Penn Medicine Hospice

“Based on a review of clinical records (CR), Penn Medicine Hospice (PMH) agency policies, PMH Hospice Resource Guide, and an interview with the regulatory compliance officer and hospice system director, the hospice failed to assure that a patient’s pain and symptoms related to the terminal illness and related conditions were managed in a timely fashion for one (1) of three (3) CR’s reviewed: CR#1. Findings include:A review of Policy Number: CA 5 Pennsylvania Hospital Pain Assessment on January 27, 2026 at 12:00 PM read in part, “Age and condition-appropriate pain scales will be utilized for the measurement of all types of pain. A combination of clinical judgment, behavioral signs and physiologic signs will be the basis for pain assessment in unresponsive or noncommunicative patients. The patient will undergo reassessment of pain at least once per shift and after pain control intervention employed by patient care providers. Pain control mechanisms include but are not limited to: Medications administered for the control or relief of pain, Medications administered for the control or relief of anxiety….” “After implementation of a pain control mechanism, the patient will be reassessed to determine the effectiveness of intervention and the amount of pain control or relief achieved.”A review of the Penn Medicine Hospice Resource Guide on January 27, 2026 at 12:30 PM stated in part, “Penn Medicine Hospice Patient Bill of Rights & Responsibilities - The right to effective pain and symptom management from the hospice for conditions related to your terminal illness.”Policy Number: 2-018.1 On-Call Services (Triage and Emergency Response) reviewed on January 21, 2026 at approximately 2:30 PM stated in part, “To maintain and assure continuity of care and the ability to meet patient/family/caregiver needs at times other than regular office hours or during unforeseen occasions when the office is closed during normal business hours such as weather events or power failure…..The patient or caregiver can call for care or other needs at any hour. Outside of business hours, calls are received by the answering service. The answering service communicates all patient/family related calls to the Triage Nurse. The Triage Nurse determines whether the patient/family needs can be met by phone intervention or requires a visit. If a visit is required, the Triage Nurse arranges for a visit and informed the patient/family in advance with the estimated arrival time (within 1-3 hours from when a visit is determined to be required to address the patient’s symptoms or needs) and any delays that may arise. The Triage Nurse provides follow up appropriate to each call. Activities may include but are not limited to: Calling the patient, family or caregiver; providing needed information, education or instructions, arranging an emergency response visit; obtaining physician orders as needed…accepting and communicating messages for agency personnel….Emergency response visits are made in a timely manner. Problems that may require an emergency response visit include, but are not limited to:….new, unusual, severe, or uncontrolled symptoms such as pain or respiratory distress…if the patient, family or caregiver perceives an emergent problem and requests and immediate visit…..All Triage and Emergency Response care and activities are documented in a timely manner in the electronic medical record…”A review of CR’s was conducted onsite on January 20, 2026 starting at 10:30 AM, and continued offsite on January 21, 27, 28, and 29, 2026 at various times. The start of care (SOC) is indicated below.CR#1 SOC 10/11/2025. CR#1 was initially admitted to an acute inpatient setting (intensive care unit) (ICU) on 10/09/2025. On 10/10/25 at approximately 8:23 PM, CR#1 was started on a Dilaudid (Hydromorphone) infusion at a rate of 0.5 mg/hr. and transferred from the ICU to a general nursing unit at approximately 9:26 PM for comfort care (non-hospice).The MAR (Medication Administration Record) contained the Penn Medicine Comfort Care Guidelines which included Dilaudid Initiation and Titration Orders: The Initiation Orders contained a 3 Step process involving increasing amounts of Dilaudid boluses with Step 3 noting that if symptoms were not controlled, to move to The Titration Orders included the initiation of a Dilaudid Infusion at 0.5 mg/hr. Per the MAR, the Initiation Orders were discontinued on 10/10 at 6:17 PM and titration orders were started. CR#1 received PRN (as needed) Dilaudid at 6:30 PM (0.4 mg IV (intravenous), 7:27 PM (0.5 mg IV) and 8:16 PM (0.5 mg IV). The Dilaudid Infusion was started at 8:23 PM at a rate of 0.5 mg/hr.The MAR dated 10/10/25 at 8:23 PM revealed that the Dilaudid infusion was running at a rate of 0.5 mg/hr. A nurses’ note dated 10/11/2025 at 6:33 AM stated that the patient was on “comfort care, continuous Dilaudid drip ongoing, patient appears comfortable and in no distress; daughter at bedside, call light within reach.”Other notable medication administrations to manage agitation during the comfort care (non-hospice) episode included: Versed (Midazolam) 1 mg IV on 10/10 at 6:12 PM Haldol (Haloperidol) 1 mg IV on 10/11 at 8:52 AM Versed 1 mg IV on 10/11 at 10:48 AM Haldol 1 mg IV on 10/11 at 12:31 PMVersed 1 mg IV on 10/11 at 1:55 PM On 10/11/2025, CR#1’s family requested an admission to inpatient hospice.The hospice benefit election form was signed by CR1’s family on 10/11/2025 at 2:41 PM.The hospice consent form, including distribution of the Patient Bill of Rights and Responsibilities was signed by CR1’s family on 10/11/2025 at 2:47 PM. The Penn Medicine Hospice Patient Bill of Rights and Responsibilities stated in part, “The right to receive effective pain and symptom management from the hospice for conditions related to your terminal illness.”Though CR#1 changed from inpatient acute comfort care to general inpatient (GIP) hospice, the location of the patient did not change. CR#1 remained on the same nursing unit, assigned to GIP Hospice.An initial comprehensive assessment (ICA) was completed by the hospice RN (PF#1) on 10/11/25 at 2:30 PM. The patient was admitted to hospice on 10/11/25 at 2:30 PM. The ICA (page 2) noted the following, “Pt. continues on Dilaudid infusion @ 0.5 mg/hr. and scope patch and required PRN Haldol x3 and Midazolam x3.” The ICA (page 15) noted the following, “Pt. continues on Dilaudid infusion @ 0.4 mg/hr. and scope patch and required PRN Haldol x3 and Midazolam x3.” The Hospice Admission/Recertification Plan of Care completed by PF#1 effective 10/11/25 stated, “Pt. continues on Dilaudid infusion @ 0.4 mg/hr. and required PRN Haldol x3 and Midazolam x3. Email correspondence with the Penn Medicine Hospice Regulatory Compliance Officer on 01/21/26 at 5:59 PM confirmed that the Dilaudid dosage around the time of hospice admission was 0.5 mg/hr. This correspondence was in accordance with documentation on the MAR effective 10/10/25 at 8:23 PM as noted earlier.The Care Plan completed at the time of admission contained a Goal: GIP Symptom Management accompanied with an “Intervention for Pain – Evaluate pain, Frequency PRN, Multimodal techniques to relieve dyspnea including medications, implement oxygen therapy and position and breathing for comfort.” Another identified Goal was GIP in a Hospital Setting accompanied with an “Intervention: Admission/Transfer to Hospice GIP, Frequency PRN, Hospice GIP level of care for management of uncontrolled pain and dyspnea related to Sepsis. Education of patient/caregiver to include: hospice philosophy, role of IDT, contact information, hospice oversight of the plan of care, GIP level of care, strategies for symptom management care coordination with hospital team and discharge planning, code status, advanced directives, use of comfort medications, and what to expect in the dying process.”A note written by the provider (PF#2) on 10/11/25 at 5:32 PM stated, “Pt. was admitted to GIP hospice on 10/11 for a diagnosis of sepsis. Orders written and medication started.”A review of the MAR found that the Dilaudid infusion was discontinued on 10/11/25 at 3:04 PM shortly after admission to hospice.A note written by PF#2 on 10/11/25 at 7:30 PM stated, “Contacted by nursing staff stating patient had been on a Dilaudid drip all day and when transferred to hospice, s/he was inadvertently ordered scheduled hydromorphone intermittently instead. Intermittent hydromorphone dc’ed (discontinued) and infusion with bolus doses ordered.”A note written by PF#3, who was providing care to CR#1, on 10/11 at 8:00 PM stated, “Hydromorphone drip was reordered with rate of 0.1 mL/h, was previously at 0.5 mL/h during day. Noted sporadic episodes of agitation, usually ~ 2 hours apart, that quickly resolve with PRNs (haloperidol, midazolam).” The above note at 8:00 PM by PF#3 did not state if the provider was notified or if clarification was sought regarding the Dilaudid rate change from 0.5 mg/hr. prior to the hospice episode, to 0.1 mg/hr. during the hospice episode.A review of the MAR found that the Hydromorphone (Dilaudid) Infusion 50 mg in 50 ml (milliliters) normal saline was restarted at *8:10 PM at a rate of 0.1 mg/hr., entered as a “custom initial dose” on the MAR. The MAR further contained a parameter for the infusion which stated, “do not titrate.”Medications administered for pain and anxiety after hospice admission per the MAR were as follows:10/11 at 4:49 PM: Haldol 1.0 mg IV10/11 at 6:33 PM: Dilaudid 0.4 mg IV*10/11 at 8:10 PM: Dilaudid Infusion started at a rate of 0.1 mg/hr.10/11 at 9:18 PM: Haldol 2.5 mg IV10/11 at 11:15 PM: Versed 1.0 mg IV10/12 at 12:38 AM: Dilaudid 0.2 mg IV bolus from bag10/12 at 12:44 AM: Haldol 2.5 mg IV10/12 at 2:19 PM: Versed 1.0 mg IV10/12 at 3:25 AM: Haldol 2.5 mg IV10/12 at 4:28 AM: Versed 1.0 mg IV10/12 at 5:11 AM: Dilaudid 0.2 mg IV bolus from bag10/12 at 5:12 AM: Haldol 2.5 mg IV10/12 at 5:38 AM: Dilaudid 0.2 mg IV bolus from bag10/12 at 6:04 AM: Dilaudid 0.2 mg IV bolus from bag10/12 at 6:25 AM: Dilaudid 0.2 mg IV bolus from bag10/12 at 6:54 AM: Dilaudid 0.2 mg IV bolus from bag10/12 at 8:14 AM: Dilaudid infusion rate changed from 0.1 mg/hr. to 0.3 mg/hr.An entry on the nursing flowsheet under “Pain” at 7:01 PM on 10/11 written by PF#3, who was providing care to CR#1, stated, “Sleeping – no distress. A note written at 8:00 PM on 10/11 by PF#3 stated, “Noted sporadic episodes of agitation, usually ~ 2 hours apart, that quickly resolve with PRNs (haloperidol, midazolam). Further documentation on the nursing flowsheet on 10/11 at 11:01 PM found that the RASS (Richmond Agitation Sedation Scale) was -4, and the GCS (Glascow Coma Score) was 4. The RASS is a validated 10-point medical tool (ranging from +4 to -5) used by clinicians to assess a patient’s level of sedation and agitation. A normal, alert, and calm patient scores 0, with positive numbers (+1 to +4) indicating restlessness or agitation and negative numbers (-1 to -5) indicating sedation levels. The GCS is a neurological tool used to objectively measure a person’s level of consciousness, ranging from 3 (deep coma/death) to 15 (fully alert). Other than the above assessments, there was no further documentation or evidence provided that the effectiveness of the above pain control interventions were assessed from 11:01 PM on 10/11 to 6:54 AM on 10/12. A phone call from the family to the hospice triage line occurred on 10/11 at 11:57 PM expressing concern that the Dilaudid infusion had been decreased to 0.1 mg/hr., and that the Haldol was only effective for “about an hour.” The response to the call was that the triage RN “notified the on-call (hospice) nurse.” There was no evidence or documentation found that the hospice on call nurse had any communication, in follow-up, with the family or the nursing staff, nor that the triage nurse engaged in any subsequently follow-up to the call. A review of the nursing flowsheet revealed a Clinical Notification written by PF#3 on 10/12 at 12:00 AM which stated, family “request titrate up hydromorphone drip, if not met; threaten to revoke hospice, escalate to administration or take pt. to ED.”A note written by PF#3 on 10/12 at 12:00 AM read, Family “at bedside upset due to witnessing occurrences of agitation, requested to increase rate of hydromorphone drip, refused to wait till morning to discuss with day team, considered revoking hospice and taking patient to ED (emergency department). At 12:15 AM, this writer witnessed phone call between covering provider (PF#4) and family, at the end of which family was agreeable to plan of scheduled haloperidol and midazolam.”Further documentation revealed that a phone call ensued with the provider on call (PF#4), CR1’s family and PF#3 on 10/12/25 at 12:15 AM whereby the family expressed their concerns about witnessing increased episodes of agitation and restlessness due to the decrease in the Dilaudid infusion rate from 0.5 mg/hr. to 0.1 mg/hr. The family noted that CR#1 had appeared much more comfortable on the Dilaudid infusion at 0.5 mg/hr. PF#4 opted not to increase the Dilaudid infusion rate until the patient could be reassessed in the morning. PF#4 discussed with the family that the most appropriate medications at this time would be to schedule Haldol and Midazolam to every 6 hours around the clock (alternating), along with the continuation of PRN (as needed) administrations. A review of a hospice service follow-up note was written by PF#2 on 10/12. The note by PF#2 stated that the patient was “admitted to GIP on 10/11 with a diagnosis of sepsis. He was initially started on intermittent scheduled IV hydromorphone along with prn comfort medication. During the evening of 10/11, at 2000 (8:00 PM) it was noted that earlier in the day prior to transfer to hospice, the patient had been on a hydromorphone drip, this was acknowledged and changed to a drip at 2000 (8:00 PM). During the night the patient required multiple doses of prn meds for agitation. Pt. calmed down with each dose of medication but when it wore off the symptoms returned. During the night changes were made to include scheduled dosing of Haldol and Midazolam. Early in the AM after review of the notes, the hydromorphone was again increased to 0.3 mg/hr. with 0.6 mg q (every)10m prn available. Advised PF#4 to call if any further increases were needed.” CR#1 was started on a Dilaudid Infusion at a rate of 0.5 mg/hr. for comfort measures on 10/10/25 at 8:23 PM. Upon admission to GIP hospice on 10/11/25, the Dilaudid infusion was inadvertently discontinued at 3:00 PM. When it was restarted five (5) hours later, it was restarted at a rate of 0.1 mg/hr. with orders not to titrate after the patient had been on a continuous rate of 0.5 mg/hr. for approximately 19 hours. There was no indication that the provider (PF#2) had been notified or was aware of the decreased infusion rate at the time of restart. There was concern expressed by the family regarding increased episodes of agitation due to the decrease in the Dilaudid infusion rate. A call to the provider (PF#4) on 10/12/25 at approximately 12:15 AM resulted in orders to increase Haldol and Midazolam to manage agitation, as opposed to increasing the Dilaudid infusion back to the original rate, as the agitation was presumed to be unrelated to pain. Nursing assessments by PF#3 to determine the effectiveness of pain and agitation (medication) interventions were not in accordance with facility policy. There was no attempt by the provider to assess the patient to determine the best course of action, nor was there evidence of a response from the on-call hospice nurse.Correspondence with the hospice system director on January 29, 2026 at 4:20 PM confirmed the above findings.”

“Based on a review of personnel files (PF), hospice policy, hospice educational programs, and an interview with the regulatory compliance officer and hospice systems director, the facility failed to provide evidence of ongoing competency for individuals furnishing care to hospice patients for three (3) of three (3) PF’s reviewed: PF#3, PF#5, and PF#6. Findings include:Policy Number: 6-021.1 Professional Staff Competency Program reviewed on January 27, 2026 at 9:00 AM reads in part, “Ongoing competency assessment is performed at least every three years or more frequently as necessary by an individual with the educational background, experience, and/or knowledge related to the skills being reviewed. Ongoing competencies can be entity-wide, agency-wide, and/or discipline=specific. An ongoing competency can be a revalidation of a core, patient-specific, or a newly developed competency….the validation of competency at least every three years will be recorded in the electronic learning management system or the employee’s file.The surveyor was provided with a document titled Pennsylvania Hospital Palliative Care Team and Penn Medicine Hospice Education Workshop, reviewed on January 27, 2026 at 9:30 AM. The workshop contains the following topics: Philosophy of Palliative Care and Hospice, Assessment Tools for Palliative and Hospice Care: Cultural Awareness, Pain and non-pain symptom management: focus on comfort order set, Hospital Team Liaison, Off shift, weekends, and holidays, bereavement support, communication workshop – balancing the needs of diverse patient population, my patient is dying – cultural and spiritual awareness, care of patients, families and self-responding to afterlife care needs in the acute care setting.The Regulatory Compliance Officer provided correspondence to the surveyor on January 27, 2026 at 5:30 pm which noted that the manager of the unit that provided care to CR#1 offers updates to employees in huddle flashes, education updates, and voluntary educational sessions, but there is “nothing formal.” Attendance at these sessions may not always be captured in the employee’s education profile.The surveyor was also provided with several educational programs that are offered by the hospice service, which were reviewed on January 28, 2026 at 9:00 AM.A review of competency and training documentation from the personnel files (PF) was conducted on January 27, 2026 starting at 10:00 AM. The date of hire is indicated below.PF#3 DOH 07/30/2025 contained a competency-based orientation skills checklist. A competency related to demonstrating the ability to assess, plan, intervene, and evaluate pain management was completed on 8/4/25. Competency related to understanding the plan of care for inpatient hospice patients was completed on 8/8/25.PF#5 initially worked as a contractor (agency nurse) starting 11/09/2020. Evidence of training on pain management and palliative care was completed on 11/10/2020. The individual transitioned to an employee on 02/06/2023. There was no evidence contained in the PF of further competency assessment after 11/10/2020.PF#6 DOH 08/11/08. Evidence of training on pain management was completed on 08/15/08 and 10/09/08. There was no evidence contained in the PF of further competency assessment after 2008.There was no evidence provided that PF#3, PF#5, or PF#6 completed the Pennsylvania Hospital Palliative Care Team and Penn Medicine Hospice Education Workshop, nor evidence that the various hospice educational offerings provided for review were completed, and no evidence that PF#5 and PF#6 completed ongoing competencies after 2020 and 2008, respectively.Correspondence with the Hospice Systems Director on January 29, 2026 at 4:30 PM confirmed the above findings.”

“Based on the findings of a clinical record (CR) review, hospice agency (HA) policies and interviews with the team manager, director of operations, compliance officer, and hospice system director, the HA failed to update the plan of care to reflect the current status and subsequent needs of the patient for one (1) of three (3) CR’s reviewed: CR#1. Findings include: The HA’s Policy Interdisciplinary Group Coordination of Care #2-007.1 reviewed on October 30, 2024 at 10:00 AM reads in part, “The Hospice Interdisciplinary Group will update the comprehensive assessment and Plan of Care (in collaboration with the individual’s attending physician, if any) as frequently as the condition of the patient requires but no less frequently than every 15 days. Findings will be shared with those involved with the patient’s plan of care (i.e., facilities, DME, etc). The attending physician will receive an update of the plan of care through the EMR (electronic medical record), phone, email communication and/or orders received.” The HA’s Policy Physician Orders and Plan of Care #4-032.1 reviewed on October 30, 2024 at 11:00 AM states in part, “Agency professional staff shall promptly alert the attending physician to changes that suggest a need to alter the plan of care.” An interview with the compliance officer on October 24, 2024 at approximately 12:30 PM confirmed that CR1 had not received requested supplies for incontinence or a commode. A review of CR was conducted onsite on October 24, 2024 starting at 10:00 AM and continued offsite on October 28, October 29, October 30, and October 31, 2024. The start of care (SOC) and Benefit Election Period (BEP) are indicated below. CR#1: SOC 08/28/2024, BEP 08/28/2024 to 11/26/2024 found the following: An initial/comprehensive assessment completed on 08/28/2024 found that the patient had dyspnea (shortness of breath) when lying flat due to abdominal distention (swelling) and that abdominal pain was being controlled with oxycodone (an opioid used for pain management). The assessment further noted that CR1 ambulated with stand-by assistance. Complaints of constipation were being managed with Senna and Lactulose (medications to help relieve constipation). On 08/29/2024, the family contacted the skilled nurse (SN) assigned to CR1 to report a “change in status and abdominal swelling” and the patient’s desire to have the (abdominal) fluid drained. Discussion ensued between the SN and family member which ultimately resulted in CR1 visiting an emergency department. There was no evidence that a skilled nursing (SN) visit was offered for evaluation, nor that the physician was contacted by the SN on 08/29/2024 to discuss the situation. There was no update to the plan of care (POC) documenting the change in patient status nor any evidence of potential changes to the POC prior to or as a result of the emergency department visit. On 08/30/2024, during a SN visit, CR1 reported difficulty sleeping. The SN contacted the physician who ordered Ambien. While there was evidence that the Ambien was ordered from the pharmacy and scheduled to be delivered to CR1 the evening of 08/30/2024, neither the POC nor the medication profile was updated to include the problem or the addition of Ambien, respectively. On 08/31/2024, the family called the triage line to report that CR1 had been incontinent and requested a commode and incontinence supplies. The triage nurse noted that supplies would need to be ordered online, and that the hospice team was emailed with the request. There was no evidence that the commode nor incontinence supplies were received by the family, nor any update to the POC regarding the new finding of incontinence. On 09/03/2024, a telemedicine (video) call took place between the attending physician, CR1 and the family. The physician noted that CR1 was bed bound, eating minimally, abdomen very distended, and incontinent of bowel and bladder. The hospice team had scheduled CR1 for an interventional radiology (IR) procedure (procedure to drain abdominal fluid) to occur at 8:00 AM on 09/04/2024. Transport to the IR appointment occurred via private vehicle (family transport). There was no evidence that given the change in status of the patient per the physician’s note (bedbound, incontinent of bowel and bladder), the POC was altered, a skilled nursing visit was scheduled prior to the IR procedure to assess the patient, nor that ambulance transport was offered or arranged for transport to the IR procedure given the tenuous condition of the patient. Findings were confirmed on November 4, 2024 at 4:27 PM in an email correspondence to the hospice systems director.”

“Based on a review of clinical records (CR), hospice agency (HA) policy, interviews with the PMH team manager, compliance officer, admission manager, and hospice system director, an interview with the executive director of another hospice agency, and a review of email communications from another hospice agency, the HA failed to assure coordination of services, specifically 1) transport of a hospice patient, and 2) transfer of a hospice patient from one hospice agency to another for one (1) of three (3) CR’s reviewed: CR#1. Findings include: The HA’s Policy Interdisciplinary Group Coordination of Care #2-007.1 reviewed on October 28, 2024 at 10:00 AM reads in part, “Interdisciplinary Group (IDG) is the interdisciplinary group responsible for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient, caregiver, and/or family member.” In an interview with the compliance officer (CO) and admissions manager (AM) on October 24, 2024 at approximately 12:30 PM, both the CO and AM stated that PMH does not have a specific policy regarding transports, transports do not require approvals, and that PMH contracts with a transport company for hospice patient transports. The CO stated that there may have been a misunderstanding as to the process regarding ambulance transports. A review of clinical records was conducted onsite on October 24, 2024 starting at 10:00 AM and continued offsite on October 28, October 29, October 30, and October 31, 2024. The start of care (SOC) and Benefit Election Period (BEP) are indicated below: CR#1 SOC 08/28/2024, BEP 08/28/2024 to 11/26/2024 found the following: On 09/04/2024, CR1 was transported by private vehicle for an interventional radiology (IR) procedure at Penn Medicine (PM). While exiting the vehicle at PM, CR1 had a syncopal episode at approximately 8:00 - 8:30 AM. A rapid response was activated. CR1 was found to be hypotensive and unable to undergo the IR procedure due to his/her clinical condition. The skilled nurse (SN) assigned to the case received a call from the rapid response nurse (RRN) alerting the SN that CR1 was not stable for transport home via private vehicle. The SN stated that that s/he would contact the team manager (TM) to determine if hospice could provide transport. SN contacted the TM at 8:55 AM. At 9:53 AM, the SN informed the TM that CR1 would be transported home via ambulance in 30 minutes. CR1, who had been moved from the lobby to the emergency department for comfort measures/observation, was picked up by the ambulance transport service at 11:09 AM. There was a delay of one hour between when the SN was made aware of the need for ambulance transport and when it was scheduled for a patient who was medically frail due to the SN’s understanding that approvals were necessary for ambulance transport. The HA’s policy Live Discharge/Transfer/Revocation from Hospice Services #2-040.1 reviewed on October 29, 2024 at 10:30 AM states in part, “Patient Initiated Discharge - Change in Designated Hospice. A Medicare of Medicaid patient can choose once in a benefit period to change the designation from the hospice agency which they are receiving hospice services from without service interruption. This is a transfer or change to another agency and not a revocation. As soon as the IDG is aware of the possibility of a discharge, discharge planning is started...For all hospice patients, regardless of the insurance coverage, patient or representative must inform both the hospice from which care has been received and with the newly designated hospice they wish to change agencies and complete a change in designated hospice form. Upon receipt of the designated hospice form, PMH (Penn Medicine Hospice) clinical team will coordinate the sending of pertinence clinical information...” An interview with the Team Manager (TM) on 10/24/2024 at 11:45 AM found that the TM stated that s/he was made aware of the transfer request from the skilled nurse (SN) on 09/04/2024 at approximately 5:00 - 5:30 PM, and that the family was still deciding on a hospice provider and would contact the HA on 09/05/2024 with the name of the new hospice provider. An interview with the executive director of the new hospice provider on Monday, October 28, 2024 at 10:00 AM revealed that the ED stated that on 09/04/2024 at approximately 2:00 PM, the family of CR1 contacted the new hospice agency and requested a transfer to their service. The ED stated that his/her agency reached out to PMH on 09/04/2024 via phone and spoke to a “receptionist.” The ED also stated that his/her agency electronically faxed a checklist to PMH on 09/04/2024 regarding transfer documents needed for the transfer. An interview with the PMH Director of Operations (DO) on 10/24/2024 at approximately 11:30 AM revealed that the DO was notified by PMH leadership on 09/05/2024 at approximately 9:00 AM of the request for the transfer at which time s/he assumed responsibility for initiating the transfer. A review of clinical records was conducted onsite on October 24, 2024 starting at 10:00 AM and continued offsite on October 28, October 29, October 30, and October 31, 2024. The start of care (SOC) and Benefit Election Period (BEP) are indicated below: CR#1 SOC 08/28/2024, BEP 08/28/2024 to 11/26/2024 found the following: during the skilled nursing visit on 09/04/2024 starting at 2:30 PM, SN documented that during the visit, the family communicated to the SN that they had decided to transfer hospice providers and identified an agency that would complete the transfer/admission after receiving “paperwork” from PMH. The SN further documented that after the visit, the SN notified the TM of the transfer request. A telephone encounter from the family to PMH occurred on 09/04/2024 at 6:45 PM at which time the family asked if the transfer process had been initiated. Email communication from the new hospice provider, reviewed on October 29, 2024 at approximately 12:00 PM, revealed that the new hospice provider had received a call from the family on 09/04/2024 at 1:57 PM regarding the desire to transfer to a new hospice agency pending verification of insurance. At 2:57 PM, email communication between the family and the new hospice provider noted that the family informed PMH of the name of the new agency. Further email documentation notes that at 3:21 PM, the new hospice agency faxed a hospice service transfer checklist to the “Penn Medicine Office.” While the family requested that the transfer process begin on 09/04/2024, the transfer process was not initiated by PMH until 09/05/2024. Findings were confirmed on November 4, 2024 at 4:27 PM in an email correspondence to the hospice systems director.”

“Based on a review of clinical records (CR), hospice agency (HA) policies, and interviews with the team manager, compliance officer, and hospice system director, the hospice agency failed to provide services as ordered for one (1) of three (3) CR’s reviewed: CR1. Findings include: The HA’s Policy Physician Orders and Plan of Care 4-032.1 reviewed on October 28, 2024 at 11:00 AM reads in part, “Prescription and nonprescription (over the counter) drugs, devices, medications and treatments shall be administered by agency in accordance with the written orders from the physician.” A review of clinical records (CR) was conducted onsite on October 24, 2024 starting at 10:00 AM and offsite on October 28, October 29, October 30, and October 31, 2024. The start of care (SOC) and Benefit Election Period (BEP) are indicated below. CR1 SOC 08/28/2024, BEP 08/28/2024 to 11/26/2024 found that the visit week for the hospice agency runs from Sunday to Saturday. Home health aide (aide) services were initially ordered for one (1) visit every week for twelve (12) weeks, starting the week of 09/01/2024 (Sunday). On 08/29/2024, the hospice scheduling coordinator documented that aide visits were ordered, and communication to the family confirmed that aide services would begin on Tuesday, 09/03/2024. On the evening of 09/01/2024, a triage call from the family was received whereby the family requested that aide visits be increased to five (5) to seven (7) visits per week. The visit schedule was changed on 09/01/2024 to 5 to 7 visits per week. Visits should have been scheduled for 09/03, 09/04, 09/05, 09/06, and 09/07 to meet the minimum of 5 visits for that week. There was no aide visit on 09/03/2024. A telephone communication note on 09/03/2024 at 5:01 PM from the scheduling department noted that the patient was contacted via automated message to make him/her aware that the aide was unable to visit on 09/03/2024, and that the next scheduled aide visit was 09/04/2024. There was no missed visit note from the aide nor communication to the physician regarding the missed visit on 09/03/2024. Findings were confirmed on November 4, 2024 at 4:27 PM in an email correspondence to the hospice systems director.”

“Based on a review of clinical records (CR), hospice agency (HA) policy, and an interview with the hospice system director, the agency failed to assure that documentation occurred in a timely manner for one (1) of three (3) CR’s reviewed: CR#1. Findings include: The HA’s Policy General Documentation #4-033.1 reviewed on October 30, 2024 at 9:00 AM reads in part, “Entries into the electronic medical record will be completed within 24 hours or as per regulation.” A review of clinical records was conducted onsite on October 24, 2024 starting at 10:00 AM, and offsite on October 28, October 29, October 30, and October 31, 2024. The start of care (SOC) and Benefit Election Period (BEP) are indicated below. CR#1 SOC 08/28/2024, BEP 08/28/2024 to 11/26/2024 found that a skilled nursing (SN) visit occurred on 09/04/2024. The SN Progress Note was not documented until 10/01/2024 at 8:24 PM. Missed home health aide (aide) visits occurred on 09/04/2024 and 09/05/2025. The progress notes from the aide to the physician regarding the missed visits were not documented until 09/08/2024 at 9:10 PM, and 09/09/2024 at 9:57 PM, respectively. Findings were confirmed on November 4, 2024 at 4:27 PM in an email correspondence to the hospice systems director.”

“Based on a review of the clinical record (CR), hospice agency policies, and an interview with the hospice systems director, the agency failed to ensure that the interdisciplinary group reviewed, revised and documented the individualized plan as frequently as the patients condition warranted for pain and symptom management for one (1) of one (1) CR reviewed: CR#1. Findings include: A review of Interdisciplinary Group Meeting Policy Number 2-008.1 conducted on May 1, 2024 at approximately 11:20 AM reads in part, “;The Interdisciplinary Group will meet to discuss patient/family/caregiver progress to goals and reassessment to the patients response to care and updates in the plan of care; and The Interdisciplinary Group in collaboration with the hospice physician will review, revise and document the individualized plan in collaboration with the attending physician as frequently as the patients condition requires but no less frequently than every 15 calendar days;” and “;An IDG summary will be documented in the medical record. The IDG summary will be used as an update for the plan of care. The summary will include documentation of the patients progress towards outcomes and goals and may include but is not limited to.... pain and symptom management strategies;” and “;Utilization of hospice team to meet the patient/family needs including increases or decreases in frequency of visits by team members.” A review of the clinical record (CR) was conducted on May 1, 2024 starting at 9:30 AM. The start of care (SOC) is indicated below. CR#1 SOC 04/05/2024 revealed that throughout the course of treatment from 04/05/2024 to 04/16/2024, there were several changes to the medication regimen requiring an increase in or change to pain medications due to an inability to control pain symptoms and maintain comfort. The Interdisciplinary Group (IDG) Plan of Care (POC) at the time of admission on 4/5/2024 identified Pain as a Problem. Pain Interventions (as needed) on the POC included effectiveness of symptom control, evaluation of other sources of pain, monitoring the effectiveness of the current pain regime, and a multimodal approach towards pain. The Interdisciplinary Group Plan of Care was updated on 04/10/2024. There was no summary note nor evidence of documentation related to changes or additions to the pain interventions on the updated IDG POC despite a triage call for pain management on 04/06/2024 resulting in a change to pain management regimen, and a change to the pain management regimen again on 04/08/2024. Beyond 04/10/2024, there was a change to the pain management regimen on 04/15/24, followed by a triage call on 04/15/24 resulting in an on-site visit and another change to the pain management regimen. The pain management regimen was again changed on 04/16/2024, followed by another triage call for pain management and subsequent on call visit. There was no evidence that the IDG POC was updated to address ongoing problems with and subsequent interventions for pain management, symptom control and maintenance of comfort measures An interview with the hospice systems director on May 1, 2024 starting at 12:00 PM confirmed the above findings.”