Integris Hospice House

“Based on record review and interview, the hospice failed to ensure it provided medications for the management of the pain for one (Patient #15) of 19 patients. Findings: Patient #15A review of the clinical record showed an election of the hospice benefit/SOC on 11/10/23. A plan of care dated 11/11/23 to 02/07/24 documented a primary diagnosis of lung cancer with metastasis to the liver. An RN note dated 11/10/25 at 5:50 p.m., documented the patient “hurt everywhere” and was experiencing ascites (swelling of the abdomen) and nausea. The medical provider was called and medications were ordered from the pharmacy for home delivery of morphine sulfate extended release for pain, morphine sulfate immediate release for pain, and Phenergan and Zofran for nausea to be delivered by the pharmacy on the 6 p.m. delivery run. An RN note dated 11/11/23 at 8:28 p.m., documented the patient had no medication in the home. A telephone call to the pharmacy to follow up on home delivery of medications ordered on 11/10/25 was conducted (26 + hours since pharmacy order placed). Medications to be delivered to the home by the pharmacy. An RN note dated 11/12/23 at 5:15 p.m., documented the daughter gave the patient morphine sulfate 30 minutes before the home visit. The patient continues to complain of pain “everywhere”. At 8:45 p.m. the patient was transferred to the hospice house for in-patient hospice care via ambulance transport. At 8:58 p.m., the patient arrived at the hospice house for in-patient hospice care. On 11/13/24 at 12:14 a.m., documentation showed the patient expired at the in-patient hospice facility (3 hours and 16 minutes from time of arrival). On 05/16/25 at 2:50 p.m., Staff B stated:1. The SN staff making the home visits should have followed up with the patient’s family to ensure the medications had been delivered to the home. 2. The pharmacy should deliver the new order medications by the same day and refills by the next business day. 3. If the physician was delayed in sending in the prescriptions for the morphine sulfate extended release and the morphine sulfate immediate release for pain the delivery could have been delayed until the next business day after the pharmacy received the prescriptions.4. The hospice was unable to find out what date and time the medications were delivered to the patient’s home between 11/10/23 at 5:50 p.m. and 11/12/23 at 5:15 p.m.”

“Based on record review and interview, the hospice failed to ensure an initial spiritual assessment was conducted within the five-day timeframe required to complete the initial comprehensive assessment for two (Patients #2 and #9) of 19 patients. Findings: Patient #2A review of the clinical record showed an election of the hospice benefit/SOC on 04/01/25. Documentation showed a spiritual assessment was conducted on 04/07/25 (6 days later) by a chaplain. Documentation showed no declined chaplain visits, no physician notifications, and no changes in orders. On 05/16/25 at 9:15 a.m., Staff A stated the chaplain had not conducted the initial spiritual assessment within the five-day timeframe. Patient #9A review of the clinical record showed an election of the hospice benefit on 01/31/25. Documentation showed no spiritual assessment was conducted by a chaplain. Documentation showed no declined chaplain visits, no physician notifications, and no changes in orders. On 05/16/25 at 10:55 a.m., Staff A stated the chaplain had not conducted the initial spiritual assessment within the five-day timeframe.”

“Based on record review and interview, the agency failed to ensure medication regimen changes were updated on the medication profile for two (Patients #2 and #12) of 19 patients. Findings: Patient #2A review of the plan of care dated 04/01/25 to 05/30/25 showed a diagnosis of Colan cancer. A case management note dated 04/16/25 stated change oral pain medication to hydromorphone 8 milligrams three times a day. A review of the clinical record showed no update to the medication profile for the medication hydromorphone and showed no review for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy. On 05/16/25 at 9:15 a.m., Staff A stated the medication should have been added to the medication profile and reviewed for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy. Patient #12A review of the plan of care dated 04/01/25 to 05/30/25 showed a diagnosis of stage 4 kidney disease and showed no medication listed in the medication profile. An IDG note dated 04/08/25 showed no medication listed in the medication profile. An IDG note dated 04/09/25 showed no medication listed in the medication profile. An IDG note dated 04/18/25 showed ordered medications on the medication profile of the POC (17 days after initiation of the POC on 04/01/25). On 05/16/25 at 11:50 a.m., Staff A stated the medication should have been added to the medication profile of the POC and reviewed for drug reactions, side effects and interactions.”

“Based on record review and interview, the hospice failed to ensure:Initial bereavement/psychosocial assessment was conducted within the five-day timeframe required to complete the initial comprehensive assessment for four (Patients #2, 6, 8 and #14) of 23 patients.A bereavement POC was established and implemented for 13 (Patients #1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14) of 23 patients. Findings: Patient #1A review of the clinical record showed an initial bereavement assessment dated 05/02/25 with an IDG update scheduled for 05/15/25. Documentation showed no bereavement POC, no patient or caregiver refusal of a bereavement POC and no change in orders. On 05/16/25 at 9:05 a.m., Staff A stated patient #1 had no bereavement POC. Patient #2A review of the clinical record showed an election of the hospice benefit on 04/01/25. Documentation showed no bereavement/psychosocial assessment was conducted, no follow up care and services were offered or provided by an MSW and no bereavement POC, no declined MSW visits, no patient or caregiver refusal of a bereavement POC, no physician notifications, and no changes in orders. On 05/16/25 at 9:15 a.m., Staff A stated:1. The MSW had not conducted the initial bereavement/psychosocial assessment within the five-day timeframe required to complete the initial comprehensive assessment.2. Patient #2 had no bereavement POC.3. The hospice does not implement bereavement care plans until after a patient’s death. Patient #3A review of the clinical record showed an initial bereavement assessment dated 04/21/25 with an IDG update scheduled for 05/02/25. Documentation showed no bereavement POC, no patient or caregiver refusal of a bereavement POC and no change in orders. On 05/16/25 at 9:25 a.m., Staff A stated patient #3 had no bereavement POC. Patient #5A review of the clinical record showed an initial bereavement assessment dated 04/25/25 with an IDG update on 05/09/25. Documentation showed no bereavement POC, no patient or caregiver refusal of a bereavement POC and no change in orders. On 05/16/25 at 9:55 a.m., Staff A stated patient #5 had no bereavement POC. Patient #6A review of the clinical record showed an election of the hospice benefit on 02/25/25. Documentation showed no bereavement/psychosocial assessment was conducted, no follow up care and services were offered or provided by an MSW, no bereavement POC, no declined MSW visits, no patient or caregiver refusal of a bereavement POC, no physician notifications, and no changes in orders. On 05/16/25 at 9:15 a.m., Staff B stated:1. The MSW did not conducted the initial bereavement/psychosocial assessment within the five-day timeframe required to complete the initial comprehensive assessment.2. Patient #6 had no bereavement POC.3. The hospice does not implement bereavement care plans until after a patient’s death. Patient #7A review of the clinical record showed an initial bereavement assessment dated 12/12/24 with an IDG meetings on 03/10/25, 03/14/25, 03/28/25, 04/11/25, 04/25/25 and on 05/09/25. Documentation showed no bereavement POC, no patient or caregiver refusal of a bereavement POC and showed no change in orders. On 05/16/25 at 10:20 a.m., Staff A stated patient #7 had no bereavement POC. Patient #8A review of the clinical record showed an election of the hospice benefit on 05/02/25. Documentation showed no bereavement/psychosocial assessment was conducted, showed no follow up care and services were offered or provided by an MSW, showed no bereavement POC, no declined MSW visits, no patient or caregiver refusal of a bereavement POC, no physician notifications, and no changes in orders. On 05/16/25 at 10:45 a.m., Staff A stated:1. The MSW did not conducted the initial bereavement/psychosocial assessment within the five-day timeframe required to complete the initial comprehensive assessment.2. Patient #8 had no bereavement POC.3. The hospice does not implement bereavement care plans until after a patient’s death. Patient #9A review of the clinical record showed an initial bereavement assessment dated 02/04/25 with an IDG meeting on 05/09/25. Documentation showed no bereavement POC, no patient or caregiver refusal of a bereavement POC and showed no change in orders. On 05/16/25 at 10:55 a.m., Staff A stated patient #9 had no bereavement POC. Patient #10A review of the clinical record showed an initial bereavement assessment dated 03/12/25 with an IDG meeting on 03/14/25, 03/24/25, 04/18/25 and on 05/02/25. Documentation showed no bereavement POC, no patient or caregiver refusal of a bereavement POC and showed no change in orders. On 05/16/25 at 11:05 a.m., Staff A stated patient #10 had no bereavement POC. Patient #11A review of the clinical record showed an initial bereavement assessment dated 12/13/25 with an IDG meeting on 04/08/25, 04/25/25 and on 05/09/25. Documentation showed no bereavement POC, no patient or caregiver refusal of a bereavement POC and showed no change in orders. On 05/16/25 at 11:30 a.m., Staff A stated patient #11 had no bereavement POC. Patient #12A review of the clinical record showed an election of the hospice benefit on 04/08/25. Documentation showed an initial bereavement and psychosocial assessment was conducted on 04/14/25 (6 days) with an IDG meeting on 04/08/25, 04/18/25 and on 05/02/25. Documentation showed no declined MSW visits, no physician notifications, and no changes in orders. On 05/16/25 at 11:50 a.m., Staff A stated:1. The MSW had not conducted the initial bereavement and psychosocial assessment within the five-day timeframe required to complete the initial comprehensive assessment. 2. Patient #12 had no bereavement POC. Patient #13A review of the clinical record showed an initial bereavement assessment dated 03/06/25 with an IDG meeting on 03/21/25, 04/02/25, 04/08/25, 04/18/25 and on 05/02/25. Documentation showed no bereavement POC, no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #14A review of the clinical record showed an election of the hospice benefit on 01/10/25. Documentation showed no bereavement and psychosocial assessment was conducted, no follow up care and services were offered or provided by an MSW, no bereavement POC, no declined MSW visits, no patient or caregiver refusal of a bereavement POC, no physician notifications, and no changes in orders. On 05/16/25 at 12:25 p.m., Staff A stated:1. The MSW had not conducted the initial bereavement and psychosocial assessment within the five-day timeframe required to complete the initial comprehensive assessment.2. Patient #14 had no bereavement POC.3. The hospice does not implement bereavement care plans until after a patient’s death.”

“Based on record review and interview, the agency failed to ensure care was coordinated between the IDG and physician for six (Patients #3, 7, 13, 14, 15 and #19) of 19 patients. Findings: Patient #3A review of a plan of care dated 04/16/25 to 07/14/25 showed a primary diagnosis of late effects cerebrovascular accident. Documentation showed orders for hospice aide visits one time for four days, two times a week for 12 weeks, then one time day for two days. Aide missed visit notifications dated 04/17/25, 04/24/25, 04/29/25, 05/06/25 and on 05/08/25 were auto faxed to the physician with no follow-up coordination of care attempts to advise of the patient’s continued missed aide visits as ordered on the POC, and documentation showed no attempts to reschedule or make up the missed aide visits during the weeks they were ordered. On 05/16/25 at 9:25 a.m., Staff A stated the auto faxed missed hospice aide visit notifications should have been followed up with the physician and the IDG members to update the POC.Patient #7A review of a plan of care dated 03/10/25 to 06/07/25 documented a primary diagnosis of prostate cancer with metastasis to the liver. A SN visit note dated 03/03/25 showed documentation that the patient was experiencing nausea and vomiting of bile and was symptomatic of febrile illness with a temperature of 102.1 degrees Fahrenheit and showed no subsequent follow up by the IDG and the physician until 03/18/25 (15 days later). On 05/16/25 at 10:20 a.m., Staff A stated the SN should have addressed the changes in the patient’s condition with the physician and the IDG when the SN noted the changes in condition. Patient #13A review of a plan of care dated 03/19/25 to 05/17/25 documented a primary diagnosis of Alzheimer’s disease. An RN case management note dated 03/04/25 showed documentation that the patient had morphine sulfate elixir (a pain medication) in the home. The POC showed no morphine sulfate elixir on the medication profile. Follow up by the IDG and the physician on 03/21/25, 04/02/25, 04/08/25, 04/18/25 and on 05/02/25 (over the course of 42 days) showed no order for morphine sulfate elixir for the treatment of pain. On 05/16/25 at 12:10 p.m., Staff A stated the IDG should have addressed the pain medication the patient was using in the home. Patient #14A review of a plan of care dated 04/10/25 to 07/08/25 showed a primary diagnosis of cardiovascular disease. A SN visit note dated 04/11/25 showed the patient was experiencing poor appetite, only ate a few bites at a time and lost 90 pounds in the last 9 months. Documentation showed no follow up by the IDG and the physician. On 05/16/25 at 12:25 p.m., Staff A stated the SN should have addressed the changes in the patient’s condition with the physician and the IDG. Patient #15A review of a plan of care dated 11/11/23 to 02/07/24 showed a primary diagnosis of lung cancer with metastasis to the liver. An RN note dated 11/10/25 at 5:50 p.m., showed medications were ordered from the pharmacy for home delivery of morphine sulfate extended release and morphine sulfate immediate release for pain, and Phenergan and Zofran for nausea. The POC showed no morphine sulfate extended release for pain, morphine sulfate immediate release for pain, and Phenergan and Zofran for nausea. On 05/16/25 at 1:24 p.m., Staff A stated the SN staff making the home visits and the IDG team should have addressed the medications the patient was using in the home when developing the comprehensive POC. Patient #19A review of a plan of care dated 01/17/25 to 04/15/25 showed a primary diagnosis of pancreatic cancer. Documentation showed IDG meetings to review and update the patient’s POC occurred on 01/03/25 and again on 02/09/25 (37 days) and showed no coordination of care communications with the physician and no IDG related to hospice provider services during IDG meetings on 01/18/25 and on 01/26/25. On 05/16/25 at 2:20 p.m., Staff A stated IDG meetings in hospice care to review and update the POC should occur every 15 days.”

“Based on record review and interview, the hospice failed to ensure:1. Aide visits were provided in accordance with the plan of care for four (Patients #3, 5, 8 and 17) of 19 patients.2. SN performed pain assessments consistent with the physician order for three (Patients #4, 9 and #11) of 19 patients.3. SN visits were provided in accordance with the plan of care for one (Patients #13) of 19 patients. Findings: Patient #3A review of a POC dated 04/16/25 to 07/14/25 with IDG updates on 04/16/25 and 05/02/25 showed an aide visit frequency of one time a day for four days, two times a week for 12 weeks, then one every two days, times two days. During the week of 04/20/25 to 04/26/25 on 04/24/25 showed an aide missed visit (one aide visit was missed, two aide visits ordered). Documentation showed no communication between the IDG and no changes in the ordered aide visit frequencies. On 05/16/25 at 9:25 a.m., Staff A stated aide visits were not provided in accordance with the POC. Patient #4A review of a clinical record showed the patient was admitted to in-patient respite care at the facility on 04/24/25 and discharged home on 05/14/25. Documentation showed orders for Morphine Sulfate (a pain medication) 100mg per five milliliters, 20 milligrams for pain every two hours. On 04/24/25 the patient received Morphine Sulfate (a pain medication) (100mg per five milliliters), 20 milligrams IV for pain as ordered for signs/symptoms of pain at 8:18 p.m. and again at 10:33 p.m. Documentation showed no follow up pain assessment to assess effectiveness of pain medication at either time. On 04/25/25 the patient received Morphine Sulfate (a pain medication) (100mg per five milliliters), 20 milligrams for pain as ordered for signs/symptoms of pain at 5:30 p.m. Documentation showed no follow up pain assessment to assess effectiveness of the pain medication and no communication or changes in orders. On 05/16/25 at 9:45 a.m., Staff A stated a follow up pain assessment should be conducted within one hour after medication administration. Patient #5A review of a POC dated 04/24/25 to 07/22/25 with IDG updates on 04/24/25 and 05/09/25 showed documentation of an aide visit frequency of four visits every 10 days times 10 days, three times a week for 10 weeks, then four visits every 10 days times 10 days. During the week of 05/04/25 to 05/10/25 on 05/05/25, 05/07/25 and on 05/10/25 aide missed visits were documented (three aide visits were missed, three aide visits ordered) and showed no communication between the IDG, no attempts to reschedule or make up the visits and no changes in the ordered aide visit frequencies. On 05/16/25 at 9:55 a.m., Staff A stated aide visits were not provided in accordance with the POC. Patient #8A review of a POC dated 05/02/25 to 07/30/25 with IDG updates on 05/02/25 showed documentation of an aide visit frequency of four visits three times a week for 12 weeks. During the week of 05/04/25 to 05/10/25 on 05/06/25 and on 05/08/25 aide missed visits were documented (two aide visits were missed, three aide visits ordered) and showed no communication between the IDG, no attempts to reschedule or make up the visits and no changes in the ordered aide visit frequencies. On 05/16/25 at 10:45 a.m., Staff A stated aide visits were not provided in accordance with the POC. Patient #9A review of a POC dated 05/01/25 to 07/29/25 with IDG updates on 05/09/25 showed SN to assess the patient’s pain level every visit and notify the physician of reported pain level of greater than 6-7 out of 10. SN visits on 05/07/25 and 05/08/25 showed no assessment of the patient’s pain levels and no communication between the IDG and no change in orders. On 05/16/25 at 1:55 p.m., Staff A stated the SN should have assessed the patient’s pain during each of the visits. Patient #11A review of a POC dated 04/08/25 to 06/06/25 with IDG updates on 04/08/25, 04/25/25 and on 05/02/25 showed SN to assess the patient’s pain reported pain level and effectiveness of pain medication every visit and notify the physician of unrelieved pain level. SN visits on 04/22/25 and 05/01/25 showed no assessment of the patient’s pain levels and showed no communication between the IDG and showed no change in orders. On 05/16/25 at 11:30 a.m., Staff A stated the SN should have assessed the patient’s pain during each of the visits. Patient #13A review of a POC dated 03/19/25 to 05/17/25 with IDG updates on 03/21/25, 04/22/25, 04/08/25, 04/18/25 and 05/02/25 showed documentation of an SN visit frequency of one visit times three days, then two times a week for eight weeks. During the week of 03/23/25 to 03/29/25 a visit was conducted on 03/27/25 (one visit conducted, two visits ordered); and during the week of 03/30/25 to 04/05/25 a visit was missed on 04/01/25 (one visit missed, two visits ordered). Documentation showed no communications between the IDG, no attempts to reschedule or make up the visits and showed no changes in the SN visit frequencies ordered. On 05/16/25 at 12:10 p.m., Staff A stated SN visits were not provided in accordance with the POC. Patient #17A review of a POC dated 11/08/25 to 01/06/25 with IDG updates on 11/08/24, 11/22/24 showed documentation of an aide visit frequency of one time a day for two days, three times a week for eight weeks, then one time a day for two days. During the week of 11/10/24 to 11/16/24 no aide visits were documented (three aide visits were missed, three aide visits ordered). Documentation showed no communication between the IDG, no attempts to reschedule or make up the visits and showed no changes in the ordered aide visit frequencies. On 05/16/25 at 1:55 p.m., Staff A stated aide visits were not provided in accordance with the POC.”

“Based on record review and interview, the hospice failed to ensure:1. The plan of care included interventions for urinary catheter management and a pain management goal for one (Patient #5) of 19 patients. 2. Plans of care included physician reporting pain level parameters for four (Patients #6, 10, 11, and #17) of 19 patients. 3. Plans of care included interventions and goals related to the hospice diagnosis for two (Patients #7 and #12) of 19 patients. Findings: Patient #5A review of a POC dated 04/24/25 to 07/22/25 with IDG updates during the weeks of 04/24/25 and on 05/09/25 showed order for SN to assess effectiveness of pain management every visit. The POC showed no goals related to pain management. SN visit notes dated 04/24/25, 04/25/25, 05/01/25, 05/07/25 and on 05/09/25 documented the patient had an indwelling foley catheter in place showed no orders for SN to perform urinary catheter management monthly, no communications between the IDG and no changes in the POC. On 05/16/25 at 9:55 a.m., Staff B stated:1. The patient had an indwelling foley catheter in place and the POC showed no orders for SN to perform urinary catheter management monthly.2. The POC had no goals related to pain management. Patient #6A review of the POC dated 04/26/25 to 06/24/25 showed orders for SN to assess and instruct severity of the patient’s pain level and effectiveness of pain medication every visit. POC documentation showed no pain reporting parameters for physician notification. SN visits conducted on 03/21/25 showed a reported pain level of 6 of 10 and on 04/22/25 a reported pain level of 3 of 10. Documentation showed no communications between the IDG and showed no changes in the POC. On 05/16/25 at 10:12 a.m., Staff A stated the POC had no pain reporting parameters to report to the physician. Patient #7A review of a POC dated 03/10/25 to 06/07/25 with IDG updates during the weeks of 03/10/25, 03/14/25, 03/28/24, 04/11/25, 04/25/25 and on 05/09/25 showed a hospice diagnosis of prostate cancer. The POC showed no interventions or goals related to hospice diagnosis of prostate cancer and no communications between the IDG and showed no changes in the POC. On 05/16/25 at 9:55 a.m., Staff A stated the POC had no interventions or goals related to hospice diagnosis. Patient #10A review of the POC dated 03/07/25 to 06/04/25 showed orders for SN to assess and instruct severity of the patient’s pain level and effectiveness of pain medication every visit. POC documentation showed no pain reporting parameters for physician notification. SN visits conducted on 03/25/25 showed a reported pain level of 7 of 10 and on 04/03/25 a reported pain level of 3 of 10 and showed no communications between the IDG and showed no changes in the POC. On 05/16/25 at 11:05 a.m., Staff A stated the POC had no pain reporting parameters to report to the physician. Patient #11A review of the POC dated 04/08/25 to 06/06/25 showed orders for SN to assess and instruct severity of the patient’s pain level and effectiveness of pain medication every visit. POC documentation showed no pain reporting parameters for physician notification. SN visits conducted on 04/22/25 showed a reported pain level of “has pain, yes” with no severity rating and on 05/01/25 a reported pain level of “has pain, yes” with no severity rating and showed no communications between the IDG and no changes in the POC. On 05/16/25 at 11:30 a.m., Staff A stated the POC had no pain reporting parameters to report to the physician. Patient #12A review of a POC dated 04/08/25 to 07/06/25 with IDG updates during the weeks of 04/8/25, 04/09/25, 04/18/24 and on 05/02/25 showed a hospice diagnosis of stage 4 chronic kidney disease. The POC showed no interventions or goals related to hospice diagnosis of stage 4 chronic kidney disease and showed no communications between the IDG and no changes in the POC. On 05/16/25 at 11:50 a.m., Staff A stated the POC had no interventions or goals related to hospice diagnosis. Patient #17A review of the POC dated 11/08/24 to 01/06/25 showed orders for SN to assess and instruct severity of the patient’s pain level and effectiveness of pain medication every visit. The POC showed no pain reporting parameters for physician notification. SN visits conducted on 11/07/24 showed a reported pain level of “has pain, yes” with no severity rating, 11/20/24 a reported pain level of “has pain, yes” with no severity rating and on 11/27/24 a reported pain level of “has pain, yes” with no severity rating and showed no communications between the IDG and no changes in the POC. On 05/16/25 at 1:55 p.m., Staff A stated the POC had no pain reporting parameters to report to the physician.”