Delaware Hospice, Inc.

“Based on a review of the Pennsylvania Department of Health (DOH) Event Reporting System (ERS), clinical record (CR), Personnel Files (PF), incident reports, Quality Assessment and Performance Improvement (QAPI), agency’s policies, and interviews with agency’s VP of Compliance, Quality, & Education, the hospice failed to ensure nursing services included instruction of the patient and family in skills necessary to support the dying process including medication administration skills for one (1) of three (3) CRs: CR#1. Findings include:A review of CRs was conducted on 9/3/25 starting at 12:30 pm.CR#1, Start of Care date: 7/23/25, Discharged date: 8/3/25 (expired at home).“PHYSICIAN ORDERS” reads, “… Orders: Medications: Active: MORPHINE SULFATE 20mg/mL 20 mg/mL Sublingual 5mg (0.25ML) PRN (as needed) Every 4 Hours comfort Start Effective Date: 07/29/2025 End Date: 08/03/2025 Notes: Indication: comfort… Discontinued: Care Kit 1 Kit Other 1 Kit PRN comfort Start Effective Date: 08/05/2025 End Date: 08/03/2025 Notes: Indication: comfort ... Morphine Concentrate 20mg/mL oral concentrate 15mL - 0.25mL (5mg) PO or SL q 4HRS PRN pain/shortness of breath…”An RN (registered nurse) on call note from 07/30/2025 5:30 PM reads, “Discussion: PCG (patient caregiver for CR#1) called to report that local Pharmacy was called to check status of morphine fill sent yesterday and Local (pharmacy#1) advised medication is back ordered and uncertain when thy will get it in. Bottle has 6 doses left and giving medication 0.25mL being given every 2 hours. Call to (pharmacy #2) for best option. Hospice staff advised that STAT (immediate) delivery and Rover to make PA (Pennsylvania) trip is a $100 charge but patient will get the medication this evening. New script updated in pharmacy for NP (nurse practitioner) signature. Hospice NP (nurse practitioner) updated on patient need and signature pending. AOC (hospice administrator on call) updated and approved STAT delivery. (Patient caregiver) updated on medication coming per delivery. Requesting liquid lorazepam to be sent as quickly as possible but will continue to crush pills until available. Resolution/Follow Up: Update IDG (interdisciplinary group) on calls and plan for med delivery…”There was no further documentation that hospice nurse provided education to CR#1’s caregiver about medication compliance. A review of the agency’s policies was conducted on 9/3/25 at approximately 3 pm. A policy titled “TITLE: HOMECARE AFTER HOURS SERVICE” reads, “POLICY: It is the policy of Delaware Hospice that patients, families, and caregivers have access to Delaware Hospice Staff 24 hours a day, 7 days a week. PURPOSE: Delaware Hospice staffs are available for patients, families, and caregivers in order to provide support, follow-up, and information via a telephone call, telehealth visit, or home visit during hours when the offices are closed. PROCEDURE: … 5. The Triage Nurse assesses the situation and offers support, information and interventions over the phone. While assisting the caller with the immediate issue, the nurse determines if a visit is needed whether by telehealth or in person. 6. A visit is made if: the patient or caregiver calls more than once concerning an unresolved issue. Can be a telehealth visit if the situation is applicable. the patient has died, or the caller believes that the patient has died. he triage nurse assesses that a physical assessment/focused visit assessment is required. the nurse assesses that the patient/caregiver is unable to follow the directions provided over the phone… 10. For on call patient visits, sections of the EMR physical assessment and plan of care pertinent to the problem are completed in documentation. Physician orders are updated as needed…”A policy titled, “TITLE: PATIENT/CAREGIVER EDUCATION PROCESS” reads, “POLICY: All patients and/or families/caregivers receive education and training specific to the patient’s needs and as appropriate to the care, treatment and services provided. The scope of teaching is determined by the assessed needs of the patient/family/caregiver, as well as the medical plan of care. Education is the responsibility of each discipline and focuses on, as appropriate: 1. Facilitating the patient/family/caregiver’s understanding of the health status, health care options and consequences of options. 2. Encouraging patient and/or family/caregiver participation in decision-making about health care options, including options related to final stages and code status. 3. Increasing patient/family/caregiver potential to follow the plan of care. 4. Maximizing care skills of the patient/family/caregiver… PROCEDURE: 1. The clinician assesses, plans, implements, and evaluates the following on each patient/family/caregiver, as appropriate: b. The pertinent information needed by the patient/family/caregiver in relation to the care being rendered c. The level of knowledge of the patient/family/caregiver in relation to the diagnosis, plan of care, required activities by patient/family/caregiver, lifestyle changes, etc d. The ability and readiness of the patient/family/caregiver to learn e. Cultural and religious practices which might affect learning f. Emotional barriers which might affect learning g. Desire and motivation to learn h. Physical and/or cognitive limitations, as well as communication and language barriers to learning 2. The patient/family/caregiver’s knowledge and skills/behavior are assessed on an on-going patient/family/caregiver basis. Based on the above, the assessments arise as the basis for planning patient/family/caregiver education. Education is coordinated among the disciplines providing care. In the event that any barriers exist to learning, these barriers, as appropriate, are discussed with the patient/family/caregiver, as well as the interdisciplinary team. If barriers cannot be overcome, the patient’s physician is contacted. 3. When appropriate, the clinician uses preprinted Delaware Hospice approved patient teaching tools. When not available, the clinician identifies available written materials to aid in the education process and collaborates on their use with IDT as appropriate. 4. If a patient’s condition prevents him/her from participating in instruction, a family/caregiver receives the information/instruction. 5. If a patient lives alone, and there is no able or willing individual to receive the instruction, the physician is informed, and notification is documented in the clinical record. 6. Unless specifically ordered by the physician, all patients/families/caregivers receive verbal and, as appropriate, written instructions using the teach back method when indicated, in: a. Their disease process and prognosis. b. An explanation of the plan for care, treatment or service, and patient rights c. Medication d. Symptom management/Pain management e. Diet f. Prescribed treatments g. Consequences of non-compliance h. Safety management i. Infection control j. Equipment management k. Environment and mobility safety l. Personal care m. Procedures to follow if care, treatment, and services are disrupted by a natural disaster or an emergency n. Handling and disposal of hazardous materials and waste 7. Patient/family/caregiver education documentation in the narrative section of assessments by each discipline in EMR consists of: a. Describing what was taught to the patient/family/caregiver (if using a preprinted handout or booklet, document the name of the booklet or the specific teaching tool/handout). b. Describing the patient’s response to the teaching, including the level of understanding, the ability to repeat or demonstrate what was taught and if teaching increased patient/family/caregivers’ ability to provide care. c. Describing any additional learning needs not currently met. d. Describing the planned teaching for subsequent visits. e. In the Safety and Education form education drop down all applicable education given should be documented. 8. When applicable, audio tapes/CD’s, video tapes/DVD, books, booklets, etc. are made available to the patient/family/caregiver to assist in the education process. Educational videos and resources are located on Share Point and on DHI website. 9. Community resources are accessed as appropriate and available based on patient/family/caregiver needs. 10. Patient/family/caregiver education is interdisciplinary, as appropriate to the plan of care. 11. The patient’s/families/caregiver’s knowledge, skills and behaviors are assessed on an on-going basis, during Delaware Hospice visits. Teach back strategies are utilized to evaluate learning. Re-education, when appropriate, is provided. RESPONSIBILITY: All Disciplines, Clinical Directors, VP, Clinical Services, President, CEO”An interview with agency’s VP of Compliance, Quality, & Education on 9/4/25 2:45 pm confirmed the above findings.”

“Based on a review of the Pennsylvania Department of Health (DOH) Event Reporting System (ERS), clinical record (CR), Personnel Files (PF), incident reports, Quality Assessment and Performance Improvement (QAPI), agency’s policies, and interviews with agency’s VP of Compliance, Quality, & Education, the hospice failed to ensure each patient’s record must include the following: physician orders for one (1) of three (3) CRs: CR#1. Findings include:A review of CRs was conducted on 9/3/25 starting at 12:30 pm.CR#1, Start of Care date: 7/23/25, Discharged date: 8/3/25 (expired at home).“PHYSICIAN ORDERS” reads, “… Orders: Medications: Active: MORPHINE SULFATE 20mg/mL 20 mg/mL Sublingual 5mg (0.25ML) PRN (as needed) Every 4 Hours comfort Start Effective Date: 07/29/2025 End Date: 08/03/2025 Notes: Indication: comfort… Discontinued: Care Kit 1 Kit Other 1 Kit PRN comfort Start Effective Date: 08/05/2025 End Date: 08/03/2025 Notes: Indication: comfort ... Morphine Concentrate 20mg/mL oral concentrate 15mL - 0.25mL (5mg) PO or SL q 4HRS PRN pain/shortness of breath…”An RN (registered nurse) on call note from 07/30/2025 5:30 PM reads, “Discussion: PCG (patient caregiver for CR#1) called to report that local Pharmacy was called to check status of morphine fill sent yesterday and Local (pharmacy#1) advised medication is back ordered and uncertain when thy will get it in. Bottle has 6 doses left and giving medication 0.25mL being given every 2 hours. Call to (pharmacy #2) for best option. Hospice staff advised that STAT (immediate) delivery and Rover to make PA trip is a $100 charge but patient will get the medication this evening. New script updated in pharmacy for NP (nurse practitioner) signature. Hospice NP (nurse practitioner) updated on patient need and signature pending. AOC (hospice administrator on call) updated and approved STAT delivery. (Patient caregiver) updated on medication coming per delivery. Requesting liquid lorazepam to be sent as quickly as possible but will continue to crush pills until available. Resolution/Follow Up: Update IDG (interdisciplinary group) on calls and plan for med delivery…”A screen shot of pharmacy #2 order change was reviewed on 9/4/25 at 3:30 pm. It reads, “Dispense History for Morphine Sulfate 20mg/mL Sol (solution), RX# 4196797, Dispense Date: 7/30/25, Quantity Dispensed: 30, Prescriber: Hospice nurse practitioner, Status Message: Delivered (Received by CR#1’s caregiver on 7/31/2025 at 12:15 AM), Instructions: TAKE 0.25ML BY MOUTH/UNDER THE TONGUE EVERY 2 HOURS AS NEEDED FOR PAIN/ SHORTNESS OF BREATH.”However, there was no hospice physician order or updated plan of care found for updated medication frequency from every 4 hours to every 2 hours.A phone interview with VP of Compliance, Quality, & Education on 9/4/25 at 2:30 pm confirmed that it is unknown why the plan of care was not changed but the pharmacy instruction was changed to every 2 hours.A review of hospice agency’s policies was conducted on 9/3/25 at approximately 3 pm.The policy titled “TITLE: HOMECARE AFTER HOURS SERVICE” reads, “POLICY: It is the policy of Delaware Hospice that patients, families, and caregivers have access to Delaware Hospice Staff 24 hours a day, 7 days a week. PURPOSE: Delaware Hospice staffs are available for patients, families, and caregivers in order to provide support, follow-up, and information via a telephone call, telehealth visit, or home visit during hours when the offices are closed. PROCEDURE: … 5. The Triage Nurse assesses the situation and offers support, information and interventions over the phone. While assisting the caller with the immediate issue, the nurse determines if a visit is needed whether by telehealth or in person. 6. A visit is made if: the patient or caregiver calls more than once concerning an unresolved issue. Can be a telehealth visit if the situation is applicable. the patient has died, or the caller believes that the patient has died. he triage nurse assesses that a physical assessment/focused visit assessment is required. the nurse assesses that the patient/caregiver is unable to follow the directions provided over the phone… 10. For on call patient visits, sections of the EMR physical assessment and plan of care pertinent to the problem are completed in documentation. Physician orders are updated as needed…”A policy titled, “MEDICATION ADMINISTRATION AND MANAGEMENT – HOME CARE” reads, “…POLICY: All drugs and biological agents must be administered according to the Physician’s Plan of Care. Medications and biological agents are administered only by a licensed nurse/licensed independent provider or the patient/family/primary care giver/facility representative… PROCEDURE: … B. On every visit/assessment, the nurse reviews medications to ensure that the patient/family/primary care giver/facility representative is administering the medications as ordered by physician. Medication reconciliation is completed, see below. D. The patient/family/primary care giver/facility representative is instructed by the nurse to notify Delaware Hospice if pain or symptoms are not controlled at an acceptable level. E. Medication Reconciliation - On all admissions/changes in level of care/discharge/comprehensive assessments, the nurse completes medication reconciliation as follows: 1. Reconcile all medications (those currently being administered and those that are in the home and have been administered in the past) to current physician orders. 2. Instruct patient/caregiver to place those medications not currently prescribed in a bag/box and place in a safe place away from medications currently being utilized. 3. On the comprehensive assessment visit, the nurse reconciles current medications as follows: a. Ask the caregiver to retrieve all prescribed and over the counter medications the patient is currently taking, including PRNs, supplements, vitamins, creams, ointments, eye/ear/nose drops, inhalers. b. Ask the patient/caregiver if any medication has been added, stopped or changed since the last visit. c. Compare the medication labels with the current physician orders. Assure all medications are accurately and completely listed on the medication profile. d. Clarify and correct any discrepancies with the patient, family, physician orders and physician if necessary. e. Educate the patient/family/PCG related to medications and specifics of administration. Evaluate and document understanding of instructions in EMR. f. As the patient’s condition changes or declines, de-prescribing initiatives are implemented as appropriate and Physicians orders are obtained.” F. Changing Medications 1. When addressing any change or addition of medication(s), the following are reviewed for any potential impact on ordering/changing medication(s): a. Clinical information from the record, including allergies. b. Relevant laboratory values. c. Duplicate therapy, potential drug interactions d. Clinical response to current and/or previous medications. e. OPPC Formulary list per diagnosis… 3. Communicate assessment data and route recommendations to the physician. Assist with the obtainment of any new medications ordered via contracted pharmacy or local pharmacy as appropriate. . Document changes in medications in the care plans, including plan, severity, and goals in EMR…”A policy titled, “ATTENDING PHYSICIAN, COMMUNICATION AND COLLABORATION” reads, “POLICY: It is the policy of Delaware Hospice, Inc. (DHI) that the Hospice Medical Director, or Team Physician (“Hospice Physician”), in conjunction with the patient’s Attending Physician, if one is chosen by the patient, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness. If the Attending Physician is unavailable, the Hospice Physician/Hospice Provider is responsible for meeting the medical needs of the patient. If a patient does not designate an Attending Physician, the Delaware Hospice Medical Director or Team Physician will manage the care of the patient related to their hospice Plan of Care. Communication between the Attending Physician and members of the interdisciplinary group begins at assessment/admission and continues throughout the patient’s care. All communication is documented in the Delaware Hospice electronic medical record (EMR) and is handled in a confidential manner… 3. Interdisciplinary Group/Coordination of Patient Care (IDG):a. The interdisciplinary group (IDG) works with the patient, family, and caregivers, and the patient’s Attending Physician (if any) to develop a coordinated, comprehensive care plan; reduce the use of diagnostics and therapies that are not conducive to achieving the patient’s end-of-life goals of care; and maintain ongoing communication with the patient, family, and caregivers about changes in the patient’s condition. The plan of care will be edited as needed to address the changing needs of the patient and caregivers as the patient approaches the end of life. b. The Attending Physician is informed in a timely manner by appropriate interdisciplinary group members of any unanticipated changes in the patient’s condition or if the patient is discharged or transferred. i. Timing of physician notification is based on the urgency of the situation and professional nursing assessment and judgment. ii. Unanticipated changes in the patient’s condition are assessed by an RN and physician notification may be based on the following decision-making tier system: Level I – notify the physician immediately: Level II – notify the physician next day, Level III – notify the physician next business day c. Any changes in the patient’s plan of care by the Attending Physician are made in consultation with appropriate member(s) of Delaware Hospice staff. d. All orders from the Attending Physician are implemented immediately with communication to the patient/family/caregiver, and others, as necessary i.e., pharmacy, vendors, etc. The orders are documented in the EMR, sent to the Attending Physician for signature, returned, and incorporated into the patient’s medical record. i. After three unsuccessful attempts to attain an Attending Physician signature, the DHI Medical Director or Team Physician reviews and signs the orders. e. When a change in orders is needed, the nurse contacts the Attending Physician. Return calls from the physician are directed to the nurse whenever possible or to the Delaware Hospice office. The patient’s nurse informs the appropriate Associate Director or designee of any pending issues to allow for prompt resolution when a response from the Attending Physician is not received. If there is no response from the Attending Physician, the nurse consults with the Delaware Hospice Medical Director or designee. f. If physician orders are implemented and not effective, the nurse contacts the Attending Physician to discuss a change in the plan of care. g. To assure continuity of care, the Attending Physician shares all information pertinent to the patient’s care, including any changes in the patient’s condition or treatment. Delaware Hospice is advised of any referrals to other physicians made by the Attending Physician, when such referrals affect the care of the patient. h. The Attending Physician receives periodic clinical updates regarding the patient from Delaware Hospice staff as determined by the patient’s condition and needs or per physician request. RESPONSIBILITY: Referral Center Staff, Admission Staff, Nursing Staff, Medical Records, Health Information Manager, Hospice Physicians, Medical Director, Clinical Directors, Clinical Managers, VP, Hospice Services, President, CEO.”An interview with agency’s VP of Compliance, Quality, & Education on 9/4/25 2:45 pm confirmed the above findings.”