Haven Hospice

“Based on policy review, record review, and interview, the hospice provider failed to ensure the interdisciplinary group reviewed, revised, and documented the patient’s individualized plan of care following significant changes in the patient’s condition and treatment regimen in, one out of three sampled patients (Record/Patient #1). This deficient practice had the potential to affect all hospice patients requiring revisions to the interdisciplinary plan of care. Findings included:Review of the provider’s policy titled, “COC.74 Plan of Care,” revised 03/16/2016, showed in part, the interdisciplinary team was required to review, revise, and document the individualized plan of care as frequently as the patient’s condition required. The policy further required the revised plan of care to include information from the patient’s updated comprehensive assessment and reflect the patient’s changing needs, services, progress toward goals, and interventions to manage pain and symptoms. RECORD/PATIENT #1: Review of the medical record showed the patient was admitted to hospice on 06/01/2026 with terminal diagnosis of lung cancer. The admission documentation showed severe dyspnea (shortness of breath) with minimal exertion, nocturnal air hunger, fatigue, progressive weakness, dysphagia (difficulty swallowing), cachexia (where a severe, underlying illness causes your body to rapidly burn fat and turn down muscle), and approximately 20% unintentional weight loss. The admission narrative documented the patient required oxygen therapy and experienced significant respiratory distress. Review of the complaint information dated 06/06/2026 showed the patient and family had concerns regarding symptom management and stated comfort medications had not been provided despite symptoms they believed warranted treatment. Review of the physician order dated 06/06/2026, showed the physician ordered concentrated morphine sulfate 20 mg (milligrams/ml (milliliter), 0.5ml orally every two hours as needed for shortness of breath and moderate to severe pain and lorazepam concentrate (antianxiety) 0.25 ml as needed for shortness of breath or anxiety/agitation. Record review did not identify documentation demonstrating the interdisciplinary plan of care was revised following these medication changes to incorporate the updated medication regimen, individualized interventions for management of dyspnea and pain, or patient/caregiver education regarding the revised mediation regimen. Review of the hospice physician narrative dated 06/06/2026 showed the patient remained severely short of breath at complete rest despite continuous oxygen, was emaciated and frail, remained on the sofa because of fatigue and weakness, and required medication changes including lorazepam (antianxiety), concentrated morphine every two hours as needed, increased prednisone (used to treat severe inflammation, allergies, and autoimmune conditions), and additional symptom management interventions. Record review did not identify documentation demonstrating the interdisciplinary plan of care was revised following the physician’s medication changes and worsening symptom management after 06/06/2026. Review of the physician orders dated 06/08/2026 showed the morphine order was revised to administer 0.25 ml orally every two hours for air hunger or moderate to severe pain, with comments that 0.25 ml-0.5 ml may be administered. Record review did not identify documentation demonstrating the interdisciplinary plan of care was revised following these additional medication changes. Observation on 06/29/2026 at 3:53 PM, showed that the registered nurse case manager provided education regarding the medication using examples of the patient’s previous episodes of shortness of breath. During the visit, the patient stated that he/she was afraid to take morphine because he/she had never taken it previously, and the patient and caregiver continued to ask questions regarding the prescribed dosing. During an interview on 06/30/2026 at 9:30 AM, the patient’s primary care giver reported that they had continued questions regarding the difference between administering 0.25 ml (milliliter) versus 0.5 ml of morphine and reported they still did not fully understand when each dose should be administered. During an interview on 06/30/2026 at 10:30 AM, the director of nursing stated that the interdisciplinary plan of care was not revised following the medication changes after 06/06/2026. The hospice’s failure to revise the interdisciplinary plan of care following changes in the patient’s condition and treatment regimen resulted in a plan of care that did not reflect the patient’s updated comprehensive assessment, revised symptom management interventions, medication changes, measurable goals, or caregiver education needs.”

“Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to establish frequencies of visits based on the needs of the patient. For example, in RRNHV #1,2,3, 4, 5, 6, 7, 8, 9, and 10 the frequencies for the Skilled Nurse (SN), 1-3 wk for 9 wks, Medical Social Worker (MSW) 3 PRN for support, Chaplain, 1-3 month for 2 months, and Certified Nursing Assistant (CNA), 1-3 wk 9 wks were noted to be the same throughout all benefit periods although, the frequencies did not reflect the need of the patient as evidenced by, the number of frequencies not being utilized throughout multiple benefit periods and the presumptive entering of frequencies not according to the patient’s assessment needs but to satisfy what was stated as the current owner of electronic medical record’s suggestion that the frequencies are best practice and if not entered as such, the program gives “an error message”. There were similar findings in RRHV 1, 2, 3, and 4. This was validated and reviewed with the Clinical Director and the Administrator.”

“Observed in Patient Home. In 1 of 3 home visits conducted, the surveyor noted the patient had loose pills on the floor and table; however, the plan of care did not include interventions to address safe administration of medication in the home. This was validated and reviewed with the Clinical Director. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to discontinue a medication on the plan of care in the facility hospice binder and in the hospice organization’s electronic medical record. For example in RRHV #1, estradiol 0.01% cream; administer 1 application applied topically to urethra Monday, Wednesday, and Friday was discontinued on the facility’s electronic medical record by the rounding Doctor in the facility for at least a month but still remained as an active medication in the hospice organization’s electronic medical record. This was validated and reviewed with the Clinical Director.”

“Observed in Record Review. In 12 of 14 patient records reviewed, the organization failed to update the plan of care. For example, in RRNHV #1 benefit period 4, the plan of care goal stated, skin integrity will be maintained and problems managed as disease process will allow by the target date which expired during benefit period 4. In benefit period 5 the same expired goal was documented on the plan of care without any documentation to indicate if the goal was met or needed to be modified. Another example, in benefit period 4 the goal stated, patient will maintain optimum bowel functioning consistent with food intake and stage of disease parameters. The goal expired in benefit period #4 but still continued into benefit period 5. Similar findings were noted in RRNHV #2, 3,4, 5, 6,7,and 9 and RRHV 1,2,3, and 4. This was validated and reviewed with the Clinical Director and the Administrator. Observed in Record Review. In 12 of 14 patient records reviewed, the organization failed to follow the plan of care. For example, in RRNHV #2, the Skilled Nurse (SN) documented goals, pt will be able to eat/drink to his/her satisfaction and the Medical Social Worker (MSW) documented, patient/caregiver able to verbalize appropriate interventions for stress/anxiety management. Both goals expired at the target date with only 70% progress documented towards meeting the goals but there is no documentation in the clinical record to indicate the Physician was notified as to continuing the goals. There are similar findings in RRNHV #1, 3, 4, 5, 6, 7, and 9 and in RRHV #1,2,3, and 4. This was validated and reviewed with the Clinical Director and the Administrator.”

“Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to develop an appropriate plan of care for the Certified Nursing Assistant (CNA). For example, during RRHV #2 the CNA’s plan of care indicated vital signs: blood pressure, pulse, respirations, and temperature and to report any of the following to RN: any vital signs outside of approved parameters but there were no parameters indicated on the plan of care for blood pressure, pulse, respirations, and temperature. The plan of care only included parameters for pain level greater than a 3/10. The CNA also could not state to the Surveyor approved parameters. This was validated and reviewed with the Clinical Director.”

“Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to provide oxygen safety teaching and education to the patient and patient’s wife. For example, in RRHV #3, the patient’s wife indicated education and teaching had not been provided on oxygen use and there was no indication in the clinical record to support the teaching/education was provided to the patient’s wife. The patient’s wife stated, the guy from the oxygen company just came and hooked it up and left. The Hospice Nurse responded, that’s because he just recently started using oxygen and still did not provide the teaching nor education during the visit. This was validated and reviewed with the Clinical Director.”