Lily Hospice

“Upon patient record review, 2 of 19 records reviewed (Patient #1, 2) 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 #1: The medication profile indicated the patient was taking an ASA 81mg po daily QAM, Albuterol 90mcg/inhalation aerosol 2 puffs BID. The patients husband verbalized she is no longer taking these medications. COS. Triamcinolone 0.1% topical cream prn three times daily for pruritis. There was no evidence of where to put this cream. Patient #2: The patient had bubble packs of Senna S one po daily available. There was no evidence of this medication listed on the medication administration record. COS.”

“Upon patient record review, 1 of 19 records reviewed (Patient #12) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #12: The record indicated the start of care was 6/28/22 and the initial bereavement risk assessment was completed on 8/9/22. There was no evidence of a bereavement risk assessment within 5 calendar days from the start of care.”

“Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2: The registered nurse was interviewed and asked if she was trained on infection control and a bag technique policy, she answered “yes”. During the home visit it was observed that she placed her bag in the chair in the dining room, then in a chair in the patients room and then on the dining room floor without a barrier. During her assessment the BP monitor fell on the ground and was placed on the table in the dining without wiping it down.”

“Upon patient record review, 1 of 19 records reviewed (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #2: The record indicated the patient was prescribed oxygen therapy. There was no evidence on the hospice aide care plan to include oxygen precautions.”

“Upon patient record review 2 of 19 records reviewed (Patient #5, #14) 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 #5: The record indicated hospice aide visit frequency was ordered for 2W13 on 4/9/24. There was no evidence of a second hospice aide visit after the patient was seen on 5/8/24 during the next week. Patient #14: The record indicated hospice aide visit frequency was ordered for 2W13 on 4/30/24. There was no evidence of two aide visits during the weeks of 4/30/24 and 5/7/24.”

“Based on record review and interview, the Agency failed to provide documentation that it had participated in the community based full-scale exercise required every two years, resulting in the potential for patients and staff not to be properly prepared in the event of an actual emergency. Findings include: On 5/1/24 at 11:25 AM., review of the Agency’s Emergency Preparedness (EP) binder found no evidence that the Agency had participated in any of the required full-scale community-based exercises over the last two years. Documentation of an actual emergency or event that could be substituted for the above exercise was not found. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Office Manager (Staff C) during an interview on 5/6/2024 at 11:25 AM.”

“Based on observation, record review and interview, the Agency failed to ensure the initial bereavement assessment identified the social, spiritual and cultural needs of all family members and other individuals that may be significantly affected by the patient’s death in 5 (P-1, 2, 3, 4, 10) of 14 records, from a total of 14 records reviewed, resulting in the potential for unmet needs for bereavement support and grieving during the end of life. Findings include: P-1: This 89-year-old patient was admitted to hospice on 11/22/23 with terminal diagnoses of non-rheumatic aortic stenosis and congestive heart failure. During record review on 5/1/24, it was noted the initial bereavement assessment completed by the social worker (Staff D), listed only the patient’s son. On 4/30/24 during a joint home visit with the Staff D and the Agency’s skilled nurse (Staff G), it was observed looking at numerous pictures and conversation with the patient that P-1 had a large and close family. Additional record review of Staff D’s initial social work evaluation of P-1 revealed the following documentation: “Pt (patient) is divorced and has 8 biological children and 6 stepchildren. According to her son (noted above), family gets along, and they are in agreement with pt. being on Hospice services.” This finding was reviewed and acknowledged by the Administrator (Staff A) and Office Manager (Staff C) during an interview on 5/6/24 at 11:40 AM. P-2: The start of care (SOC) date was 4/4/24 with terminal diagnoses of chronic obstructive pulmonary disease (COPD), and chronic respiratory failure with hypoxia. During record review on 5/1/24, it was noted the initial bereavement assessment completed by Staff D, listed only the patient’s son. However, review of Staff D’s initial evaluation of P-2, the following documentation revealed additional members that are significantly close to the patient: “Pt (patient) is married and lives with her husband there. Pt. has one adult son (noted above) and a daughter-in-law who are actively involved in pt’s care. Pt’s sister also lives in the facility.” This finding was reviewed and acknowledged by Staff A and Staff C during an interview on 5/6/24 at 11:50 AM. P-3: This 87-year-old patient was admitted to hospice on 6/28/22 with terminal diagnoses of malignant neoplasm of left lung, atrial fibrillation, and major depression. During record review on 5/6/24, it was noted there was no initial bereavement assessment located in the record. Staff A was asked to locate the initial bereavement assessment during an interview on 5/6/24 at 9:05 AM. Staff A reviewed the record and confirmed that the initial bereavement assessment had not been completed for this patient. P-4: The start of care (SOC) date was 9/28/23 with terminal diagnoses of pulmonary fibrosis, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and hypertension (HTN). During record review on 5/6/24, it was noted the initial bereavement assessment completed by Staff D, listed only the patient’s son. However, review of Spiritual Counselor’s (Staff H) initial evaluation of P-4 noted the following documentation of additional members that may be significantly close to the patient: “Pt (patient) married (husband) after his service in the United States Navy during World War 2 and the Korean War, returning to have four children together.” This finding was reviewed and acknowledged by the Administrator (Staff A) and Office Manager (Staff C) during an interview on 5/6/24 at 12:20 PM. The Agency failed to incorporate pertinent individuals that may significantly grieve in the required bereavement risk assessment for Hospice and failed to adhere to its policy referenced below. Agency Policy: “Initial Assessment/Comprehensive Assessment” 9.6.1 (Revised June 2019) stated, “An initial bereavement risk assessment of the needs of the patient’s family and other individuals focusing on the social, spiritual and cultural factors that may impact their ability to cope with the patient’s death.” P-10: This 87-year-old female patient was admitted to hospice on 1/24/2024 with a terminal diagnosis of Malignant Neoplasm of left bronchus of lung (Lung Cancer). Upon review of the Bereavement Assessment completed by the Social Worker (Staff D) on 1/24/2024, only included an interview with the patient’s daughter and only documented the needs of the daughter. There was no information or Bereavement Assessment for the patient’s husband. A Social Work Bereavement Telephone Visit included a Bereavement Counseling Note dated 2/26/2024 with the patient’s daughter, documented the following communication: “Daughter reports the family is coping manageably. Peggy inquires if patient’s spouse Patrick could receive a bereavement visit. Writer notified Social Worker who states she will visit Patrick.” The agency failed to provide Bereavement Assessments for all affected family members. This finding was reviewed and acknowledged by Staff A and Staff C during an interview on 5/6/24 at 2:00 p.m.”

“Based on record review and interview, it was determined the hospice agency failed to include safety precautions on the Plan of Care (POC) for 4 (P-2, P-4, P-11, P-13) of 14 records reviewed, resulting in the potential for negative patient outcomes. Findings include: P-11: The Start of Care (SOC) was dated 2/23/24. The POC identified diagnoses of malignant neoplasm of breast and lung. During review of the POC on 5/1/24, it was noted that the patient was receiving supplemental oxygen. The POC failed to include oxygen safety precautions. P-13: The SOC was dated 3/21/24. The POC identified diagnoses of pulmonary fibrosis, respiratory failure, and chronic obstructive pulmonary disease (COPD). During review of the POC on 5/2/24, it was noted that the patient was receiving supplemental oxygen. The POC failed to include oxygen safety precautions. The above findings were acknowledged by the administrator (Staff A) during a meeting on 5/6/24 at 1:30 p.m. P-2: The start of care (SOC) date was 4/4/24 with terminal diagnoses of chronic obstructive pulmonary disease (COPD), and chronic respiratory failure with hypoxia. During record review on 5/1/24, it was noted the POC for P-2 ordered oxygen therapy (2 Liters/minute nasal canula every hour as needed) under medications. However, the POC also ordered oxygen at a different rate than above under “Dyspnea” (difficulty in breathing) at 3 Liters/min. No explanation was found in the medical record why the POC had two different rates of oxygen therapy for P-2. Further, the POC failed to include oxygen safety precautions and safety education. P-4: The start of care (SOC) date was 9/28/23 with terminal diagnoses of pulmonary fibrosis, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and hypertension (HTN). During record review on 4/29/24, it was noted the POC ordered oxygen 4 Liters/minute continuous therapy under medications. In addition, the SOC comprehensive assessment performed by skilled nursing on 9/28/23 noted P-4 was a high fall risk and “broke 2 ribs last month and has a hairline hip fracture. The POC failed to incorporate both oxygen and falls risk in the POC’s safety precautions. The Administrator (Staff A) and Office Manager (Staff C) acknowledged the findings during an interview on 5/6/24 at 12:35 PM.”

“Based on record review, and interview, it was determined the hospice failed to develop a plan of care (POC) that included the frequency and duration for all services needed for the palliation and management of the patient in 11 records (P-1, 2, 3, 4, 6, 7, 8, 9, 10, 11 and 13), out of a total sample of 14 records reviewed, potentially not providing needed services. Findings include: P-11: The Start of Care (SOC) was dated 2/23/24. The POC identified diagnoses of malignant neoplasm of breast and lung. During review of the record on 5/1/24, it was noted that skilled nursing services were being provided, but there was no frequency or duration of visits documented on the POC. P-13: The SOC was dated 3/21/24. The POC identified diagnoses of pulmonary fibrosis, respiratory failure, and chronic obstructive pulmonary disease (COPD). During review of the record on 5/2/24, it was noted that social worker and spiritual care services were being provided, but there was no frequency or duration of visits documented on the POC. The above findings were acknowledged by the administrator (Staff A) during a meeting on 5/6/24 at 1:30 p.m. P-1: This 89-year-old patient was admitted to hospice on 11/22/23 with terminal diagnoses of non-rheumatic aortic stenosis and congestive heart failure. During review of the record on 5/2/24, it was noted the POC (11/22/23) failed to incorporate the required core service of MSW (Master of Social Work), its frequency and duration of visits to be provided. The above findings were acknowledged by the administrator (Staff A) and Office Manager (Staff C) during a meeting on 5/6/24 at 12:05 PM. P-2: The start of care (SOC) date was 4/4/24 with terminal diagnoses of chronic obstructive pulmonary disease (COPD), and chronic respiratory failure with hypoxia. During review of the record on 5/2/24, it was noted the POC (4/4/24) failed to incorporate the required core service of Counseling-Spiritual, its frequency and duration of visits to be provided. The above findings were acknowledged by the administrator (Staff A) and Office Manager (Staff C)during a meeting on 5/6/24 at 12:10 PM. P-3: This 87-year-old patient was admitted to hospice on 6/28/22 with terminal diagnoses of malignant neoplasm of left lung, atrial fibrillation, and major depression. During review of the record on 5/2/24, it was noted the POC (6/28/22) failed to incorporate the required core service of Counseling-Spiritual, its frequency and duration of visits to be provided. The above findings were acknowledged by the administrator (Staff A) and Office Manager (Staff C) during a meeting on 5/6/24 at 12:20 PM. P-4: The start of care (SOC) date was 9/28/23 with terminal diagnoses of pulmonary fibrosis, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and hypertension (HTN). During review of the record on 5/6/24, it was noted the POC (9/28/23) failed to incorporate the required core service of Counseling-Spiritual, its frequency and duration of visits to be provided. The above findings were acknowledged by the administrator (Staff A) and Office Manager (Staff C) during a meeting on 5/6/24 at 12:30 PM. P-6: This patient was admitted to Hospice Services on 12/20/23 with a terminal diagnosis of Colon Cancer. During review of the record on 5/1/24 for the certification period 12/20/23 to 2/16/24 it was noted the Plan of Care failed to include the frequency and duration of services for Skilled Nursing. P-7: This patient was admitted to Hospice Services on 12/21/23 with a terminal diagnosis of Parkinson’s Disease without dyskinesia and fluctuations. During review of the record for benefit period 3/21/24 to 6/18/24 it was noted the agency failed to include the frequency and duration of services for Spiritual, Skilled Nursing, and Social Worker. P-8: This patient was admitted to Hospice Services on 3/22/24 with a terminal diagnosis of Malignant Neoplasm of pancreas. During review of the record on 5/2/23, it was noted the Plan of Care dated 3/22/24 to 5/20/24 failed to include the frequency and duration of services for Spiritual, Skilled Nursing, Social Worker, and Hospice Aide. P-9: This patient was admitted to Hospice Services on 2/5/24 with a terminal diagnosis of Acute Diastolic (congestive) Heart Failure. During review of the record, on 5/6/24, it was noted the Plan of Care dated 2/5/24 to 3/16/24 failed to include the frequency and duration of services for Spiritual, Skilled Nursing, and Social Worker Services. P-10: This patient was admitted to Hospice Services on 1/23/24 with a terminal diagnosis of Malignant Neoplasm of left bronchus of lung. During review of the record on 5/6/24, it was noted the Plan of Care dated 1/24/24 to, it was noted the Plan of Care failed to include the frequency and duration of visits to be provided by Skilled Nursing, Hospice Aide, Spiritual, and Social Work Services. This finding was reviewed and acknowledged by Staff A and Staff C during an interview on 5/6/24 at 2:00 p.m.”

“Based on record review, and interview, the agency failed to ensure the medical record contained a current Plan of Care (POC) that was complete with objectively measurable goals in 14 of 14 (P-1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) records reviewed, which resulted in the potential for failure to meet the patient’s needs. Findings included: P-11: The Start of Care (SOC) was dated 2/23/24. The POC identified diagnoses of malignant neoplasm of breast and lung. Upon review of the POC on 5/1/24, it was noted that the goals were not objectively measurable. For example, one goal stated, “Patient will verbalize understanding of oxygen safety and use of equipment.” Another stated, “Patient will receive coordinated care from hospice IDG and facility staff.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-12: The SOC was dated 3/7/24. The POC identified diagnoses of cerebral infarction, hypertension and dementia. Upon review of the POC on 5/1/24, it was noted that the goals were not objectively measurable. For example, one goal stated, “Incontinence of bowel and/or bladder will be managed by caregivers.” Another stated, “Patient will exhibit a decrease in pain-related behaviors.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-13: The SOC was dated 3/21/24. The POC identified diagnoses of pulmonary fibrosis, respiratory failure, and chronic obstructive pulmonary disease (COPD). Upon review of the POC on 5/2/24, it was noted that the goals were not objectively measurable. For example, one goal stated, “Patient will use alternative methods of communication effectively to meet needs.” Another stated, “Patient will be able to participate in ADL’s and diversional activities with environmental adaptations made for visual loss.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-14: The SOC was dated 3/28/24. The POC identified diagnoses of toxic encephalopathy, COVID-19, and dysphagia. Upon review of the POC on 5/6/24, it was noted that the goals were not objectively measurable. For example, one goal stated, “Patient will have all ADL, safety, and activity needs met.” Another stated, “Patient and caregiver will verbalize when to call hospice for seizure activity.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The above findings were acknowledged by the administrator (Staff A) during a meeting on 5/6/24 at 1:30 p.m. P-1: This 89-year-old patient was admitted to hospice on 11/22/23 with terminal diagnoses of non-rheumatic aortic stenosis and congestive heart failure. On 5/1/24, review of the POC for P-1 dated 11/22/23 contained no goals listed among the core services of Skilled Nurse (SN), Master of Social Work (MSW), and Counseling-Spiritual (C-S). The POC section under “Problems/Goals/Interventions” was left blank. This finding was reviewed and acknowledged by the Administrator (Staff A) and Office Manager (Staff C) during an interview on 5/6/24 at 11:40 AM. P-2: The start of care (SOC) date was 4/4/24 with terminal diagnoses of chronic obstructive pulmonary disease (COPD), and chronic respiratory failure with hypoxia. On 5/1/24, review of the POC noted that 9 of 9 listed goals were not objectively measurable. Examples include: “Patient will receive coordinated care from hospice IDG (Inter-Disciplinary Group) and facility staff; Patient will have all ADL, safety, and activity needs met...” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. This finding was reviewed and acknowledged by Staff A and Staff C during an interview on 5/6/24 at 11:55 AM. P-3: This 87-year-old patient was admitted to hospice on 6/28/22 with terminal diagnoses of malignant neoplasm of left lung, atrial fibrillation, and major depression. On 5/6/24, review of the POC noted that 1 of 1 listed goal was not objectively measurable which was: “Wounds will have no signs of infection.” No listed goals were found in the POC under the other core services of MSW and C-S. This finding was reviewed and acknowledged by the Administrator (Staff A) and Office Manager (Staff C) during an interview on 5/6/24 at 12:20 PM. P-4: The start of care (SOC) date was 9/28/23 with terminal diagnoses of pulmonary fibrosis, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and hypertension (HTN). On 5/6/24, review of the POC noted that 1 of 1 listed goal was not related to Hospice care and not objectively measurable which was: “(Patient) will have comprehensive assessment completed by the 5th day of admission.” No listed goals were found in the POC under the core services of SN, MSW, and C-S. This finding was reviewed and acknowledged by the Administrator (Staff A) and Office Manager (Staff C) during an interview on 5/6/24 at 12:35 PM. P-5: The start of care (SOC) date was 1/29/24 with terminal diagnoses of Alzheimers disease-unspecified and repeated falls. On 5/6/24, review of the POC noted that 5 of 6 listed goals were not objectively measurable. Examples include: “(Patient) will have all ADL, safety, and activity needs met; (Patient) will have all ADL, safety, and activity needs met through anticipation; (Patient) will verbalize a plan for preventing impaired skin integrity.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. This finding was reviewed and acknowledged by the Administrator (Staff A) and Office Manager (Staff C) during an interview on 5/6/24 at 12:50 PM. Both acknowledged the findings above failed to meet Agency policy referenced below. Agency Policy: “IDG Care Planning Process” 9.12.1 (Revised June 2019) stated, “Measurable outcomes (goals) anticipated from implementing and coordinating the plan of care.” P-6: This patient was admitted to Hospice Services on 12/20/23 with a terminal diagnosis of Colon Cancer. During review of the record on 5/1/24 for the certification period 12/20/23 to 2/16/24 it was noted the Plan of Care failed to include objectively measurable goals to determine the patient’s progress toward achieving the goals. Examples included: “Patient will verbalize the adverse effects of exercise, ways activity intolerance affects the ability to accomplish goals and ADLs, and report onset of symptoms; Incontinence of bowel and bladder will be managed by caregivers; Patient will have comprehensive assessment completed by end of 5th day.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-7: This patient was admitted to Hospice Services on 12/21/23 with a terminal diagnosis of Parkinson’s Disease without dyskinesia and fluctuations. During review of the record for benefit period 3/21/24 to 6/18/24 it was noted the agency failed to include objectively measurable goals. Examples included: “Patient/caregiver will verbalize/demonstrate feeling supported by hospice team, family, and/or friends and will adapt to changes, challenges and crises; Patient/Caregiver will express acceptance of health status and will find meaning in personal and health care treatment choices; Caregiver will report reduced or acceptable feeling of burden/distress.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-8: This patient was admitted to Hospice Services on 3/22/24 with a terminal diagnosis of Malignant Neoplasm of pancreas. During review of the record on 5/2/23, it was noted the Plan of Care dated 3/22/24 to 5/20/24 failed to include objectively measurable goals. Examples included: “Patient/Caregiver will verbalize/demonstrate feeling supported by hospice team, family, and/or friends and will adapt to changes, challenges, and crisis throughout hospice admission”; Patient/caregiver will express acceptance of health status and will find meaning in personal and health care treatment choices.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals.” P-9: This patient was admitted to Hospice Services on 2/5/24 with a terminal diagnosis of Acute Diastolic (congestive) Heart Failure. During review of the record, on 5/6/24, it was noted the Plan of Care dated 2/5/24 to 3/16/24 failed to include objectively measurable goals. Examples included: “Patient/Caregiver will express acceptance of health status and will find meaning in personal and health care treatment choices; Patient/Caregiver will verbalize/demonstrate feeling supported by hospice team, family, and/or friends and will adapt to changes, challenges, and crisis.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-10: This patient was admitted to Hospice Services on 1/23/24 with a terminal diagnosis of Malignant Neoplasm of left bronchus of lung. During review of the record on 5-6-24, it was noted the Plan of Care failed to include objectively measurable goals. Examples included: “Patient/caregiver will verbalize/demonstrate feeling supported by hospice team, family, and/or friends and will adapt to changes, challenges, and crises; Patient/Caregiver will express acceptance of health status and will find meaning in personal and health care treatment choices; Caregiver will report reduced or acceptable feeling of burden/distress” (goal for caregiver, and not the patient). These goals are not personalized to the patient, nor are these goals objectively measurable to determine the patient’s progress towards achieving the goals.” Agency Policy: “IDG Care Planning Process” 9.12.1 (Revised June 2019) stated, “Measurable outcomes (goals) anticipated from implementing and coordinating the plan of care.” This finding was reviewed and acknowledged by Staff A and Staff C during an interview on 5/6/24 at 2:00 p.m.”

“Based on record review and interview, it was determined that the Hospice failed to ensure safety needs of the patient were optimized and coordinated with another facility in 2 (P-4, P-5) in 10 records reviewed with patients living in a care facility, out of a total sample of 14 records reviewed, resulting in the increased potential of poor clinical outcomes. Findings include: P-4: The start of care (SOC) date was 9/28/23 with terminal diagnoses of pulmonary fibrosis, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and hypertension (HTN). On 5/6/24, record review of the SOC comprehensive assessment performed by skilled nursing (SN) revealed P-4 was a very high falls risk per the following factors noted in the assessment: Visual impairment, narcotic drug prescriptions, use of oxygen with accompanying oxygen line, incontinence, environmental hazards, poor physical condition needed help to walk short distances. In addition, SN documented “Patient broke 2 ribs last month and has a hairline hip fracture.” Further review found an “Unattended Discharge Note” dated 4/11/24 which documented “Patient had a fall on 4/10/24 and was experiencing pain that could not be controlled with meds available from comfort Pak, she was sent to ED for imaging and pain control... Physicians found that fracture required total hip replacement because it could not be stabilized, pt refused and revoked services in order to receive in patient hospice services at (hospital).” Review of the Plan of Care (POC) dated 9/28/23, revealed a failure to have any orders, treatments, interventions, or goals concerning mitigating P-4’s falls risk amongst any members of the hospice team or members at the senior living facility (primary care givers) where P-4 has lived for the last 8 years. In addition, review of the recertification POC dated 12/8/23, also revealed a failure to have any orders, treatments, interventions, or goals concerning mitigating P-4’s falls risk amongst any members of the hospice team or members at the senior living facility (primary care givers). This finding was reviewed and acknowledged by the Administrator (Staff A) and Office Manager (Staff C) during an interview on 5/6/24 at 12:20 PM. The Hospice agency failed to coordinate and implement further fall prevention measures to all staff involved in the care of P-4. Subsequently, the patient’s safety was jeopardized resulting in a fall with significant injury and severe pain towards the end of life. P-5: The start of care (SOC) date was 1/29/24 with terminal diagnoses of Alzheimers disease-unspecified and repeated falls. This patient had been a resident at a senior care living facility since June of 2023. On 5/6/24, record review of the SOC comprehensive assessment performed by SN revealed P-5 was an extreme falls risk per the following SOC assessment documentation: Cognitive impairment, visual impairment, narcotic drug prescriptions, incontinence, environmental hazards, very limited mobility, and poor physical condition needing help to stand. SN also documented P-5 had more than “10 falls in the last week, up to 3 falls per day.” Review of P-5’s POC dated 1/29/24, revealed one goal concerning falls which documented, “(Patient) will have no falls.” Interventions were orient the patient to environment, call light within reach and calling for assistance, and helping patient with toileting on her own schedule or every 2 hours while awake. However, it was unclear if these standard fall interventions were implemented before or after the SOC date while P-5 was having 10 plus falls/week. If the interventions were after 1/29/24, it calls into the safety of the facility for allowing the continuation of numerous falls and the failure of the Hospice agency to be the patient’s advocate concerning safety. If the interventions were already in place prior to the SOC date and the numerous falls were still occurring, then what new measures were coordinated and implemented to help optimize the patient’s safety. This finding was reviewed and acknowledged by the Administrator (Staff A) and Office Manager (Staff C) during an interview on 5/6/24 at 12:40 PM. Staff A was noted the medical record should have had more details concerning the fall risk environment and the timing of the fall risk interventions due to the extreme rate P-5 was experiencing falls at the SOC. The Hospice agency failed to coordinate additional safety measures to augment interventions already in place which were failing or failed to intervene on the patient’s behalf to ensure the patient was safe from harm and neglect at the senior living facility where P-5 resided.”

“Based on record review and interview, it was determined that the Hospice failed to ensure a Discharge Summary was completed, detailed the course of care provided, including symptom/pain management, and findings that led to the Hospice to terminate services in 1 (P-5) of 2 records reviewed with a live discharge, from a total of 14 sampled records reviewed, resulting in the potential for unmet care needs and an incomplete clinical record concerning the events leading up to discharge. Findings include: P-5: The start of care (SOC) date was 1/29/24 with terminal diagnoses of Alzheimers disease-unspecified and repeated falls. The Plan of Care ordered the following disciplines with associated home visit frequencies: Skilled Nursing (SN) 1w13 (once a week times 13 weeks), Hospice Aide (HA) 2w13, Medical Social Worker (MSW) 1m3 (once a month times three months, and Spiritual Counselor (SC) 1m3. During the record review on 5/6/24, it was noted that P-5 had an “Unattended Discharged Note” dated 4/20/24. It stated, “patient no longer eligible for hospital services due to not being terminally ill. both patient and daughter understood reason for discharge and had no questions or concerns at this time.” (sic) No documentation that constituted a “Discharge Summary” per this requirement was found in the medical record such as a summary of care provided by each discipline noted above, medication list at time of discharge, or the findings that led up to the decision by the Hospice to terminate services with P-5. These findings were reviewed with and acknowledged by the Administrator (Staff A) and Office manager (Staff C) during an interview on 5/6/24 at 12:43 PM. Both noted this did not meet Agency expectations or its policy referenced below. Agency Policy: “Discharge Summery” 9.29.1 (Revised June 2019) stated, “If a patient revokes the election of Hospice care, or is discharged from Hospice, Hospice will forward to the patient’s attending physician, a copy of: The Hospice discharge summary.””