S2DON provided informal education to S5RN on the importance of performing visits as required and confirmed there was no additional documented evidence of the education provided aside from what was documented on the above CIR. S1ED confirmed S5RN was not written up nor did she receive any disciplinary action with monitoring for not performing visits as required. S1ED confirmed she did not open a QAPI nor investigate and monitor any further than documented in the aforementioned CIR. Patient #5 Review of Patient #5s Triage Coordination Note, dated 01/12/2024, revealed, in part, the following: 01/12/2025 at 3:28 p.m. – NH stated Patient #5 started new Fentanyl patch dose on 01/09/2025 with increased confusion since that time. NH stated a new Fentanyl patch was due tonight. NH requested PRN SNV to address family concerns and discuss dose changes to pain medication regimen. 01/12/2025 at 3:48 p.m. – S5RN was assigned to the requested PRN SNV. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed she was Patient #5s regular nurse on 01/12/2025 and 01/13/2025. S8RN confirmed S5RN was the nurse on-call on 01/12/2025 when the NH called about Patient #5s pain medication. S8RN confirmed when she went to see Patient #5 on 01/13/2025, the NH told her S5RN did not come to the NH on 01/12/2025 but had given them a telephone order to discontinue Patient #5s Fentanyl patch. Review of documentation from the agency to indicate the aforementioned concern had been reported, investigated, monitored, and/or handled was attempted throughout the course of the survey with no documented evidence produced for review to indicate the issue had been investigated by the Hospice agency. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed the information received from Patient #5s NH and S8RN indicated S5RN had not performed an in-person PRN SNV and she should have. S2DON confirmed S8RN did not make her aware S5RN did not perform a PRN SNV for Patient #5 on 01/12/2025 and should have. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed the information received from Patient #5s NH and S8RN indicated S5RN had not performed an in-person PRN SNV and she should have. S1ED confirmed S8RN did not make her aware S5RN did not perform a PRN SNV for Patient #5 on 01/12/2025 and should have. Patient #2 Review of Patient #1s Triage Coordination Notes, dated 01/20/2025 through 01/21/2025, revealed, in part, the following: 01/20/2025 at 11:54 p.m. - NH stated Patient #2 had an unwitnessed fall due to increased agitation. 01/21/2025 at 1:00 a.m. - S5RN was assigned. 01/21/2025 at 4:54 a.m. - NH stated Patient #2 had another unwitnessed fall due to increased agitation uncontrolled by current medication regimen. NH stated Patient #2 had increased confusion and kept trying to get out of bed.01/21/2025 at 5:04 a.m. - S5RN was assigned to the requested PRN SNV. An interview was conducted on 02/10/2025 at 1:00 p.m. with the DON for Patient #2s NH. She confirmed just before 5:00 a.m. on 01/21/2025, Patient #2 had another fall when his agitation remained uncontrolled and the NH contacted the hospice agency again to request a PRN SNV. The DON stated no one came or called back with any new orders for Patient #2. She confirmed a few days after Patient #2s falls, she made S1ED and S2DON aware of the NHs dissatisfaction with the way S5RN handled Patient #2s uncontrolled symptoms. Review of documentation from the agency to indicate the aforementioned concern had been investigated, monitored, and/or handled was attempted throughout the course of the survey with no documented evidence produced for review. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed a few days after Patient #2s fall, the NH DON made her aware S5RN did not perform a PRN SNV on 01/20/2025 and 01/21/2025 and she did not obtain new orders to manage his agitation. S2DON confirmed after being made aware, she and S1ED spoke with S5RN and provided informal education on the importance of performing visits as required and confirmed there was no documented evidence of the conversation or education provided. S2DON confirmed S5RN was not written up nor did she receive any disciplinary action with monitoring for not performing visits as required. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED stated she reviewed the Triage Call Reports every morning from all calls received the previous day. S1ED confirmed she did not review reports or hold daily stand-up meetings during weekends, holidays, and/or office closures but would review and discuss them on the following business day. S1ED stated when she reviewed the Triage Call Reports for 01/20/2025 through 01/23/2025, she noted Patient #2 had a fall on 01/20/2025 and another on 01/21/2025. S1ED confirmed no PRN SNVs had been documented by S5RN nor was there any documentation of S5RNs actions following the on-call assignments. S1ED stated she called S5RN who confirmed she did not make visits but handled the situation by phone. S1ED confirmed the NHs DON also made her aware S5RN had not performed any PRN SNVs following Patient #2s falls on 01/20/2025 and 01/21/2025 nor did she obtain new orders to manage his agitation. S1ED confirmed after speaking with the NHs DON, S5RN received a phone call for informal education making her aware of the importance of performing visits as required, the importance of contacting the physician to obtain orders when symptoms were uncontrolled and the importance of documenting her actions in response to an on-call assignment. S1ED confirmed there was no documented evidence of the conversation or education provided to S5RN. S1ED confirmed S5RN was not written up nor did she receive any disciplinary action with monitoring for not performing visits as required. S1ED stated she did not go further with the incident because she did not recall the previous incidents and thought this was the first time any potential issues involving S5RN had come up. S1ED confirmed following notification of S5RNs lack of response to Patient #2 on 01/20/2025 and 01/21/2025, she did not file a CIR, open a QAPI or investigate the situation or S5RN any further. S1ED confirmed the Hospice agency failed to have a system in place to ensure further investigation and monitoring through opening a PIP for QAPI was conducted following any of the aforementioned incidents involving S5RN and Patient #1, #2, #3 and #5. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed he was the Medical Director for the Hospice agency. S3MD confirmed if S1ED, S2DON and/or anyone employed by the Hospice agency became aware a nurse was not performing PRN SNVs as required, he would expect a system to be in place to ensure the situation was investigated further, corrected and monitored in order to ensure it did not recur moving forward.”

“Based on interviews and record reviews, the Hospice agency failed to ensure the patients clinical record contained accurate documentation of their plan of care, assessments and clinical notes. The facility failed to ensure: 1. SN visits were performed as documented for 2 (#1 and #5) of 6 (#1, #2, #3, #4, #5, and #6) patients in the final sample;2. Accuracy of Physicians Orders in the EHR for 4 (#1, #2, #3 and #5) of 6 (#1, #2, #3, #4, #5, and #6) patients in the final sample;3. All action taken by the on-call nurse was documented for 4 (#1, #2, #3 and #6) of 6 (#1, #2, #3, #4, #5, and #6) patients in the final sample; and 4. Missed Visits were documented accurately for 1 (#1) of 6 (#1, #2, #3, #4, #5, and #6) patients in the final sample. Cross Reference: L670. Review of the agencys “;Hospice Medical Record” policy, last revised 10/01/2023, revealed, in part, the following: Purpose: To define the contents and requirements of the Hospice medical record. Procedure:2. The Hospice medical record shall contain the following: b. Any summaries of care, treatment, or services, including changes in patients condition.k. The patients response to care treatment and services. l. Documentation and communication with the patient, caregivers and physicians. m. Any assessment relevant to care, treatment and services. n. Physicians Orders.7. Entries in the Hospice record must be according to acceptable standards of practice. a. All entries recorded in the Hospice record must be accurate. Review of the agencys “;On-Call and Back-up Services” policy, last revised 10/01/2024, revealed, in part, the following: Purpose: To ensure essential services will be available to all Hospice patients at all times, 24 hours a day, 7 days a week.Policy: The agency will make all attempts to provide full services at the times, frequencies and level of care specified in the patients plan of care. The agency will have a plan for back-up on-call services when the regular staff cannot report to work and during times when the office is closed. Procedure: 5. Hospice patient/representative calls are handled in the following manner: a. If the patient/representative requests a visit, a visit should be made. b. On-call events will be documented by the on-call nurse. This documentation will detail the timeline of event notification and follow-up, reason for call; and actions taken to resolve concerns of patient/representative. 7. All on-call coordination notes will be maintained in the electronic medical record. 1. Hospice Agency failed to ensure SN visits were performed as documented. Patient #1 Review of Patient #1s Clinical Record revealed she was admitted to the Hospice agency on 09/05/2024 and was a resident of a local NH facility. Review of Patient #1s Triage Coordination Notes, dated 12/14/2024 through 12/15/2024, revealed, in part, the following: 12/14/2024 at 10:24 a.m. – NH requested PRN SNV. 12/14/2024 at 10:31 a.m. – S5RN was assigned.12/15/2024 at 8:16 a.m. - NH stated S5RN did not show up to assess Patient #1 on 12/14/2024. Review of Patient #1s PRN SNV Notes, dated 12/14/2024 through 12/15/2024, revealed, in part, the following:12/14/2024 at 2:45 p.m. – S5RN documented her visit began at 3:30 p.m. and ended at 5:14 p.m. for a total in-home time of 1.73 hours. Review of Patient #1s Nurse Notes from her NH, dated 12/13/2024 through 12/14/2024, revealed, in part, the following: 12/14/2024 12:21 a.m. - Late entry following fall on 12/13/2024 at 11:00 p.m. S5RN called to say she would not be coming to the facility to assess Patient #1 12/14/2024 at 12:25 p.m. – S5RN called to say she was over an hour away and could not come at this time. Review of Patient #1s Run Reports from the local EMS, dated 12/14/2024, revealed, in part, the following: Run #1: Transport from NH to local EDDate/Time On Scene at NH: 12/14/2024 at 1:04 p.m.; Departed NH: 12/14/2024 at 1:19 p.m.Run #2: Transport from local ED to NHDate/Time of Arrival to NH: 12/14/2024 at 6:21 p.m.Further review revealed no documented evidence to indicate S5RN was present during either transport. Review of Patient #1s Medical Record from the local ED, dated 12/14/2024, revealed, in part, the following: Admit Date/Time: 12/14/2024 1:26 p.m. Discharge Date/Time: 12/14/2024 6:00 p.m.Further review revealed no documented evidence to indicate S5RN was present during visit. An interview was conducted on 02/03/2025 at 2:30 p.m. with S5RN. S5RN confirmed she was not aware the NH sent Patient #1 out on 12/14/2024. S5RN stated she assessed Patient #1 in the NH on 12/14/2024 and did not see her in the ED. S5RN confirmed the visit date/time on 12/14/2024 was accurate because she documented the PRN SNV note during her visit with Patient #1. An interview was conducted on 02/04/2025 at 1:12 p.m. with Patient #1s daughter who confirmed she was her roommate in the NH. She confirmed she remained in their room from the time Patient #1 fell on 12/13/2024 until Patient #1 went inpatient Hospice on 12/15/2024. She confirmed her mother was not present in the NH from lunchtime on 12/14/2024 until after supper the same day because she was at the ED. She confirmed S5RN did not come to their room at any time on 12/13/2024 or 12/14/2024. An interview was conducted on 02/04/2025 at 12:55 p.m. with Patient #1s night shift nurse at the NH where she resided. She confirmed she worked on 12/14/2024 from 6:00 p.m. to 6:00 a.m. as Patient #1s nurse. She confirmed neither S5RN nor anyone from the Hospice agency came to the NH to see Patient #1 during her shift on 12/14/2024. She confirmed Patient #1s daughter was her roommate and was cognitively intact. An interview was conducted on 02/05/2025 at 9:44 a.m. with Patient #1s day shift nurse at the NH where she resided. She confirmed she worked on 12/14/2024 from 6:00 a.m. until after 7:00 p.m. as Patient #1s nurse. She confirmed she contacted the Hospice agency immediately on the morning of 12/14/2024 to request a PRN SNV immediately. She stated S5RN called and told her she would not be coming to the NH at that time. She confirmed neither S5RN nor anyone from the Hospice agency came to the NH to see Patient #1 during her shift on 12/14/2024. She confirmed Patient #1 was sent to the ED via ambulance per family request around lunchtime on 12/14/2024 and did not return until just prior to the end of her shift. She stated if someone from Hospice had come to assess Patient #1 during that timeframe, they would have had to ask her or Patient #1s daughter where the patient was and no one did. An interview was conducted on 02/04/2025 at 1:25 p.m. with the Supervisor of the local EMS. He reviewed the run reports for Patient #1 dated 12/14/2024. He confirmed she was picked up from the NH on 12/14/2024 at 1:19 p.m. and transported to the ED. He confirmed she arrived back to the NH from the ED on 12/14/2024 at 6:21 p.m. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed S5RN had not contacted him regarding Patient #1 at any time on 12/14/2024. S3MD confirmed if Patient #1 was not present in the NH on 12/14/2024 at the time S5RN documented a visit was performed for her in the NH, there was no way the documented visit could be accurate. S3MD confirmed a Hospice employee should never falsely document a visit they did not actually perform. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed if Patient #1 was not present in the NH on 12/14/2024 at the time S5RN documented a visit was performed for her in the NH, there was no way the documented visit could be accurate S2DON confirmed a Hospice employee should never falsely document a visit they did not actually perform. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed if Patient #1 was not present in the NH on 12/14/2024 at the time S5RN documented a visit was performed for her in the NH, there was no way the documented visit could be accurate S1ED confirmed a Hospice employee should never falsely document a visit they did not actually perform. Patient #5 Review of Patient #5s Clinical Record revealed he was admitted to the agency on 12/16/2024 and was a resident of a local NH facility. Review of Patient #5s Triage Coordination Notes, dated 01/12/2024, revealed, in part, the following: 01/12/2025 at 3:28 p.m. – NH requested PRN SNV. 01/12/2025 at 3:48 p.m. – S5RN assigned. Review of Patient #5s PRN SNV Narrative Notes, dated 01/12/2025, revealed, in part, the following: 01/12/2025 at 5:41 p.m. – S5RN documented her visit began at 5:41 p.m. and ended at 6:21 p.m. for a total in-home time of 0.5 hours. An interview was conducted on 02/05/2025 at 12:00 p.m. with the DON for Patient #5s NH. She reviewed Patient #5s Nurse Notes at the NH and confirmed there was a note written on 01/12/2025 at 11:46 a.m. which indicated a PRN SNV was requested for Patient #5. She stated the note indicated S5RN informed the NH she would not be coming today because his regular nurse would come the following day during normal business hours. An interview was conducted on 02/05/2025 at 1:16 p.m. with the Administrator for Patient #5s NH. She reviewed Patient #5s Nurse Notes at the NH and confirmed there was a nurse note written on 01/12/2025 at 11:46 a.m. which indicated a PRN SNV was requested for Patient #5. She stated the note indicated S5RN informed the NH she would not be coming today and his regular nurse would come the following day during normal business hours. She confirmed she reviewed Patient #5s hard chart, Hospice chart and EHR and no documentation was present to indicate S5RN came to the NH on 01/12/2025. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed she was Patient #5s regular nurse. S8RN confirmed S5RN was the Hospice nurse on-call when the NH called to request a PRN SNV for Patient #5 on 01/12/2025. S8RN confirmed when she went to see Patient #5 on 01/13/2025 for her regular visit, the NH nurse told her S5RN gave a telephone order the previous night for his pain medication regimen. An interview was conducted on 02/11/2025 at 9:33 a.m. with S4MD. S4MD confirmed S5RN had not contacted him regarding Patient #5 at any time on 01/12/2025. S4MD confirmed the information received from Patient #5s NH indicated S5RN did not perform an in-person visit on 01/12/2024 as she documented and her visit documentation was inaccurate. S4MD confirmed a Hospice employee should never falsely document a visit they did not actually perform. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed the information received from Patient #5s NH indicated S5RN did not perform an in-person visit as she documented on 01/12/2024 and her visit documentation was inaccurate. S2DON confirmed a Hospice employee should never falsely document a visit they did not actually perform. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed the information received from Patient #5s NH indicated S5RN did not perform an in-person visit on 01/12/2024 as she documented and her visit documentation was inaccurate. S1ED confirmed a Hospice employee should never falsely document a visit they did not actually perform. 2. Hospice Agency failed to ensure accuracy of Physicians Orders in the EHR Patient #1 Review of Patient #1s Nurse Notes from her NH, dated 12/13/2024 through 12/14/2024, revealed, in part, the following: 12/14/2024 12:21 a.m. - Late entry following fall on 12/13/2024 at 11:00 p.m. S5RN provided verbal telephone orders to change the frequency of Patient #1s Dilaudid and Lorazepam from PRN to scheduled every 4 hours and to have an in-house XR performed of Patient #1s left leg in the morning. 12/14/2024 at 12:25 p.m. – S5RN gave verbal telephone orders to continue Patient #1s Dilaudid and Lorazepam scheduled every 4 hours to manage pain. Review of Patient #1s Physician Orders, dated 12/13/2024 through 12/14/2024, revealed, in part, the following: 12/13/2024 – No Physician Orders entered by S5RN to change the frequency of Dilaudid and Lorazepam from PRN to scheduled every 4 hours or for an in-house XR of the left leg. 12/14/2024 – No Physician Orders entered by S5RN to change the frequency of Dilaudid and Lorazepam from PRN to scheduled every 4 hours or for an in-house XR of the left leg. An interview was conducted on 02/04/2025 at 12:55 p.m. with Patient #1s night shift nurse at the NH. She confirmed she worked on 12/13/2024 from 6:00 p.m. to 6:00 a.m. as Patient #1s nurse. She stated S5RN called the NH on 01/13/2024 after Patient #1 fell and gave verbal telephone orders to change the frequency of her Dilaudid and Lorazepam from PRN to scheduled every 4 hours and to have an in-house XR performed of Patient #1s left leg in the morning. An interview was conducted on 02/05/2025 at 9:44 a.m. with Patient #1s day shift nurse at the NH. She confirmed she worked on 12/14/2024 from 6:00 a.m. until after 7:00 p.m. as Patient #1s nurse. She confirmed S5RN called on 12/14/2024 around lunch time and gave verbal telephone orders to continue administering Patient #1s Dilaudid and Lorazepam scheduled every 4 hours to manage pain. An interview was conducted on 02/03/2025 at 2:30 p.m. with S5RN. S5RN confirmed when she was assigned to a patients on-call request, if the situation was handled by telephone, she did not document what the conversation entailed or what instructions she provided. S5RN confirmed if the assignment required her to contact a physician for notification of a situation or to obtain new orders, she did not document her communication with the physician or any orders/instructions received. S5RN stated she did not consider the verbal order she provided to Patient #1s NH nurse to discontinue PRN Dilaudid and Lorazepam and change to scheduled every 4 hours or the verbal order to obtain an XR of the left leg to require a documented note or new orders to be entered into her EHR. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed Patient #1s Physicians Orders did not accurately reflect the verbal orders S5RN gave the NH on 12/13/2024 and 12/14/2024 for Patient #1 and should. S2DON confirmed if S5RN received a verbal medication order from S3MD for Patient #1, she would expect an electronic order to be entered into the EHR as soon as possible to protect the accuracy of the record. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed Patient #1s Physicians Orders did not accurately reflect the verbal orders S5RN gave the NH on 12/13/2024 and 12/14/2024 for Patient #1 and should. S1ED confirmed if S5RN received a verbal medication order from S3MD for Patient #1, she would expect an electronic order to be entered into the EHR as soon as possible to protect the accuracy of the record. Patient #2 Review of Patient #2s Clinical Record revealed he was admitted to the Hospice agency on 11/15/2022 and was a resident of a local NH facility. Review of the agencys Client Occurrence Report for Patient #2s fall on 01/21/2025 at 5:04 a.m. revealed, in part, the following: Person Preparing Report: S5RNLocation: Patient #2s NHNature of Occurrence: Unattended FallDescription: S3MD gave a new verbal order to increase Patient #2s Morphine Concentrate to 0.75mLs. Review of Patient #2s Physician Orders, dated 01/21/2025 through 01/23/2025, revealed in part, the following: 01/21/2025 – No Physician Order entered by S5RN to increase Morphine Concentrate to 0.75mLs. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed Patient #2s Physicians Orders did not accurately reflect the verbal orders S5RN documented she received from S3MD on 01/21/2025 and should. S2DON confirmed if S5RN received a verbal medication order from S3MD for Patient #2, she would expect an electronic order to be entered into the EHR as soon as possible to protect the accuracy of the record. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed Patient #2s Physicians Orders did not accurately reflect the verbal orders S5RN documented she received from S3MD on 01/21/2025 and should. S1ED confirmed if S5RN received a verbal medication order from S3MD for Patient #2, she would expect an electronic order to be entered into the EHR as possible to protect the accuracy of the record. Patient #3 Review of Patient #3s Clinical Record revealed she was admitted to the Hospice agency on 04/18/2024 and was a resident of a local ALF. Review of Patient #3s Physician Orders, dated 12/15/2024 through 12/16/2024, revealed, in part, the following:12/15/2024 – No physician orders entered by S5RN for Tramadol 50mg by mouth three times daily.12/16/2024 – No physician orders entered by S5RN for Tramadol 50mg by mouth three times daily12/16/2024 at 11:46 a.m. – Tylenol 325mg 1 tab by mouth every 4 hours as needed for fever or pain entered by S8RN per S4MD.12/16/2024 at 11:46 a.m. – Tramadol 50mg 1 tab by mouth three times daily as needed for pain entered by S8RN per S4MD. An interview was conducted on 02/10/2025 at 10:40 a.m. Patient #3s nurse at the ALF. She confirmed she worked on 12/15/2024 and 12/16/2024 as Patient #3s nurse. She confirmed following Patient #3s fall around 11:00 p.m. on 12/15/2024, S5RN called shortly after midnight on 12/16/2024 with a new verbal order for Tramadol 50mg three times daily as needed for pain and stated she was sending the prescription to the pharmacy now. She confirmed the pain medication S5RN ordered on 12/16/2024 never arrived from the pharmacy. An interview was conducted on 02/10/2025 at 12:25 p.m. with S8RN. S8RN confirmed she was Patient #3s regular nurse on 12/16/2024. S8RN confirmed around lunchtime on 12/16/2024 she obtained an order from S4MD for Tramadol when she realized S5RN had not followed through with the verbal order she gave the ALF while on-call. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed Patient #3s Physicians Orders did not accurately reflect the verbal orders given to the ALF by S5RN on 12/16/2024 and should. S2DON confirmed if S5RN gave a verbal medication order for Patient #3, she would expect an electronic order to be entered into the EHR as soon as possible to protect the accuracy of the record. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed Patient #3s Physicians Orders did not accurately reflect the verbal orders S5RN gave the ALF on 12/16/2024 and should. S1ED confirmed if an order was given verbally for a patient, she would expect an electronic order to be entered into the patients EHR as soon as possible to protect the accuracy of the record. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed he was the Medical Director for the Hospice agency. S3MD confirmed a nurse not documenting physician orders they received should never occur. S3MD confirmed if a verbal order was given to a nurse by a physician, he would expect the nurse receiving the order to enter it into the patients EHR as soon as possible to protect the accuracy of the record. Patient #5 Review of Patient 5s PRN SNV Notes, dated 01/12/2025, revealed, in part, the following: 01/12/2025 at 5:41 p.m. by S5RN – Verbal order given to NH nurse to discontinue current Fentanyl patch. Will confer with S4MD per S8RN regarding change. Review of Patient #5s Physician Orders, dated 01/12/2025, revealed, in part, the following order:01/12/2025 at 5:51 p.m. – Entered by S5RN per verbal order of S4MD - Discontinue Fentanyl patch. An interview was conducted on 02/11/2025 at 9:33 a.m. with S4MD. S4MD confirmed he was Patient #5s physician and was familiar with his care during January 2025. S4MD confirmed he was not contacted by S5RN to obtain orders for Patient #5 on 01/12/2025 and had not given S5RN verbal orders to discontinue Patient #5s Fentanyl patch. S4MD stated if there was an order in Patient #5s EHR to discontinue his Fentanyl patch, the order was inaccurate. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed S5RN entering a false Physicians Order into Patient #5s EHR was inaccurate documentation and should not have occurred. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed S5RN entering a false Physicians Order into Patient #5s EHR was inaccurate documentation and should not have occurred. 3. Hospice Agency failed to ensure all action taken by the on-call nurse was documented Patient #1 Review of Patient #1s Triage Coordination Notes, dated 12/13/2024 through 12/15/2024, revealed, in part, the following: 12/13/2024 at 11:16 p.m. - NH requested PRN SNV due to Patient #1s fall with obvious signs of injury.12/13/2024 at 11:22 p.m. - S5RN was assigned.12/15/2024 at 8:16 a.m. - NH requested PRN SNV ASAP for continued uncontrolled pain. 12/15/2024 at 9:24 a.m. - S5RN was assigned. Review of Patient #1s Nurse Notes from the NH, dated 12/13/2024 through 12/15/2024, revealed, in part, the following: 12/14/2024 at 12:21 a.m. - Late entry regarding fall on 12/13/2024 at 11:00 p.m. S5RN was given a report of Patient #1s status over the telephone. S5RN gave verbal orders to change the frequency of Dilaudid and Lorazepam from PRN to scheduled every 4 hours and in-house XR of left leg the next morning. 12/14/2024 at 12:25 p.m. - S5RN returned call at 11:30 a.m. S5RN was given an update on Patient #1s status over the telephone. S5RN gave verbal orders to continue Dilaudid and Lorazepam scheduled every 4 hours to manage pain. 12/15/2024 at 9:45 a.m. – S5RN returned call and stated Patient #1 required transfer to inpatient Hospice and stated she would be in shortly to make arrangements. 12/15/2024 at 10:58 a.m. – S5RN called to state S3MD had given orders for Patient #1 to be transferred to inpatient Hospice at a local hospital. Review of Patient #1s Physician Orders, dated 12/13/2024 through 12/15/2024, revealed, in part, the following: 12/15/2024 at 5:47 a.m. – Change level of care from routine to inpatient entered by S5RN per S3MD. Review of Patient #1s PRN SNV Notes, dated 12/13/2024 through 12/15/2024, revealed, in part, the following:12/13/2024 – No documentation present by S5RN. 12/14/2024 at 2:45 p.m. by S5RN - Patient #1 in bed, stable, and responded “;no” to being in pain. Patient #1s NH nurse educated on the use of Dilaudid to control pain. Patient #1s POC, medication regimen and effectiveness, use of comfort kit, and pharmacologic and non-pharmacologic measures reviewed with her NH nurse. Patient #1s NH nurse verbalized understanding. 12/14/2024 – No additional documentation present on this date by S5RN.12/15/2024 – No documentation present by S5RN. Review of Patient #1s Nurse Coordination Notes, dated 12/13/2024 through 12/15/2024, revealed, in part, the following:12/13/2024 – No documentation present by S5RN. 12/14/2024 at 2:45 p.m. by S5RN - Patient #1 in bed, stable, and responded “;no” to being in pain. Patient #1s NH nurse educated on the use of Dilaudid to control pain. Patient #1s POC, medication regimen and effectiveness, use of comfort kit, and pharmacologic and non-pharmacologic measures reviewed with her NH nurse. Patient #1s NH nurse verbalized understanding. 12/14/2024 – No additional documentation present on this date by S5RN.12/15/2024 – No documentation present by S5RN. An interview was conducted on 02/04/2025 at 1:12 p.m. with Patient #1s daughter. She confirmed she was Patient #1s roommate in the NH. She confirmed she was in their room from the time of Patient #1s fall on 12/13/2024 until Patient #1 went inpatient Hospice on 12/15/2024. She confirmed S5RN came to their room on 12/15/2024 around lunchtime to assess her mother and let her know she would be transferred to a local hospital for inpatient Hospice. An interview was conducted on 02/04/2025 at 12:55 p.m. with Patient #1s night shift nurse at the NH where she resided. She confirmed she worked 6:00 p.m. to 6:00 a.m. She confirmed she was Patient #1s nurse on the night of 12/13/2024 when she fell. She confirmed she provided S5RN with a telephone report of Patient #1s status following her fall and was told to change the frequency of her Lorazepam and Dilaudid from PRN to scheduled every four hours and obtain an in-house XR of the left leg in the morning. She confirmed Patient #1 was transferred to a local hospital per S5RN for inpatient Hospice on 12/15/2024 during her shift. An interview was conducted on 02/05/2025 at 9:44 a.m. with Patient #1s day shift nurse at the NH on 12/14/2024. She confirmed she and S5RN had multiple phone calls throughout the morning on 12/14/2024 regarding Patient #1s status and care. She stated during the first call, she informed S5RN Patient #1s pain remained uncontrolled. She stated S5RN told her she was going to try to locate a pharmacy to fill and deliver new pain medications to the NH. She stated she spoke with S5RN on the phone again after Patient #1s in-house XR confirmed a left femur fracture, at which point S5RN told her not to send her out because nothing could be done. She stated S5RN told her to continue giving Lorazepam and Dilaudid every 4 hours. She confirmed she contacted the Hospice Triage Nurse on 12/15/2024 at 8:16 a.m. to make them aware S5RN had not shown up to assess Patient #1 since her fall on 12/13/2024. She confirmed she informed the Triage Nurse Patient #1s pain remained uncontrolled and requested a PRN SNV immediately for additional pain medication orders. She stated she received a return call from S5RN on 12/15/2024 at 9:45 a.m. informing her Patient #1 needed to be transferred to inpatient hospice for aggressive IV pain control. She confirmed the first time S5RN arrived to the NH to physically assess Patient #1 was around lunch time on 12/15/2024 when they were preparing her for transfer to inpatient hospice. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed he was contacted by S5RN on 12/15/2024 to request Patient #1 be transferred to a local hospital for inpatient Hospice due to uncontrolled pain following a fall on 12/13/2024 resulting in left femur fracture. S3MD confirmed a nurse not documenting the care they provided or the care they instructed caregivers to provide should never occur. S3MD stated he would expect all steps taken by a nurse regarding the status and care of a patient to have been documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed she would expect all steps taken by a nurse regarding the status and care of a patient to have been documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained and S5RN had not. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed she would expect all steps taken by a nurse regarding the status and care of a patient to have been documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained and S5RN had not. Patient #2 Review of Patient #2s Triage Coordination Notes, dated 01/20/2025 through 01/25/2025, revealed in part, the following: 01/21/2025 at 12:54 a.m. – NH called to report an unwitnessed fall out of bed. 01/21/2025 at 1:00 a.m. – S5RN was assigned. 01/21/2025 at 4:54 a.m. – NH called to report a second unwitnessed fall with scrapes present to elbows and forehead. Patient fell again, scraped his elbows with scrape to forehead, unclear if he hit his head. Denies pain. Patient #2 remains confused and attempting to get out of bed. Receiving medications as instructed following first fall but it is ineffective at this time. 01/21/2025 at 5:09 a.m. – S5RN was assigned. Review of Patient #2s PRN SNV Notes, dated 01/21/2025 through 01/22/2025, revealed, in part, the following:01/21/2025 – No documentation present by S5RN. Review of Patient #2s Nurse Coordination Notes, 01/21/2025 through 01/22/2025, revealed, in part, the following:01/21/2025 – No documentation present by S5RN. An interview was conducted on 02/10/2025 at 1:00 p.m. with the DON of the NH where for Patient #2 resided. She confirmed S5RN contacted Patient #2s NH nurse by telephone on 01/21/2025 following his first fall and told them to administer his agitation medications as frequently as they could per his orders, to increase safety rounds and to call back with any changes. She confirmed Patient #2 fell again a few hours later due to continued agitation. She confirmed Patient #2s NH nurse contacted the Triage Nurse to report the second fall with continued uncontrolled agitation. She confirmed S5RN contacted Patient #2s NH nurse by telephone following his second fall on 01/21/2025 and told them to make sure they were administering his agitation medications as frequently as his orders would allow, to continue the increased safety rounds and to call back with any additional changes. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed she would expect all steps taken by a nurse regarding the status and care of Patient #2 to be documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained and S5RN had not. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed she would expect all steps taken by a nurse regarding the status and care of Patient #2 to be documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained and S5RN had not. Patient #3 Review of Patient #3s Triage Coordination Notes, dated 12/15/2024 through 12/17/2024, revealed, in part, the following: 12/15/2024 11:40 p.m. – ALF reported Patient #3 fell and was having dizziness when she stood up. Blood pressure was 182/88. 12/16/2024 at 3:23 a.m. – ALF reported Patient #3 with increased dizziness and no longer able to stand independently. 2nd call for the night. Per protocol patient requires PRN SNV. 12/16/2024 at 3:36 a.m. – S5RN was assigned. Review of Patient #3s PRN SNV Notes, dated 12/15/2024 through 12/16/2024, revealed, in part, the following:12/15/2024 – No documentation present by S5RN. 12/16/2024 – No documentation present by S5RN. Review of Patient #3s Nurse Coordination Notes, dated 12/15/2024 through 12/16/2024, revealed, in part, the following:12/15/2024 – No documentation present by S5RN. 12/16/2024 – No documentation present by S5RN. An interview was conducted on 02/10/2025 at 10:40 a.m. Patient #3s nurse at the ALF on 12/15/2024 through 12/16/2024. She confirmed she was familiar with Patient #3 and her care during December 2024. She confirmed Patient #3 had a change of condition followed by a fall on 12/15/2024 a little before midnight so she contacted the Hospice Triage Nurse to report it. She confirmed around 4:00 a.m. on 12/16/2024, Patient #3s condition declined further and she began complaining of pain so she contacted the Hospice Triage Nurse again and requested a PRN SNV. She reviewed her nurse notes, dated 12/15/2024 and 12/16/2024, and confirmed she received a phone call on 12/16/2024 around 4:00 a.m. from S5RN with a verbal telephone order for Tramadol 50mg three times daily as needed for pain. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed she would expect all steps taken by a nurse regarding the status and care of Patient #3 to be documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained and S5RN had not. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed she would expect all steps taken by a nurse regarding the status and care of Patient #3 to be documented; including all contact with the caregiver, contact with the physician and any follow up contact to ensure relief was obtained and S5RN had not. Patient #6 Review of Patient #6s Clinical Record revealed he was admitted to the Hospice agency on 12/06/2024 and lived at home with family. Review of Patient #6s POC, for a Certification Period of 12/06/2024 through 03/05/2025, revealed, in part, he was ordered to receive one SNV twice weekly for one week, seven SNVs weekly for twelve weeks, four SNVs weekly for one week and visits as needed for symptom management. Review of Patient #6s Clinical Triage Coordination Notes, dated 12/26/2024, revealed, in part, the following: 12/26/2024 at 2:12 a.m. – Patient #6s daughter requested a PRN SNV immediately due to uncontrolled symptoms. 12/26/2024 at 2:33 a.m. – S5RN was assigned. Review of Patient #6s Nurse Coordination Notes, dated 12/26/2024, revealed, in part, the following: 12/26/2024 – No Nurse Coordination Notes documented by S5RN. Review of Patient #6s PRN SNV Notes, dated 12/26/2024, revealed, in part, the following: 12/26/2024 – No PRN SNV Notes documented by S5RN. An interview was conducted on 02/03/2025 at 2:30 p.m. with S5RN. S5RN confirmed when she was assigned to a patients on-call request, if the situation was handled by telephone, she did not document what the conversation entailed or what instructions she provided. S5RN confirmed if the assignment required her to contact a physician for notification of a situation or to obtain new orders, she did not document her communication with the physician or any orders/instructions received. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON reviewed the lack of documentation for Patient #6 by S5RN and confirmed she would have expected S5RN to document whatever actions she took following her assignment to Patient #6s request for a PRN SNV and she did not. S2DON confirmed she would expect any steps taken by S5RN regarding the status and care of Patient #6 to be documented; including all contact with the caregiver, any contact with their physician and any follow up contact made to ensure relief was obtained and S5RN had not. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED reviewed the lack of documentation for Patient #6 by S5RN and confirmed she would have expected S5RN to document whatever actions she took following her assignment to Patient #6s request for a PRN SNV and she did not. S1ED confirmed she would expect any steps taken by S5RN regarding the status and care of Patient #6 to be documented; including all contact with the caregiver, any contact with their physician and any follow up contact made to ensure relief was obtained and S5RN had not. 4. Hospice Agency failed to ensure missed visits were documented accurately Patient #1 Review of Patient #1s POC, for the Certification Period of 12/04/2024 through 12/19/2024, revealed she was to receive HA visits three times weekly. Review of Patient #1s Visit Calendar and Client Coordination Notes, dated 11/01/2024 through 12/19/2024, revealed, in part, the following: 11/01/2024 – HA Missed Visit - Caregiver/Patient Refused. 11/20/2024 – HA Missed Visit - Caregiver/Patient Refused. 11/22/2024 – HA Missed Visit - Caregiver/Patient Refused. 11/25/2024 – HA Missed Visit - Caregiver/Patient Refused. 11/27/2024 – HA Missed Visit - Caregiver/Patient Refused.12/03/2024 – HA Missed Visit - Caregiver/Patient Refused.12/11/2024 – HA Missed Visit - Caregiver/Patient Refused. 12/16/2024 – HA Missed Visit - Caregiver/Patient Refused. 12/18/2024 – HA Missed Visit - Caregiver/Patient Refused. An interview was conducted on 02/04/2025 at 1:12 p.m. with Patient #1s daughter who confirmed she was her roommate at the NH. She confirmed she, nor her mother refused care from any of the Hospice employees, especially the HA. An interview was conducted on 02/06/2025 at 11:30 a.m. with S6HA. S6HA confirmed she was Patient #1s normal HA. S6HA confirmed neither Patient #1 nor her daughter had ever refused an aide visit. S6HA stated she could not always make it to Patient #1s NH in time to provide care when she wanted to have it performed, so Patient #1s daughter would ask the NH aide to do it before she arrived. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed S6HAs missed visits documented as patient refused did not accurately reflect the reason for the missed visit and was inaccurate documentation. S2DON stated their EHR system did not have many options for why visits were missed, so missed visits were frequently documented as refusal even if the patient/family had not refused and they should not have been charted as refused visits. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed S6HAs missed visits documented as patient refused did not accurately reflect the reason for the missed visit and was inaccurate documentation. S1ED stated their EHR system did not have many options for why visits were missed, so missed visits were frequently documented as refusal even if the patient/family had not refused and they should not have been charted as refused visits. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed he was the Medical Director of the Hospice agency. S3MD confirmed documenting a visit as performed when it had not been and documenting a visit as refused when it had not been would be fraudulent and should never occur. S3MD confirmed a nurse not documenting the care they instructed or instructions provided to caregivers should never occur. S3MD confirmed when an on-call nurse was assigned to a patient by the Triage Nurse, he would expect them to document in the patients EHR any and all actions taken, otherwise, it would be impossible for him or anyone else to look back and see what occurred and what was done for the patient. S3MD confirmed he would expect a nurse to add a Physicians Order into the patients EHR as soon as the order was received from the physician in order to ensure the accuracy of the patients medication list at all times. S3MD confirmed a nurse entering a Physicians Order into the EHR for an order they did not receive from the physician would not only be fraudulent but would also cause the patients medication list to be inaccurate and should never occur. S3MD confirmed he would expect a patients mediation list to accurately reflect the orders given by their physician at all times and if they were not, the medication list would be inaccurate and would put the patients safety at risk.”

“Based on interviews and record reviews, the Hospice agency failed to ensure drugs were ordered by a physician or nurse practitioner for 3 (#1, #3 and #5) of 6 (#1, #2, #3, #4, #5, and #6) total sampled patients. Cross Reference: L686. Review of Patient #1s Clinical Record revealed she was admitted to the Hospice agency on 09/05/2024. Further review revealed she was a resident of a local NH facility and her Hospice Physician was S3MD. Review of Patient #1s Triage Coordination Notes, dated 12/13/2024 through 12/15/2024, revealed, in part, the following: 12/13/2024 at 11:16 p.m. - NH stated Patient #1 had an unwitnessed fall with complaints of left leg pain and visible displacement noted, with raised, hard area to outside of left knee. 12/13/2024 at 11:22 p.m. - S5RN was assigned.12/14/2024 at 10:24 a.m. - NH stated Patient #1s in-house XR indicated broken femur. 12/14/2024 at 10:31 a.m. - S5RN was assigned. Review of Patient #1s Nurse Notes from her NH, dated 12/13/2024 through 12/14/2024, revealed, in part, the following: 12/14/2024 12:21 a.m. - Late entry following fall on 12/13/2024 at 11:00 p.m. S5RN provided verbal telephone orders to change Patient #1s Dilaudid and Lorazepam from PRN to scheduled every 4 hours, and to have an in-house XR performed of Patient #1s left leg first thing this morning. 12/14/2024 at 12:25 p.m. – S5RN gave verbal telephone orders to continue Patient #1s Dilaudid and Lorazepam every 4 hours to manage pain. An interview was conducted on 02/04/2025 at 12:55 p.m. with Patient #1s night shift nurse at the NH on 12/13/2024 when she fell. She confirmed S5RN called the NH on 12/13/2024 just before midnight and gave verbal orders to discontinue Patient #1s PRN Dilaudid and Lorazepam and change them both to scheduled administration every 4 hours. She confirmed S5RN also gave her a verbal order for an in-house XR of Patient #1s left leg first thing in the morning. An interview was conducted on 02/05/2025 at 9:44 a.m. with Patient #1s day shift nurse at the NH on 12/14/2024. She confirmed S5RN called the NH on 12/14/2024 around lunch time and gave verbal orders to continue administering Patient #1s Dilaudid and Lorazepam scheduled every 4 hours. An interview was conducted on 02/05/2025 at 2:40 p.m. with S3MD. S3MD confirmed he was the Medical Director of the Hospice agency and the Hospice agency did not utilize standing orders. S3MD confirmed he was Patient #1s physician and was familiar with her care during December 2024. S3MD confirmed he was working and available on 12/13/2024 and 12/14/2024 and no other physician would have been taking calls for him during that time. S3MD reviewed his call log, text messages and emails for 12/13/2024 and 12/14/2024 and confirmed he was not contacted by S5RN at any time regarding orders for Patient #1. S3MD confirmed he had not given S5RN verbal orders to change the administration frequency for Patient #1s Dilaudid and Lorazepam. S3MD confirmed a frequency change for a controlled substance required a physicians order and he would have expected S5RN to contact him in order to receive an order and she did not. S3MD confirmed he had not given S5RN a verbal order to perform an in-house XR of Patient #1s left leg. S3MD confirmed an order for imaging required a physicians order and he would have expected S5RN to contact him to request an order and she did not. S3MD confirmed when S5RN did not contact him to obtain the above orders, she performed actions outside of her scope of practice as a Registered Nurse which was very dangerous for patients. Patient #3 Review of Patient #3s Clinical Record revealed she was admitted to the hospice agency on 04/18/2024. Further review revealed she resided at a local ALF and her Hospice Physician was S4MD. Review of Patient #3s Triage Coordination Visit Notes, dated 12/15/2024 through 12/16/2024, revealed, in part, the following: 12/16/2024 3:23 a.m. – ALF stated Patient #3 had a fall earlier, dizziness now increased, pain reported and patient no longer able to stand on her own. 02/16/2024 at 3:36 a.m. – S5RN was assigned. An interview was conducted on 02/10/2025 at 10:40 a.m. with Patient #3s nurse at the ALF on 12/16/2024. She reviewed her nurse notes, dated 12/16/2024, and confirmed she received a phone call around 4:00 a.m. from S5RN with a verbal telephone order for Tramadol 50mg three times daily as needed for pain. An interview was conducted on 02/11/2025 at 9:33 a.m. with S4MD. S4MD confirmed he was one of the physicians for the Hospice agency and confirmed the Hospice agency did not utilize standing orders. S4MD confirmed he was Patient #3s physician and was familiar with her care during December 2024. S4MD reviewed his call and text logs for 12/16/2024 and confirmed he was not contacted by S5RN to obtain orders for Patient #3. S4MD confirmed he had not given S5RN verbal orders for Tramadol for Patient #3. S4MD confirmed a controlled substance required a physicians order and he would have expected S5RN to contact him to request an order and she did not. S4MD stated when S5RN did not contact him to obtain the above order for Patient #3, she performed actions outside of her scope of practice as a Registered Nurse which was very dangerous for patients. Patient #5Review of Patient #5s Clinical Record revealed he was admitted to the agency on 12/16/2024 with diagnoses, which included, in part, Pressure Ulcer Stage 4 Sacral Region, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region, and Pressure Ulcer of Unidentified Site with Unidentified Staging. Further review revealed on 01/12/2025 Patient #3 > change to #5 resided at a local NH and his Hospice Physician was S4MD. Review of Patient #5s Triage Coordination Note, dated 01/12/2025, revealed, in part, the following: 01/12/2025 at 3:28 p.m. – NH stated Patient #5 started new Fentanyl patch dose on 01/09/2025 with increased confusion since that time. NH stated a new Fentanyl patch was due tonight. NH requested PRN SNV to address family concerns with the Fentanyl patch dosage. 01/12/2025 at 3:48 p.m. – S5RN was assigned. Review of Patient #3s PRN SNV Notes, dated 01/12/2025, revealed, in part, the following: 01/12/2025 at 5:41 p.m. by S5RN – Patient #5s son requested his Fentanyl patch be discontinued and resumed at a lower dose. Verbal order given to NH nurse to discontinue current Fentanyl patch. Will confer with S4MD per S8RN regarding dosage change. An interview was conducted on 02/11/2025 at 9:33 a.m. with S4MD. S4MD confirmed he was Patient #5s physician and was familiar with his care during January 2025. S4MD reviewed his call and text logs for 01/12/2025 and confirmed he was not contacted by S5RN to obtain orders for Patient #5. S4MD confirmed he had not given S5RN verbal orders to discontinue Patient #5s Fentanyl patch. S4MD confirmed he would not have approved an order to discontinue Patient #5s Fentanyl patch because his pain had been difficult to get down to a comfortable level. S4MD confirmed the discontinuation of a controlled substance required a physicians order and he would have expected S5RN to contact him in order to receive an order and she did not. S4MD stated when S5RN did not contact him to obtain the above order for Patient #5, she performed actions outside of her scope of practice as a Registered Nurse which was very dangerous for patients. An interview was conducted on 02/11/2025 at 11:05 a.m. with S2DON. S2DON confirmed an RN writing and/or giving prescriptions without a physicians order was considered operating outside of their scope of practice and should not occur. S2DON confirmed S5RN was hired by the Hospice agency in January of 2024 as a RN and would not be authorized to write prescriptions for Patient #1, #3 and #5, only S3MD and S4MD were able to do so. S2DON confirmed all of their nurses were aware S3MD and S4MD did not utilize standing orders and preferred to make decisions regarding patient orders on a case by case basis. S2DON confirmed all of their nurses were aware they were expected to contact S3MD and S4MD to obtain orders for their patients and each of them had been provided with their contact information. S2DON reviewed the aforementioned information for Patient #1, #3 and #5 and confirmed S5RN was practicing outside of her scope by giving orders without a physician and should not have. An interview was conducted on 02/11/2025 at 11:08 a.m. with S1ED. S1ED confirmed an RN writing and/or giving prescriptions without a physicians order was considered operating outside of their scope of practice and should not occur. S1ED confirmed S5RN was hired by the Hospice agency in January of 2024 as a RN and would not be authorized to write prescriptions for Patient #1, #3 and #5, only S3MD and S4MD were able to do so. S1ED confirmed all of their nurses were aware they were expected to contact either S3MD or S4MD to obtain orders for their patients and all of the staff had been provided with their contact information. S1ED reviewed the aforementioned information for Patient #1, #3 and #5 and confirmed S5RN was practicing outside of her scope by giving orders without a physician and should not have.”