Ozarks Healthcare at Home, Hospice

“Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to develop an individualized written plan of care with goals that were specific, measurable and time-bound. Throughout all active patient records review there were goals that were not specific, measurable, and time-bound. For example: in HosRRHV#1 a goal that was not measurable or time-bound was pt and/or caregiver will have necessary information, support and direction and counsel to make informed end of life decisions. and pt and or nursing staff at facility will report that patient’s pain is at or below 5/10 was measurable but not time-bound. In HosRRHV#2 a goal was pt will be provided with end of life care to mitigate symptoms, meet spiritual and emotional needs while maintaining her dignity to control pain. In HosRRHV#3 a goal was pt/family/caregiver will ____________________. The blank was not filled in. In HosRRNHV#4 a goal was Symptoms problematic to patient will be addressed to meet patient goal of comfort at the end of life. Similar goals that lacked being specific, measurable, and time-bound could be seen throughout all active records reviewed. These observations were reviewed with the Director of Home Care, and the Hospice Manager.”

“Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness. On review of HosRRHV#1 there was documentation of a wound to the bottom with wound care ordered yet there was no integumentary care plan open to guide the care. In HosRRHV#3 there was documentation of constipation, nausea, and stroke like symptoms but the issues were noted reflected in the care plans. In HosRRNHV#4 there was a documented fall but no update to the plan of care to reflect the change in patient status. In HosRRNHV#6 there was documentation of an infection to the throat with antibiotics orders but no care plan to guide the care. In HosRRNHV#8 the patient primary diagnosis was end stage renal disease with symptoms of edema, poor sleep, decreased appetite and hypertension but the issues were not reflected in the care plans. In HosRRNHV#9 the patient had documented dyspnea with continuous oxygen use, increased weakness and decreased appetite but no care plans related to the issues to guide the care. In HosRRNHV#10 there was documentation on an infection with antibiotics ordered but no infection care plan established. These observations were reviewed with the Director of Home Care and Hospice Manager.”

“Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of HosRRHV#1 there was an order for oxygen that read Oxygen 2-6 inhalations as needed for shortness of breath. The order did not specify a route, the patient had a tracheostomy, nor did it specify a specific clear liter flow , only stating 2-6 inhalations. There were no specific instruction to guide the patient to know when to use which liter flow. A similar oxygen order with 2-6 inhalations was seen in HosRRNHV#10. In HosRRNHV#4 there were range orders for Morphine and Lorazepam such as Morphine 20 mg as directed: 0.25ml - 1ml q 1 hour PRN, may increase to 0.5ml - 1ml q 1 hour PRN and Lorazepam 0.25 ml - 1 ml q 4 hours PRN anxiety/seizures. Start 0.25ml may increase to 0.5ml - 1ml q 4 hours. There was no specific instructions on when to use what dosage. Similar orders for Morphine and Lorazepam could be seen in HosRRNHV#6. Further, there were both oxycodone and morphine for PRN pain, but no specific instructions to guide the user as to which one to choose for what situation. These observations were reviewed with the Director of Home Care and Hospice Manager.”

“Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure plan of care revisions were based on information from updates to the patient’s comprehensive assessment and address the patient’s progress toward goals and outcomes. Throughout all active clinical records reviewed there was a noted lack of revisions to the care plans based on updates to patient’s comprehensive assessment and progress toward goals. Many of the care plan goals and interventions were nearly identical IDT to IDT meeting and further from certification to certification when recertified, not changing based on progress toward goals or changes in patient status. These observations were reviewed with the Director of Home Care and the Hospice Manager.”

“Observed in Record Review. In 3 of 7 patient records reviewed, with hospice aide services provided, the organization failed to ensure the registered nurse provide written patient care instructions for the hospice aide. On review of HosRRHV#1 the patient had a tracheostomy, g-tube and wound dressing yet there were no specific instructions to guide the aide on how to handle the trach, g-tube, and dressing while providing care. The patient also had oxygen via trach collar but no instructions on whether the oxygen could be removed while care was given. In HosRRNHV#4 there were tasks assigned to the aid for foley and ostomy care yet the patient did not have a foley or ostomy. Further, the patient was assigned a shower but became unable to shower and needed bed baths yet the plan was not updated to bed bath. In HosRRNHV#7 the patient had a peg tube but no instructions of how the aide was to handle the tube while providing care. These observations were reviewed with the Director of Home and Hospice Manager.”

“Observed in Record Review. In 4 of 7 patient records reviewed, the organization failed to ensure the registered nurse supervise the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. On review of HosRRHV#1 there was a 28 day gap in aide supervisory visits documented from August to September. In HosRRHV#3 there was an 18 day gap in June and a 21 day gap in July to August. In HosRRNHV#7 there was a 20 day gap in July and in Hos RRNHV#10 a 20 day gap since August. These observations were reviewed with the Director of Home Care and Hospice Manager.”

“Observed in Record Review. In 6 of 6 patient records reviewed, where recertification was completed, the organization failed to ensure the medical director review the patient’s clinical information at recertification. On review of HosRRHV#1 the recertification narrative in the certificate of terminal illness (CTI) failed to include all required elements. The verbiage in the initial CTI and the verbiage in the 2nd CTI were nearly identical and lacked current objective and subjective clinical findings as required. Similar lack of current subjective and objective clinical findings that described continued hospice eligibility could be found in all clinical record that recertifications were completed (HosRRHV#2, HosRRHV#3, HosRRNHV#5, HosRRNHV#7, HosRRNHV#9. These observations were reviewed with the Director of Home Care and Hospice Manager.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure: - The plan of care was individualized for each patient (L545); - All medication orders were individualized and had specific dosages and directions for use (L547); - The plan of care included all medical supplies necessary for the care of the patient (L550); - The plan of care was updated and included the patient’s progress toward stated goals (L552); and - All visits were completed as ordered by the physician (L555). The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.”

“Based on policy review, record review, home visit observation, and interview the hospice failed to ensure that all complaints were investigated and added to the grievance log in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the hospice providers policy titled, “;Complaints/Grievances, Patients,” dated 08/2023, showed in part: - Patient grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient or the patients representative regarding the patients care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospitals compliance with the CMS Hospital Conditions of Participation or a Medicare beneficiary billing complaint related to rights and limitations; - Staff attempts to resolve complaints as the time of occurrence. If the event meets grievance criteria, documentation is sent to the Risk Management department; - The Risk Management department tracks/trends patient grievances and provides quarterly reports to the Safety and Quality Committee of the governing body; and - Findings of the investigation are documented by the Risk Manager/Patient Advocate. Review of the hospice providers policy titled, “;Client Rights and Responsibilities,” dated 09/2024, showed in part, that clients have the right to: - Have addressed and resolved promptly any grievances, concerns, or complaints and receive education in the availability and use of the hospices grievance process; and - The right to voice a complaint/concern regarding care or service that is (or fails to be) furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of Home Care, or recommended changes in policy, personnel or care/service or any other issue without restraint, interference, coercions, discrimination, or reprisal. Home Care will investigate any such complaints made by a client or clients family or guardian and document both the existence of the complaint and the resolution of the complaint. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 05/15/2024 with a diagnosis of malignant neoplasm of the occipital lobe (cancer of the occipital lobe of the brain). The patient resided in their own home with the assistance of their spouse. Review of a skilled nurses note, dated 07/10/2024, showed the following: - “;Patient/caregiver expressed frustration with the LPN’s (licensed practical nurse) conduct during the last visit with them and so that was presented during the supervisory assessment. Interventions have been put in place for correction to this behavior and chart has been modified to reflect the change in clinician assignment for this patient per their request;” - A supervisory assessment for the LPN showed that the family and patient were dissatisfied with the care provider; and - The record failed to show why the patient and caregiver were dissatisfied with the LPN. Review of the grievance log on 09/09/2024 failed to show any complaints or grievances related to Record/Patient #1. Observation of registered nurse (RN) A on 09/10/2024 beginning at 9:30 AM, led to an interview that was conducted with the patient and caregiver. Both stated that a complaint had been made to a RN during a visit regarding an LPNs conduct in the home. RN A stated that the complaint was regarding the LPN discussing political views with the patient and caregiver when they had expressed on admission that they did not want any religious or political views discussed in the home. The LPN was then removed as the nurse that would provide skilled care to the patient. The patient and caregiver agreed with what RN A stated and felt that the situation had been handled to their satisfaction. During an interview on 09/11/2024 at 9:25 AM, the administrator stated that there was no complaint related to Record/Patient #1 on the grievance log.”

“Based on policy review, record review, observation, and interview the hospice provider failed to ensure that the patient received the supplies necessary to manage the symptoms related to the terminal illness in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Finding included: Review of the hospice providers policy titled, “;Client Rights and Responsibilities,” dated 09/2024, showed in part, that clients have the right to: - Receive hospice services in a manner that neither physically nor emotionally abuses the client, nor neglects the clients needs; - Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness and related conditions; - Have training for self, primary caregiver, and family related to issues of care and comfort; and - Have an understanding of the availability and access to hospice services and the hospice team 24 hours per day, seven days per week. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 06/26/2024 with a diagnosis of malignant neoplasm of the upper lobe, left bronchus or lung (a cancerous lesion of the lung). Co-morbidities included chronic obstructive pulmonary disease, unspecified (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient resided in their own home with the assistance of their spouse. Review of the initial comprehensive assessment, dated 06/26/2024, showed: - The patient reported dyspnea (shortness of breath); - The patient was “;sitting in the corner of a sectional sofa with approximately 10 pillows of varying sizes situated around patient to keep patient sitting up in a comfortable position, both to relieve pain and dyspnea;” - The patient was dyspneic at rest; - The patient had audible wheezing (a high-pitched whistling sound during breathing) noted on entrance to the home and rhonchi (continuous, low-pitched sounds during breathing) and wheezes noted throughout lungs; - The patient reported a cough that was productive of thin, light-yellow sputum (a thick substance produced in the lungs and airways and brought up when coughing); and - The patient refused oxygen at the time. Review of the licensed practical nurse (LPN) visit, dated 07/02/2024, showed: - The patient complained of dyspnea; - The patient continued with a cough with sputum; - The patient’s lungs continued with rhonchi and congestion; - The patient had edema (swelling) in the right arm, hands, right foot, legs, and ankles; and - Oxygen was ordered due to the patients request and shortness of breath. Review of a delivery receipt from the oxygen delivery company dated 07/02/2024, showed that one e-tank (an emergency supply of oxygen) was delivered to the patients home on 07/02/2024. Review of the LPN visit, dated 07/22/2024, showed: - The patient was requiring oxygen from two (2) to four (4) liters per minute continuously; - The patients oxygen saturation was 87% to 95% and was 88% on 4 liters of oxygen when the nurse left the home; - The patient reported dyspnea; and - The patient reported a cough with sputum. Review of visits dated 07/23/2024, 07/30/2024, 08/02/2024, 08/06/2024, and 08/13/2024 showed the patient required continuous oxygen and was dependent on oxygen. Review of a communication note, completed by a LPN on 08/16/2024, showed the following: - Approximately at 4:38 AM, he/she had received a call from the switchboard for the patient. He/she spoke with the caregiver who stated their power was out and they had used the etank of oxygen; - At 4:40 AM he/she had called the police to get first responders to go help with O2 (oxygen); - At 4:44 AM he/she called the oxygen supplier and got the on-call person, who stated would get ahold of the driver; - At 4:46 AM he/she called the clinical manager to see if he/she could call EMS (emergency medical services) only for the O2 since the patient was a hospice client. The clinical manager advised to call the house supervisor to see if they could borrow one for the mean time; - At 4:48 AM c he/she called the house supervisor and spoke with him/her, not sure of his/her name and he/she stated he/she would check and call back, but never did call back; - At 4:50 AM the police called back to say the fire station phones were out; - At 5:10 AM the oxygen supplier stated he/she had gotten ahold of the driver and would get them delivered to the client (patient); - At 5:25 AM EMS arrived with a gurney and the caregiver explained that he/she did not need a gurney, they only needed the O2. The caregiver stated EMS could not comprehend so he/she tried to explain that the patient was on hospice and only needed O2, finally the caregiver grabbed an O2 tank and started hooking the patient up with the O2, then the caregivers child stated to the EMS to get out of the house because and an argument was about to happen. When EMS left they called the police to report a stolen O2 tank, when the police arrived at approximately 6:00 AM, the caregiver tried to explain what happened and about that time while the police were there, the oxygen supplier arrived with their O2 tanks and police understood and took the tank that was from EMS and returned it back to them; - At approximately 6:15 AM he/she called to check on the client and the caregiver told him/her the story of what had happened at that time; and - At approximately 6:30 AM he/she called to check on the client again and they was doing well. The O2 never dropped below 88%. The house supervisor still had not returned his/her call. Observation on 09/09/2024 beginning at 1:05 PM, led to an interview that was conducted with the patients caregiver. During the interview the caregiver stated that since the patient had been on hospice services the electricity had gone out once and that hospice had to bring them oxygen and that everything had been taken care of to his/her satisfaction. Review of documents provided by the hospice provider on 09/11/2024 from the city office showed that the electricity was off from 08/15/2024 at 11:16 PM to 08/16/2024 at 5:17 AM (a total of six (6) hours and one minute). The provider failed to ensure that the patient had an appropriate amount of emergency oxygen supply and a back-up plan to provide needed supply for the patient’s symptoms related to his/her terminal illness. During an interview on 09/11/2024 beginning at 11:25 AM, the administrator stated that he/she was aware of the situation with the oxygen and that the leadership team had completed a safety huddle the morning of 08/16/2024, to ensure that the issue did not occur again. He/she also stated that emergency oxygen supplies were now housed at the office to ensure that oxygen is available if needed.”

“Based on policy review, clinical record review, and interview the hospice provider failed to ensure clinicians performed a complete pain assessment in five of five applicable records reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to affect the pain management for all the hospice providers patients. Findings included:Review of the providers policy titled, “;Comprehensive Initial Assessment of Patient,” last revised 03/2024, showed that:- The comprehensive assessment includes, but not limited to, a complete pain assessment; - A complete pain and symptom assessment is conducted at the time of admission based on protocols for assessment and management of pain. The assessment includes, but is not limited to, a history of pan and its treatment (including pharmacological and non-pharmacological treatment); and characteristics of pain, such as:- Intensity of pain (e.g., as measured on a standardized pain scale); - Descriptors of pain (e.g., burning, stabbing, tingling, aching); - Pattern of pain (e.g., constant, or intermittent); - Frequency, timing, and duration of pain; - Impact of pain on quality of life (e.g., sleeping functioning, appetite, and mood); - Factors such as activities, care, or treatment that precipitate or exacerbate pain; - Strategies and factors that reduce pain; and- Patients/familys goals for pain management and their satisfaction with the current level of pain control. Review of the providers policy titled, “;Pain Management,” last revised 08/2022, showed that:- When a pain condition is identified, or when a patient is caused to experience pain associated with a procedure, assessment data is obtained and documented in the electronic health record. Pain assessment data includes: * Pain intensity (0-10 scale); * Character/quality (a description of pain, i.e., dull, sharp, cold, pressure); * Frequency (how often, when, timing); * Location/radiation location; * Duration/onset (When did the patient first notice/experience the pain?); and * Patient pain goal; and- Reassessment of pain is documented according to the following standards: * By location; * When appropriate, a change in the patients condition may warrant a reassessment of pain at any time during the patients treatment or visit; and * Minimally, pain is reassessed for pain intensity (Scale of 0-10) and location. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/15/2024 with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure (structural and functional changes in the heart as a result of chronic high blood pressure leading to heart and kidney failure). The patient resided in their own home with the assistance of an adult child. Review of the initial, comprehensive pain assessment, dated 08/15/2024, showed the patient had chronic pain of their left and right back. The documentation showed the patients pain had:- Occurred prior to the nursing visit;- Was controlled with medication;- Had pain, rated at a 3 on a 0-10 high scale, at the time of the nursing visit;- Was constant; and- The documentation failed to contain an assessment of: * Descriptors of pain (e.g., burning, stabbing, tingling, aching); * Impact of pain on quality of life (e.g., sleeping functioning, appetite, and mood); and * Patients/familys goals for pain management and their satisfaction with the current level of pain control. Review of the Plan of Care dated 08/15/2024 showed orders for:- Hydrocodone with acetaminophen (an opioid pain medication);- Morphine concentrate (an opioid pain medication); and- Tramadol (an opioid pain medication). Review of nursing visit documentation for, but not limited to, 08/16/2024, 08/19/2024, 08/22/2024, 09/03/2024, and 09/05/2024 showed the documentation failed to contain an assessment of the patients pain including the intensity, frequency, location, duration and onset, and goals for pain management. During an interview on 09/11/2024 at 9:12 AM, the administrator and clinical manager stated that they are unable to locate a complete pain assessment in the patients clinical record. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 6/04/2024 with a terminal diagnosis of atherosclerotic heart disease (thickening of the arterial wall that results in decreased supply of blood flow). The patient resided in their own home with the assistance of their spouse and adult children. Review of the comprehensive assessment dated 06/04/2024 showed:- The patient, “;denies pain at this time, reports [they] rarely has pain”. - Pain Overview Assessment showed: * Pain: Denies experiencing pain * Pain Management: Denies difficulty managing pain * Pain Control: Denies difficulty controlling pain * Adverse Effects of Pain: Pain does not adversely affect patient * Expectations and Goals for Pain: Patient has defined expectations and goals for pain control * FLACC Pain Scale: Not performed- Review of the medication profile showed that the patient takes gabapentin for pain. Review of nursing visit documentation for, but not limited to, 07/26/2024, 07/30/2024, 08/01/2024, 08/06/2024, 08/08/2024, 08/13/2024, 08/22/2024, 08/27/2024, 08/29/2024, 09/05/2024 showed the documentation failed to contain an assessment of the patients pain including the intensity, frequency, location, duration and onset, and goals for pain management. Review of the licensed practical nurse (LPN) visit documentation for 08/15/2024 showed that the patient was experiencing lower back pain, and the pain:- Had occurred before, with the most recent episode occurring now;- Was rated at a six; - Had an achy character and was constant; and- The visit documentation failed to contain: * A complete pain assessment that included the pains duration, onset, and the patients pain goal; and * Evidence that the registered nurse was notified of the patients development of moderate pain. Review of the licensed practical nurse (LPN) visit documentation for 08/20/2024 showed that the patient was experiencing lower back pain, and the pain:- Was rated at a 7 on a 0-10 high scale; - Was constant and worsened with activity; and- The visit documentation failed to contain: * A complete pain assessment that included the pains character, quality, duration, onset, and the patients pain goal; and * Evidence that the registered nurse was notified of the patients development of severe pain. Review of the medical social services (MSS) visit documentation for 08/30/2024 showed that the patient had, “;no pain, except for lower back which is always there.” The documentation failed to contain:- A complete pain assessment that included the pains character, quality, duration, onset, and the patients pain goal; and- Evidence that the registered nurse was notified of the patients unrated pain. Per interview on 09/10/2024 at 1:40 PM, the patient stated that they were satisfied with their pain and symptom management. During an interview on 09/11/2024 at 9:09 AM, the administrator and clinical manager stated that they are unable to locate a complete pain assessment in the patients clinical record. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 05/15/2024 with a diagnosis of malignant neoplasm of the occipital lobe (cancer of the occipital lobe of the brain). The patient resided in their own home with the assistance of their spouse. Review of the initial, comprehensive pain assessment, dated 05/15/2024, showed: - The patient, “;denies pain at this time.” - Pain Overview Assessment showed: * Pain: Denies experiencing pain; * Pain Management: Denies difficulty managing pain; * Pain Control: Denies difficulty controlling pain; * Adverse Effects of Pain: Pain does not adversely affect patient; * Expectations and Goals for Pain: Patient has defined expectations and goals for pain control; and * FLACC Pain Scale: The FLACC behavioral scale for scoring pain was not performed. Review of the plan of care (POC), dated 05/15/2024, showed that the patient took Tylenol Extra Strength (a mild pain medication) as needed and Morphine concentrate (a narcotic pain medication) as needed. Review of a registered nurse (RN) visit, dated 05/16/2024, showed that the patient denied pain at the time of assessment, but reported: - A headache the day before; - He/she treated the headache with Oxycodone (a narcotic medication used for pain) 10 milligrams (mg) with good relief; - There had been no reoccurrence since; and - The visit documentation failed to include: * A complete pain assessment that included the pains intensity, descriptors, pattern, impact on the patients quality of life, factors that precipitate or exacerbate the pain, additional symptoms that are associated with the pain, or the patients personal pain goal. Review of an RN visit, dated 05/22/2024, showed the patient complained of: - A toothache in the right lower jaw; - The pain had a pain rating of 5 out of 10 (a pain rating measures the amount of pain the patient is having using a number scale of 0 to 10 with 0 being no pain and 10 being the worst pain imaginable); and - The visit documentation failed to include: * A complete pain assessment that included: the pains pattern, impact on the patients quality of life, factors that precipitate or exacerbate the pain, additional symptoms that are associated with the pain, or the patients personal pain goal. During an interview on 09/11/2024 beginning at 9:15 AM, the administrator stated that a completed pain assessment was not located in the patients record. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 06/26/2024 with a diagnosis of malignant neoplasm of the upper lobe, left bronchus or lung (a cancerous lesion of the lung). The patient resided in their own home with the assistance of their spouse. Review of the initial, comprehensive pain assessment, dated 06/26/2024, showed the patient denied pain at the time of assessment. The visit documentation failed to show a complete pain assessment that included: a history of pain and its treatment, the pains pattern, impact on the patients quality of life, factors that precipitate or exacerbate the pain, additional symptoms that are associated with the pain, or the patients personal pain goal. Review of the POC, dated 06/26/2024, showed that the patient took Oxycodone as needed for pain. Review of an RN visit, dated 06/27/2024, showed: - The patient complained of pain 5 out of 10 generalized in the chest area; - The patient reported taking pain medication of Oxycodone five minutes prior to the nurses arrival; - By the end of the visit patient reported pain 2 out of 10; and - The visit documentation failed to include: * A complete pain assessment that included the pains pattern, impact on the patients quality of life, factors that precipitate or exacerbate the pain, additional symptoms that are associated with the pain, or the patients personal pain goal. Review of an RN visit, dated 07/05/2024, showed: - The patient complained of generalized pain of 7 to 8 on the pain scale; -The patient denied the need for further pain medication; -The patient stated, “;meds are relieving pain, in that it takes the edge off;” and - The visit documentation failed to include: * A complete pain assessment that included the pains pattern, impact on the patients quality of life, factors that precipitate or exacerbate the pain, additional symptoms that are associated with the pain, or the patients personal pain goal. Review of an RN visit, dated 07/11/2024, showed: - The patient complained of a headache to the top or front of his/her head; - The patient rated the pain a score of 7; and - The visit documentation failed to include: * A complete pain assessment that included the pains pattern, impact on the patients quality of life, factors that precipitate or exacerbate the pain, additional symptoms that are associated with the pain, or the patients personal pain goal. Review of a licensed practical nurse (LPN) visit, dated 07/30/2024, showed: - The patient complained of pain in the chest; - The pain was described as burning, constant, and worsening; - The pain was reported as an 8; and - The visit documentation failed to include: * A complete pain assessment that included the pains impact on the patients quality of life, factors that precipitate or exacerbate the pain, additional symptoms that are associated with the pain, or the patients personal pain goal. Review of an LPN visit, dated 08/30/2024, showed: - The patient complained of pain in his/her legs, neck, and chest; - The pain was described as the neck with aches, repositioned legs with some pain, and chest with burning; - The total pain 7 to 8 on pain scale; and - The visit documentation failed to include: * A complete pain assessment that included the pains pattern, impact on the patients quality of life, factors that precipitate or exacerbate the pain, additional symptoms that are associated with the pain, or the patients personal pain goal. Review of an LPN visit, dated 09/03/2024, showed: - The patient complained of pain in his/her neck, stomach, and legs; - The pain was described as achy neck, nausea in stomach, and pins and needles; - The total pain was 6; and - The visit documentation failed to include: * A complete pain assessment that included the pains pattern, impact on the patients quality of life, factors that precipitate or exacerbate the pain, additional symptoms that are associated with the pain, or the patients personal pain goal. Review of an LPN visit, dated 09/06/2024, showed: - The patient complained of pain in his/her neck and back; - The pain had a level of 7; - The patient did take pain medication for relief; and - The visit documentation failed to include: * A complete pain assessment that included the pains pattern, impact on the patients quality of life, factors that precipitate or exacerbate the pain, additional symptoms that are associated with the pain, or the patients personal pain goal. During an interview on 09/11/2024 beginning at 9:15 AM, the administrator stated that a completed pain assessment was not located in the patients record. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 05/22/2024 with a diagnosis of Alzheimers Disease, unspecified (a disease marked by progressive loss of mental capacity). The patient resided in the home of an adult child who was also their caregiver. Review of the initial, comprehensive pain assessment, dated 05/22/2024, showed: - The patient and caregiver denied pain, no pain was observed, and the patient scored 0 out of 10 on the FLACC pain scale. - Pain Overview Assessment showed: * Pain: Denies experiencing pain; * Pain Management: Denies difficulty managing pain; * Pain Control: Denies difficulty controlling pain; * Adverse Effects of Pain: Pain does not adversely affect patient; * Expectations and Goals for Pain: Patient has defined expectations and goals for pain control; and * FLACC Pain Scale: The FLACC behavioral scale for scoring pain was not performed. Review of the POC showed that the patient took Morphine oral concentrate (a narcotic medication for pain) as needed. Review of an LPN visit, dated 06/06/2024, showed: - The patient had achy type pain in the lower back; - The visit documentation failed to include: * A complete pain assessment that included the history of the pain and its treatment, the pains pattern, impact on the patients quality of life, factors that precipitate or exacerbate the pain, additional symptoms that are associated with the pain, or the patients personal pain goal; and - Evidence that the RN was notified of the patients development of pain. During an interview on 09/11/2024 beginning at 9:15 AM, the administrator stated that a completed pain assessment was not located in the patients record.”

“Based on policy review, clinical record review, home visit observation, and interview, the hospice provider failed to ensure clinicians performed a comprehensive assessment that included a review of all the patients medications and to identify duplicate drug therapy in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all of the providers patients. Findings included: Review of the providers policy titled, “;Medication procurement, Management, Reconciliation and Administration,” last revised 03/2024, showed that:- The Registered Nurse (RN) case manager is responsible for reconciliation of all medications on admission and whenever there are new or changed medications added to the plan of care; and- Licensed Practical Nurses (LPNs) and therapists may transcribe patient reported changes in medications and communicate changes to the RN case manager. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/04/2024 with a terminal diagnosis of atherosclerotic heart disease (thickening of the arterial wall that results in decreased supply of blood flow). The patient resided in their own home with the assistance of their spouse and adult children. Review of the provider’s medication profile report, printed on 09/09/2024, found the patient was taking clopidogrel (an antiplatelet medication used to prevent or treat blood clots) and warfarin (used to prevent blood clots from forming or growing larger in your blood and blood vessels). During the patients home visit observation on 09/10/2024 at 1:40 PM, a medication reconciliation between the provider’s medication profile, printed 09/09/2024, and the medications in the patient’s home showed the medication profile failed to contain: - Vitamin E 400 IU daily (a supplemental vitamin); and - Enteric coated aspirin 81mg daily (an antiplatelet agent). During an interview on 09/11/2024 at 9:10 AM, the clinical manager and administrator stated that they would expect the medications to be on the medication profile.”

“Based on policy review, record review, and interview the hospice provider failed to ensure that the plan of care was individualized for each patient in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the hospice providers policy titled, “;Client Rights and Responsibilities,” dated 09/2024 showed in part, that clients have the right to appropriate, individualized, compassionate, and professional care provided by a team of qualified trained hospice professionals based on physician orders and appropriate for the client and/or family members. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 05/15/2024 with a diagnosis of malignant neoplasm of the occipital lobe (cancer of the occipital lobe of the brain). The patient resided in their own home with the assistance of their spouse. Review of the initial, comprehensive assessment, dated 05/15/2024, showed the following: - The patient reported having Oxycodone (a narcotic medication for pain) and Hydromorphone (a narcotic medication for pain) in the home to help with occasional headaches; and - The pain overview assessment showed that the patient “;has defined expectations and goals for pain control.” Review of the POC, dated 05/15/2024, failed to include orders for Oxycodone and Hydromorphone, or a pain goal for the patient. During an interview on 09/11/2024 beginning at 9:15 AM, the administrator agreed that the POC failed to contain all information for the patient. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 06/26/2024 with a diagnosis of malignant neoplasm of the upper lobe, left bronchus or lung (a cancerous lesion of the lung). The patient resided in their own home with the assistance of their spouse. Review of the initial, comprehensive assessment, dated 06/26/2024, showed that the patient reported that he/she was currently smoking cigarettes, marijuana, and using marijuana gummies. Review of the POC, dated 06/26/2024, failed to include any specific smoking precautions or an order for the patients use of marijuana. During an interview on 09/11/2024 beginning at 9:15 AM, the administrator agreed that the POC failed to contain all information for the patient. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 05/22/2024 with a diagnosis of Alzheimers Disease, unspecified (a disease marked by progressive loss of mental capacity). The patient resided in the home of an adult child who was also their caregiver. Review of the initial, comprehensive assessment, dated 05/22/2024, showed the following: - The pain overview assessment showed that the patient “;has defined expectations and goals for pain control;” - The patient was experiencing “;increasing weakness to the point of requiring wheelchair transportation;” and - The patient was receiving Eliquis (a medication used to treat or prevent blood clots) 2.5 milligrams twice per day. Review of the POC, dated 05/22/2024 failed to include any goals for pain control or bleeding precautions related to the patient receiving Eliquis. The POC stated that the patient used a walker for ambulation. During an interview on 09/11/2024, beginning at 9:15 AM, the administrator agreed that the POC did not contain the bleeding precautions or pain goal for the patient. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/15/2024 with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure (structural and functional changes in the heart as a result of chronic high blood pressure leading to heart and kidney failure). Review of the initial, comprehensive, nursing assessment dated 08/15/2024 showed the patient had: - Type 2 diabetes mellitus (DM2) (a problem in the way the body regulates and uses sugar as a fuel);- A pressure ulcer (a skin injury caused by unrelieved pressure); - Dyspnea, after speaking about five words, with oxygen therapy in the home; - Occasional confusion and difficulty establishing time frames;- A high risk of inadequate nutrition; - Become non-ambulatory since 07/2024, and was dependent in bathing, grooming, and transfers; and- Chronic back pain that worsens with any position change that was controlled with medication. Review of the hospice plan of care (POC), dated 08/15/2024, showed the document failed to contain patient specific interventions and/or measurable goals for problems identified in the initial, comprehensive assessments, including management DM2, pressure ulcer, dyspnea, confusion, nutritional risk, and pain control. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 6/04/2024 with a terminal diagnosis of atherosclerotic heart disease (thickening of the arterial wall that results in decreased supply of blood flow). The patient resided in their own home with the assistance of their spouse and adult children. Review of the initial, comprehensive nursing assessment dated 06/04/2024 showed the patient: - Had a urinary catheter; - Was prescribed two different medications to thin the blood; - Experienced dyspnea with moderate exertion; and- Was at risk of inadequate nutrition; Review of the hospice plan of care, dated 08/15/2024, showed the document failed to contain patient specific interventions and/or measurable goals for problems identified in the initial, comprehensive assessments, including the urinary catheter, the patients risk for abnormal bleeding related to multiple anticoagulant therapies, dyspnea with moderate exertion, and the patients nutritional risk. During an interview on 09/11/2024 the administrator and clinical manager stated that the items were not individualized for the patient or not one the plans of care.”

“Based on policy review, record review, and interview the hospice provider failed to ensure that all medication orders were individualized with specific dosages and directions for use, in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5.) This deficient practice has the potential to affect all patients served by the provider. Findings included:Review of the hospice providers policy titled, “;Medication Procurement, Management, Reconciliation, and Administration,” dated 03/2024, showed in part:- An order for medications shall contain the name of the client, the name of the drug, dosage, frequency, method or site of injection, and an order from the physician if the client or caregiver is to be taught to give the medication;- A verbal order for medication or change in medication shall include the following: *Clients name; *Date and time of the order; *Medication start and stop date if applicable; *Specific order received (medication name, dosage, route, frequency); and *Signature and title; and-The medication profile includes, but not limited to; *Clients name, age, sex, diagnoses, height and weight (when necessary), pregnancy and lactation (when necessary); *All current client medications; *Date prescribed or taken; *Name of medication; *Dose; *Frequency; *Drug classification; *Date discontinued; *Drug and/or food allergies or sensitivities; and *Laboratory results (when necessary). RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 05/15/2024 with a diagnosis of malignant neoplasm of the occipital lobe (cancer of the occipital lobe of the brain). Review of a medication profile report, dated 09/09/2024, showed the following:- “Lorazepam (a medication used for anxiety) 2 milligrams (mg) per milliliter (ml) oral concentrate give 0.25 ml to 1 ml every four (4) hours as needed for anxiety/seizure/nausea sublingually. Start at 0.25 ml’s, if continued symptoms after one (1) hour, give additional dose of 0.25 ml up to a max of 1 ml every 4 hours;” and- “Morphine concentrate (a narcotic medication used for pain) 100 mg/5 ml (20 mg/ml) give 0.25 ml to 1 ml every two (2) hours as needed for pain/SOB (shortness of breath) sublingually. Start at 0.25 ml, if symptoms are not controlled within 1 hour, give additional 0.25 ml up to a maximum of 1 ml every 2 hours;” and-The plan of care failed to contain specific instructions for the variable dosages of the medications. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/26/2024 with a diagnosis of malignant neoplasm of the upper lobe, left bronchus or lung (a cancerous lesion of the lung). Review of a medication profile report, dated 09/09/2024 showed the following:- “Albuterol sulfate 2.5 mg/3 ml (0.083%) inhalation solution (a medication used for shortness of breath) for nebulization give 2.5 mg every 2 to 4 hours as needed for dyspnea (shortness of breath) or wheezing (a high-pitched whistling sound made while breathing);”- “Lorazepam 2 mg/ml oral concentrate give 2 mg every 4 hours as needed, 0.25 ml to 1 ml every 4 hours PRN (pro re nata- as needed) anxiety/seizure start 0.25 ml may increase to 0.5 ml to 1 ml every 4 hours. Do not give at the same time as diazepam;”- “Hydroxyzine HCl (a medication used for anxiety) 50 mg oral tablet give 1 to 2 tablets as needed; and- “Oxycodone (a narcotic medication used for pain) 10 mg oral tablet give one-half to 1 tablet every 4 hours as needed for pain (4 to 10);” and- The plan of care failed to contain specific instructions for the variable dosages of the medications. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/15/2024 with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure (structural and functional changes in the heart/ as a result of chronic high blood pressure leading to heart and kidney failure). The patient resided in their own home with the assistance of an adult child. Review of the hospice plan of care dated 08/15/2024 showed:- “;Lorazepam (a medication used for anxiety) 2 milligrams (mg) per milliliter (ml) oral concentrate give 0.25 ml to 1 ml every 4 hours as needed for anxiety/seizure/nausea sublingually. Start at 0.25 ml’s, if continued symptoms after 1 hour, give additional dose of 0.25 ml up to a max of 1 ml every 4 hours;” - “;Morphine concentrate (a narcotic medication used for pain) 100 mg/5 ml (20 mg/ml) give 0.25 ml to 1 ml every 2 hours as needed for pain/SOB (shortness of breath) sublingually. Start at 0.25 ml, if symptoms are not controlled within 1 hour, give additional 0.25 ml up to a maximum of 1 ml every 2 hours;” and- The plan of care failed to contain specific instructions for the variable dosages of the medications. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/04/2024 with a terminal diagnosis of atherosclerotic heart disease (thickening of the arterial wall that results in decreased supply of blood flow). The patient resided in their own home with the assistance of their spouse and adult children. Review of the hospice providers medication profile printed 09/09/2024 showed:- “;Lorazepam (a medication used for anxiety) 2 milligrams (mg) per milliliter (ml) oral concentrate give 0.25 ml to 1 ml every 4 hours as needed for anxiety/seizure/nausea sublingually. Start at 0.25 ml’s, if continued symptoms after 1 hour, give additional dose of 0.25 ml up to a max of 1 ml every 4 hours;” - “;Morphine concentrate (a narcotic medication used for pain) 100 mg/5 ml (20 mg/ml) give 0.25 ml to 1 ml every 2 hours as needed for pain/SOB (shortness of breath) sublingually. Start at 0.25 ml, if symptoms are not controlled within 1 hour, give additional 0.25 ml up to a maximum of 1 ml every 2 hours;” and- The plan of care failed to contain specific instructions for the variable dosages of the medications. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 05/22/2024 with a diagnosis of Alzheimers Disease, unspecified (a disease marked by progressive loss of mental capacity). Review of a medication profile report, dated 09/09/2024 showed the following:- “Lorazepam 2 mg/ml oral concentrate give 2 mg every 4 hours as needed, 0.25 ml to 1 ml every 4 hours PRN anxiety/seizure start 0.25 ml may increase to 0.5 ml to 1 ml every 4 hours;” - “Morphine concentrate 100 mg/ 5 ml (20 mg/ml) oral solution give 0.25 ml to 1 ml every 1 hour PRN may increase to 0.5 ml to 1 ml every 1 hour PRN for pain or SOB;” and- The plan of care failed to contain specific instructions for the variable dosages of the medications. During an interview on 09/11/2024 at 9:09 AM, the administrator and clinical manager stated they were unable to locate specific parameters for the variable doses on the medications.”

“Based on record review, home visit observation, and interview the hospice provider failed to ensure that the plan of care (POC) included all medical supplies necessary for the care of the patient in two of four home visits conducted (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 05/15/2024 with a diagnosis of malignant neoplasm of the occipital lobe (cancer of the occipital lobe of the brain). Review of the initial, comprehensive assessment, dated 05/15/2024, showed that the patient had no physical limitations and had a fall risk of one (1) (indicated the patient was not at risk of falls). Review of the POC, dated 05/15/2024, failed to include any durable medical equipment (DME). Review of the registered nurse (RN) recertification visit, dated 07/31/2024, showed that the patient had an unstable gait/difficulty with transfers and the caregiver expressed concern that the patient might fall. Fall risk of four (4) (indicated the patient was at risk for falls). Review of a communication note, dated 08/12/2024, showed that the patients caregiver called and reported that the patient had went to sit down in his/her recliner and fell onto his/her right elbow causing a fracture. Review of the POC, dated 08/13/2024, failed to include any DME. Review of an interdisciplinary team (IDT) note, dated 08/21/2024, showed the patient was to have a cast applied to the right arm due to the recent fracture. Review of an IDT note, dated 09/04/2024, showed the patient had a hard cast to the right upper arm since 08/21/2024 and was using a sling for positioning of the casted arm. Observation on 09/10/2024 beginning at 9:30 AM, during the patients home visit, showed the patient had a walker and manual wheelchair in the home. The patients right arm was in a cast and there was no sling visible. During an interview on 09/10/2024 beginning at 9:30 AM, the patients caregiver stated that the walker was being used prior to the patients fall because his/her gait had gotten worse and that the wheelchair had been used for a few weeks since the fall because the patient could no longer use the walker with the cast in place. The POC failed to show the use of the DME (the walker and the wheelchair). RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 06/26/2024 with a diagnosis of malignant neoplasm of the upper lobe, left bronchus or lung (a cancerous lesion of the lung). Review of the initial, comprehensive assessment, dated 06/26/2024, the equipment assessed showed a wheelchair and a nebulizer. Review of the POC, dated 06/26/2024, showed DME and supplies as wheelchair and nebulizer. Review of a skilled nurses note dated, 07/02/2024, showed that oxygen was ordered for delivery to the home due to patient request and shortness of breath. Review of an IDT note, dated 07/10/2024, showed a hospital bed was ordered for the patient. Observation on 09/09/2024, beginning at 1:05 PM, during the patients home visit, showed the patient was using oxygen at five (5) liters per minute. Other equipment in the home included a hospital bed and a bed side commode. The POC failed to include the oxygen concentrator, hospital bed, and the bedside commode. During an interview on 09/11/2024 beginning at 9:15 AM, the administrator agreed that the DME information was not updated on the POC and stated that he/she would expect it to be updated as needed.”

“Based on clinical record review and interview, the hospice provider failed to ensure the plan of care was updated and included the patients progress toward stated goals, in four of five full records reviewed (Records/Patients #1, #2, #3, and #4). This deficient practice has the potential to affect all the providers patients. Findings included: RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/15/2024 with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure (structural and functional changes in the heart as a result of chronic high blood pressure leading to heart and kidney failure). The patient resided in their own home with the assistance of an adult child. Review of the hospice plan of care (POC) dated 08/15/2024 showed, but not limited to, the following goals for care: - Patient will remain free from falls throughout episode of care; - Throughout care, the patient will demonstrate improvement and/or stabilization of signs/symptoms and be free from complications; and- Within two weeks, and ongoing, sacral wound and bilateral groin rash will show evidence of healing by a reduction I size and no signs and symptoms of infection. Review of nursing visit documentation showed the following changes in the comprehensive assessment of the patient:- On 08/19/2024 showed the patient used barrier cream to a closed pressure injury on their sacrum, and Monistat 7 (an antifungal cream) to bilateral groin folds for rash twice a day. The caregiver stopped using the Monistat 7 due to worsening of the rash, and is now using barrier cream to the groin folds; and- On 08/20/2024 the physician was notified of morphine allergy and instructed the staff that the morphine was, “;not a true allergy, morphine works very well for patient but requires small doses.” Review of the hospice IDT Report (Interdisciplinary Team) on 08/21/2024 showed the document failed to contain an update to the POC that included documentation of the patients progress toward stated goals, and removal of morphine as an allergy for the patient. Review of the nursing visit documentation showed the following changes in the comprehensive assessment of the patient on:- 08/29/2024 the patients pain was increased, rated at a 5 on a 0-10 high scale, and - 09/03/2024 the patient reporting seeing a “;little girl in the corner” who was not there. Review of the hospice IDT Report (Interdisciplinary Team) on 09/04/2024 showed the document failed to contain an update to the POC that included documentation of the patients progress toward stated goals including the increase in the patients pain, and the patients visual hallucinations. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 6/04/2024 with a terminal diagnosis of atherosclerotic heart disease (thickening of the arterial wall that results in decreased supply of blood flow). The patient resided in their own home with the assistance of their spouse and adult children. Review of the hospice plan of care (POC) dated 06/04/2024 showed, but not limited to, the following goals for care: - Patient will remain free from falls throughout episode of care; and- Patient/family will be provided with end-of-life care to mitigate symptoms, meet spiritual and emotional needs while maintaining patient dignity to control pain. Review of nursing visit documentation showed the following changes in the comprehensive assessment of the patient on:- 08/01/2024 an order was received for warfarin 3mg daily; and- 08/06/2024 the nurse changed the patients urinary catheter. Review of the hospice IDT Report (Interdisciplinary Team) on 08/07/2024 showed the document failed to contain an update to the POC that included documentation of the patients progress toward stated goals, and the initiation of additional goals related to the management of the patients anticoagulant therapy and urinary catheter. Review of nursing visit documentation showed the following changes in the comprehensive assessment of the patient on:- 08/08/2024 the client continued to have a urinary catheter, and the nurse obtained a sample for lab work related to anticoagulant therapy; - 08/15/2024 the client reported achy, constant pain that had occurred in the past and was present during the visit, and the use of oxygen as needed; and- 08/20/2024 the client continued to report pain and the urinary catheter remained in place. Review of the hospice IDT Report (Interdisciplinary Team) on 08/21/2024 showed the document failed to contain an update to the POC that included documentation of the patients progress toward stated goals, the patients reported pain, the initiation of oxygen therapy on an as needed basis, and management of the patients anticoagulant therapy and urinary catheter. During an interview on 09/11/2024 at 9:09 AM, the administrator and clinical manager stated that they:- Would expect the POC to be updated during the IDT meetings: and - They were unable to find documentation that the IDT had documented updates to the POC and progress toward patient goals in the IDT notes. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 05/15/2024 with a diagnosis of malignant neoplasm of the occipital lobe (cancer of the occipital lobe of the brain). The patient resided in their own home with the assistance of their spouse. Review of the plan of care (POC), dated 05/15/2024, showed: - The patient had an allergy to Tylenol (a medication used for mild pain) and Oxycodone (a narcotic medication used for pain); - A safety goal that the patient would be free of falls throughout the episode of care; and - The patient had no durable medical equipment (DME) in the home. Review of a hospice medication review, dated 08/01/2024, showed: - The pharmacist notified the physician that the patient was receiving duplicate medication therapy that included Oxycodone and Hydromorphone (a narcotic medication used for pain) and there was potential for a drug interaction; - The physician signed the medication review; and - The provider failed to remove the patients allergy to Oxycodone from the POC. Review of a communication note dated, 08/12/2024, showed that the patients caregiver called and reported that the patient had went to sit down in his/her recliner and fell onto his/her right elbow causing a fracture. Review of the POC, dated 08/13/2024, failed to include any updates related to the recent fall or fracture. Review of an interdisciplinary team (IDT) note, dated 08/21/2024, showed the patient was to have a cast applied to the right arm due to recent fracture. Review of an IDT note, dated 09/04/2024, showed the patient had a hard cast to right upper arm since 08/21/2024 and was using a sling for positioning of the casted arm. Observation on 09/10/2024 beginning at 9:30 AM, during the patients home visit, showed the patient had a walker and manual wheelchair in the home. The patients right arm was in a cast and no sling was visible. During an interview on 09/10/2024 beginning at 9:30 AM, the patients caregiver stated that the walker was being used prior to the patients fall because his/her gait had gotten worse and that the wheelchair had been used for a few weeks since the fall because the patient could no longer use the walker with the cast in place. The provider failed to update the POC to include any interventions related to DME or the patients casted arm fracture. During an interview on 09/11/2024 beginning at 9:15 AM, the administrator agreed that the POC was not updated. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 06/26/2024 with a diagnosis of malignant neoplasm of the upper lobe, left bronchus or lung (a cancerous lesion of the lung). The patient resided in their own home with the assistance of their spouse. Review of the plan of care, dated 06/26/2024, showed: - The patient was receiving Lorazepam oral concentrate (a medication used for anxiety) 2 milligrams (mg) per milliliter (ml) give 2 mg every 4 hours as needed for anxiety or seizure; - The patient had an allergy to Lorazepam; and - The patient had DME in the home that consisted of a nebulizer and a wheelchair. Review of a hospice medication review, dated 07/17/2024, showed: - The pharmacist notified the physician that the patient was receiving duplicate medication therapy that included Lorazepam and Diazepam (a medication used for anxiety) and there was potential for a drug interaction; - The physician signed the medication review; and - The provider failed to remove the patients allergy to Lorazepam from the POC. Observation on 09/09/2024, beginning at 1:05 PM, during the patients home visit, showed the patient was using oxygen at 5 liters per minute. Other equipment in the home included a hospital bed, and a bed side commode. The provider failed to update the POC to include oxygen, the hospital bed, and the bed side commode. During an interview on 09/11/2024 beginning at 9:15 AM, the administrator agreed that the POC was not updated.”

“Based on record review and interview the hospice provider failed to ensure all visits were completed as ordered by the physician, in two of five full records reviewed (Records/Patients #2 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 06/26/2024 with a diagnosis of malignant neoplasm of the upper lobe, left bronchus or lung (a cancerous lesion of the lung). The patient resided in their own home with their spouse as their caregiver. Review of the POC, dated 06/26/2024, showed the physician ordered social services visits every week for 13 weeks. Review of social services visits showed that visits were missed on the following dates: - The week of 07/07/2024 to 07/13/2024 with a notation that the visit was missed due to unable to confirm and computer issues; - The week of 07/21/2024 to 07/27/2024 with a notation that the visit was missed due to unable to confirm and social worker unable to work; - The week of 07/28/2024 to 08/03/2024 with a notation that the visit was missed due to unable to confirm; and - The provider failed to notify the physician of missed visits. During an interview on 09/11/2024 beginning at 9:15 AM, the administrator stated that the visits were documented as missed and there was no documentation that the physician was notified. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 05/22/2024 with a diagnosis of Alzheimers Disease, unspecified (a disease marked by progressive loss of mental capacity). The patient resided in the home of an adult child who was also their caregiver. Review of the POC, dated 08/20/2024, showed the physician ordered spiritual counseling visits every week for 13 weeks. Review of chaplain visits showed: - A visit was missed the week of 09/01/2024 to 09/07/2024 with a notation that the visit was missed due to unable to confirm; and - The provider failed to notify the physician of the missed visit. During an interview on 09/11/2024 beginning at 9:15 AM, the administrator stated that the visits were documented as missed and there was no documentation that the physician was notified.”

“Based on clinical record review and interview, the hospice provider failed to ensure the clinicians forwarded a copy of the discharge summary to the patients attending physician, at discharge, in one of three applicable records reviewed (Record/Patient #9). This deficient practice has the potential to affect the coordination of care for all the patients discharged from the provider. Findings included:RECORD/PATIENT #9: Review of the clinical record showed the patient was admitted to hospice services on 10/03/2022 with a terminal diagnosis of malignant neoplasm of the head, face, and neck (cancer). The hospice provider discharged the patient from services as they no longer qualified for hospice services. The patient resided in a long-term care facility. Review of the discharge documentation showed the clinical record failed to contain:- A document that summarized the patients stay including treatments, symptoms, and pain management; - The patients latest physician orders (including but not limited to the discharge order); and- Evidence that the discharge summary was sent to the attending physician at the time of discharge. During an interview on 09/11/2024 at 11:16 AM, the clinical manager and administrator stated there was no discharge summary available for this patient.”