First Hospice Care, Inc.

“Upon patient record review, 4 of 14 (Patient #2,3,6,7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2-Orders on 11/7/2024 for Acetaminophen dosage could exceed 4000mg and no evidence of orders for “Not to exceed” parameters on the medication profile. Corrected on site. Patient #3-Orders on 10/21/2024 for Nitro 0.4mg tab, no evidence of orders stating what to do when the medication is ineffective after the ordered 3 doses on the medication profile. Corrected on site. Patient #6-Orders on 5/23/2025 for Miconazole Nitrate to be applied externally, no evidence of specific location on medication profile. Orders for Norco 5-325mg and Acetaminophen 650mg RS exceed the 4000mg/ day and no evidence of ‘Not to exceed” parameters on medication profile. Corrected on Site. Patient #7-Orders on 9/8/2025 for Cipro x10 days, no evidence of medication discontinued on medication profile. POC contains Oxygen concentrator, no evidence of Oxygen admin orders on medication profile. Corrected on Site.”

“Upon patient record review, 3 of 14 (Patient #2,3,6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2-Orders on 11/7/2024 for Acetaminophen dosage could exceed 4000mg and no evidence of orders for “Not to exceed” parameters on POC. Corrected on site. Patient #3-Orders on 10/21/2024 for Nitro 0.4mg tab, no evidence of orders stating what to do when the medication is ineffective after the ordered 3 doses on POC. Corrected on site. Patient #6-Orders on 5/23/2025 for Miconazole Nitrate to be applied externally, no evidence of specific location on medication profile. Orders for Norco 5-325mg and Acetaminophen 650mg RS exceed the 4000mg/ day and no evidence of ‘Not to exceed” parameters on POC. Corrected on Site.”

“Upon patient record review 3 of 14 (Patient #2,3,6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2-Aide visit 9/8/2025, no evidence aide completed the task for pain rating per aide care plan. Patient #3-Aide visits 9/2/2025-9/18/2025, no evidence aide complete the task for Shampoo, Clean/file nails and Change bed linen weekly as per the aide care plan. Patient #6-Aide visits 9/2/2025-9/18/2025, no evidence aide complete the task for shampoo and clean/file nails weekly as per the aide care plan.”

“Based on record review and interview, the hospice failed to perform an assessment on patients for 3 records (P-1, 6, 10) of 10 sampled patients, resulting in the potential for negative patient outcomes. This resulted in Immediate Jeopardy (IJ) to the health and safety of P-1, with falls, injury, pain, and subsequent death. (see L-591). Findings include: The cumulative effect of these systemic problems resulted in the hospice’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR §418.64, Core Services.”

“Based on record review and interview, the hospice failed to perform an assessment on a patient for 3 records (P-1, 6, 10) of 10 sampled patients, resulting in the potential for negative patient outcomes. Findings include: P-6: The patient was admitted to hospice services on 11/2/23 with a terminal illness of Hypertensive Heart Disease with Heart Failure. The Hospice plan of care ordered Skilled Nursing (SN), Spiritual Care (SC), Medical social Work (MSW) and Hospice Aide (HHa) services to be provided. During the clinical record review on 4/10/24 at 10:35 a.m., a Care Coordination Note authored by the Director of Nursing (DON-1) dated 11/11/23 documented, “ 2:45 a.m. Telephone call received from family stating that patient was still not sleeping and that he had given her the Restoril like he was supposed to and that she had been up all night screaming and carrying on that she was dying and yelling out “Help me, help me I’m dying!” Family stated that he was getting no sleep and did not know what to do. RN (Registered Nurse) instructed family to get patient another Restoril and see if that would help and the RN would check on her in the morning and if that did not work then RN would call doctor for other suggestions. 9:00 a.m. RN checked with family regarding the extra Restoril. Family stated that patient slept for 1 hour and then started screaming again.” Upon further review, there was no documented evidence that the Director of Nursing sent a nurse to evaluate the patient and reported symptomology. A Coordination note, again authored by the Director of Nursing, dated 12/24/23 documented, “11:30 a.m. telephone call from RN at [Facility] stating patient had been crying out/screaming in pain since yesterday, stating help me, help me. This RN (DON-1) asked where the patient was in pain. According to the facility, patient was stating all over..., This RN heard the facility RN state to the patient that she was talking to her RN..., she (patient) was crying out “help me, help me.” Hospice contacted doctor and obtained an order to restart Seroquel and to give a dose immediately upon arrival at the facility. There was no documented evidence that the Director of Nursing had a Hospice nurse go out and evaluate the patient and reported symptoms. It was further noted that the plan of care ordered SN visits at a frequency of 2x/wk. x 10 weeks. The record reflected that SN saw the patient twice during the first, third and fifth week of services, and only made one visit during the 2nd, 4th, 6th, 7th, 8th and 9th weeks of care. The Hospice failed to provide Nursing services that adequately addressed and managed the identified needs of the patient. These findings were reviewed with and confirmed by the Director of Nursing during an interview on 4/10/24 at 12:30 p.m., and again on 1:20 p.m. P-10: The patient was admitted to Hospice services on 10/11/23 with a terminal diagnosis of Hypertensive Heart Disease with Heart Failure. The plan of care ordered SN, MSW, SC, HHa and Physical Therapy (PT) services to be provided. During the record review on 4/11/24 at 9:25 a.m., it was noted that a Coordination Note, authored by the Director of Nursing, dated 10/20/23 documented, on 10/19/23 “9:00 p.m. telephone call from daughter stating the patient’s left foot was extremely swollen. Instructed daughter to get patient’s foot elevated through the night and call RN in the morning..., Primary RN saw patient today (10/20/23) and there was no mention of any edema in her note.” Upon further review, there was no documented evidence that the Director of Nursing informed the RN of the patient’s complaints of extreme left foot swelling. Additionally, there was no documented evidence that the Director of Nursing sent a nurse to evaluate the patient and associated symptoms. A Care Coordination Note authored by the Director of Nursing dated 11/6/23 documented, “11/5/23 1:00 p.m., telephone call received from patient’s daughter stating that her father was saying that he could not breath, so she checked his oxygen with the pulse oximeter and that it read 69%. She (daughter) had him (patient) use his inhaler and the oxygen level went up to 99%. The patient’s daughter stated that patient was still complaining that he could not breath and that he had fluid in the back of his throat. RN (Director of Nursing) stated that he needed to cough up the fluid in the back of his throat but that his breathing was good as his O2 was at 99%...” Upon further review of the record, there was no documented evidence that the Director of Nursing sent a nurse to evaluate the patient’s breathing status in the patient’s home. These findings were reviewed with and confirmed by the Director of Nursing during a telephone interview on 4/11/24 at 12:36 p.m. who reported, I would be expecting the nurses to make an onsite visit to assess the patient. P-1: This patient was admitted to hospice care on 11/29/23, with terminal diagnoses of Alzheimers disease and dementia. During record review on 4/10/24, a Care Coordination Note dated 12/26/23 stated, “On 12/26/23, the patient (P-1) had a fall with combativeness.” On 12/27/23 at 8:05 a.m., a call from the assisted living facility (ALF) was made to the hospice regarding the patient falling. The ALF stated, “The patient was weak and in pain and wanted a nurse to check him out.” The hospice Director of Nursing (DON-1) said they would, “make sure the registered nurse (Staff-1) saw the patient today.” During an interview on 4/10/24 at 12:27 p.m., DON-1 said she informed the primary registered nurse, Staff-1, at approximately 8:10-8:15 a.m., to go see the patient. The ALF called again at 3:30 p.m., asking again, “To have the RN out to check on the patient.” The Care Coordination Note states, “Staff-1 again paged to go see the patient.” At 4:22 p.m., Staff-1 stated that she would call the facility and ask them what was wrong with the patient. Staff-1 called DON-1 back and stated that the patient had diarrhea and a fever and that was to be expected because he had COVID and that she told them she would be there in the morning. At 6:45 p.m., a telephone call was received by the hospice notifying them that the patient had passed away. There was no documented evidence that the hospice assessed the patient after the fall. During an interview on 4/10/24 at 12:27 p.m., DON-1 was asked if the agency provided a skilled nursing visit on 12/26 or 12/27, to assess the patient (P-1) after the falls. DON-1 stated, “;A nurse did not go out to see the patient on the 26th or the 27th. I talked to the nurse and told her she needed to go see the patient.” During an interview on 4/10/24 at 2:43 p.m., Staff-1 was asked about the patients falls on 12/26 and 12/27. Staff-1 said she had no recollection of the falls. During an interview on 4/10/24 at 4:00 p.m., DON-1 was asked for any more details about the falls on 12/26 and 12/27. DON-1 said there were two falls on 12/26, but one was undocumented. The hospice failed to assess the patient’s change in condition related to falls, resulting in injury, untreated pain, and subsequent death. During an interview on 4/10/24 at 4:20 p.m., the administrator (ADM-1) and DON-1 acknowledged the findings.”