Tennessee Quality Care - Hospice

“Upon patient record review, 12 of 23 (Patients #1,#2,#6,#9,#10,#11,#12,#13,#14,#15,#17,#18) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: The medication profile contained nitroglycerin with no instructions on what to do if max 3rd dose was reached with no relief of chest pain. Patient 2: The medication profile contained clotrimazole topical cream with no area defined for administration, MiraLAX oral powder with no instructions to mix with a diluent, and TobraDex eye drops with no instructions for one or both eyes. Patient 6: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile. Patient 9,12,15: The medication profile contained oxygen with no delivery method. Patient 10: The medication profile contained dorzolamide and timolol eye drops with no instructions for one or both eyes. Patient 11: The medication profile contained duplicative listings of oxygen with differing doses and frequencies. Patient 13: The medication profile contained duplicative listings of lactulose with differing doses. The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile. Patient 14: The medication profile contained MiraLAX oral powder with no instructions to mix with a diluent. Patient 17: The medication profile contained azelastine 2 sprays as directed with no frequency identified. Patient 18: The medication profile contained nystatin topical powder and triamcinolone cream with no areas defined for administration.”

“Upon patient record review, 1 of 23 (Patient #1) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 1: There was no evidence of the social worker updating the patient’s progress toward psychosocial goals since 3/18/26. The social worker completed visits on 4/14/26 and 5/11/26.”

“Upon patient record review, 15 of 23 (Patients #1,#2,#4,#5,#6,#8,#9,#10,#11,#12,#13,#14,#15,#16,#18) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The patient was receiving social worker visits and is a risk for falls since admission. There was no evidence of problems, goals, and interventions related to the issues included in the plan of care. Patient 2: The patient was receiving spiritual care visits and is diabetic receiving blood glucose checks four times a day since admission. There was no evidence of problems, goals, and interventions related to the issues included in the plan of care. Patient 4: The nursing documentation since admission identifying patient issues with wounds, cardiac dysfunction, and incontinence issues. There was no evidence of problems, goals, and interventions related to the issues included in the plan of care. Patient 5: The nursing documentation since admission identifying patient issue with brain metastasis. There was no evidence of problems, goals, and interventions related to the issue included in the plan of care. Patient 6: The nursing documentation since admission identifying patient is a risk for falls. There was no evidence of problems, goals, and interventions related to the issue included in the plan of care. Patient 8: The nursing documentation since admission identifying patient is a risk for skin impairment, requires oxygen, and has chronic diarrhea. There was no evidence of problems, goals, and interventions related to the issues included in the plan of care. Patient 9: The patient is a risk for bleeding due to use of Eliquis since admission. There was no evidence of problems, goals, and interventions related to the issue included in the plan of care. Patient 10: The nursing documentation since admission identifying patient is a risk for skin impairment and dysphagia. There was no evidence of problems, goals, and interventions related to the issues included in the plan of care. Patient 11: The patient has a diagnosis of atrial fibrillation. There was no evidence of problems, goals, and interventions related to the issue included in the plan of care. Patient 12: The patient has a diagnosis of hypertension. There was no evidence of problems, goals, and interventions related to the issue included in the plan of care. Patient 13: The patient has a CPAP since admission. There was no evidence of problems, goals, and interventions related to the issue included in the plan of care. Patient 14: The patient has a diagnosis of heart failure. There was no evidence of problems, goals, and interventions related to the issue included in the plan of care. Patient 15: The patient has a diagnosis of atrial fibrillation and bradycardia. There was no evidence of problems, goals, and interventions related to the issues included in the plan of care. Patient 16: The patient has a history of myocardial infarction. There was no evidence of problems, goals, and interventions related to the issue included in the plan of care. Patient 18: The nursing documentation since admission identifying patient is a risk for skin impairment and insulin dependent diabetes. There was no evidence of problems, goal, and interventions related to risk for skin impairment and endocrine dysfunction included in the plan of care.”

“Upon patient record review, 13 of 23 (Patients #1,#2,#4,#6,#9,#10,#12,#13,#14,#15,#16,#17,#18) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The medical record contained an order for nitroglycerin with no instructions on what to do if max 3rd dose was reached with no relief of chest pain. Patient 2: The medical record contained orders for clotrimazole topical cream with no area defined for administration, MiraLAX oral powder with no instructions to mix with a diluent, and TobraDex eye drops with no instructions for one or both eyes. The record also contained orders for peg-tube site care 4/22/26 and 4/27/26 with no frequency of cleansing and dressing changes. Patient 4: The medical record contained an order for wound care to left outer calf weekly or PRN. Patient 6: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of an order for oxygen. Patient 9,12,15: The medical records contained orders for oxygen with no delivery method. Patient 10: The medical record contained orders for dorzolamide and timolol eye drops with no instructions for one or both eyes. Patient 13: The medication profile contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of an order for oxygen included in the plan of care. Patient 14: The medical record contained an order for MiraLAX oral powder with no instructions to mix with a diluent. Patient 16: The medical record contained nursing documentation since admission identifying patient has an indwelling catheter. There was no evidence of an order for catheter type, size, change frequency and maintenance included in the plan of care. Patient 17: The medical record contained an order for azelastine 2 sprays as directed with no frequency identified. Patient 18: The medical record contained orders for nystatin topical powder and triamcinolone cream with no areas defined for administration.”

“Upon patient record review, 14 of 23 (Patients #1,#2,#5,#6,#8,#9,#10,#11,#12,#13,#14,#15,#16,#18) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The medical record contained nursing documentation identifying patient use of a shower chair since admission and a hospital bed since recertification assessment 5/19/26. There was no evidence of orders for the DME included in the plan of care. Patient 2: The medical record contained nursing documentation identifying patient use of a catheter since 5/4/26. There was no evidence of an order for the catheter supplies included in the plan of care. Patient 5: The medical record contained nursing documentation identifying patient use of a suction machine since admission and a wheelchair since 6/8/26. There was no evidence of orders for the DME included in the plan of care. Patient 6: The medical record contained nursing documentation identifying patient use of a cane and raised toilet seat since admission. There was no evidence of orders for the DME included in the plan of care. Patient 8: The medical record contained social worker documentation 5/8/26 identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Patient 9: The medical record contained nursing documentation identifying patient use of a hospital bed since admission. There was no evidence of an order for the DME included in the plan of care. Patient 10,14: The medical record contained nursing documentation identifying patient use of a shower chair since admission. There was no evidence of an order for the DME included in the plan of care. Patient 11: The medical record contained nursing documentation identifying patient use of a specialty mattress since admission and a fall mat since 5/11/26. There was no evidence of orders for the DME included in the plan of care. Patient 12: The medical record contained nursing documentation identifying patient use of a hospital bed, commode, cane, shower chair, walker, and oxygen since admission. There was no evidence of orders for the DME included in the plan of care. Patient 13: The medical record contained nursing documentation identifying patient use of a CPAP since admission and oxygen since 6/16/26. There was no evidence of orders for the DME included in the plan of care. Patient 15: The medical record contained nursing documentation identifying patient use of a wheelchair since admission and a shower chair and overbed table since recertification assessment 4/8/26. There was no evidence of orders for the DME included in the plan of care. Patient 16: The medical record contained nursing documentation identifying patient use of a shower chair and catheter since admission. There was no evidence of orders for the DME and supplies included in the plan of care. Patient 18: The medical record contained nursing documentation identifying patient use of a hospital bed, bedrails, oxygen, overbed table, and wheelchair since admission. The medication orders indicated patient had prescriptions for albuterol and DuoNeb treatments via nebulizer. There was no evidence of orders for the DME and supplies included in the plan of care.”

“Upon patient record review, 17 of 23 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14,#15,#16,#18) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 1: The plan of care contained initial assessment specific problems, goals, and interventions for the RN, social worker, and spiritual care provider. There was no evidence the plan of care was updated to resolve the issues after the initial assessments. Patient 2: The plan of care contained initial assessment specific problems, goals, and interventions for the social worker, and bleeding risk care planning due to prescription for Eliquis. There was no evidence the plan of care was updated to resolve the issues after the initial assessment and discontinuation of Eliquis 5/4/26. Patient 3,8: The plan of care contained initial assessment problems, goals, and interventions for the social worker. There was no evidence the plan of care was updated to resolve the issues after the initial assessment. Patient 4: The plan of care contained initial assessment problems, goals, and interventions for the RN and social worker, . There was no evidence the plan of care was updated to resolve the issues after the initial assessments. Patient 5: The plan of care contained initial assessment problems, goals, and interventions for the RN, social worker, and spiritual care provider. There was no evidence the plan of care was updated to resolve the issues after the initial assessments. Patient 6: The plan of care contained initial assessment problems, goals, and interventions for the social worker. There was no evidence the plan of care was updated to resolve the issues after the initial assessment. The medical record contained nursing documentation 4/29/26 identifying persistent issues with dizziness and dysphagia. There was no evidence the plan of care was updated to add the problems, goals, and interventions related to the issues. Patient 7: The plan of care contained initial assessment specific problems, goals, and interventions for the social worker and goals and interventions related to lab draws. There was no evidence the plan of care was updated to resolved the issues after the initial assessment and discontinuation of future labs in May. Patient 9: The plan of care contained initial assessment problems, goals, and interventions for the nurse. There was no evidence the plan of care was updated to resolve the issues after the initial assessment. Patient 10: The plan of care contained initial assessment problems, goals, and interventions for the social worker and a need for respite stay 4/22/26-4/27/26. There was no evidence the plan of care was updated to resolve the issues after the initial assessment and respite stay was completed. Patient 11: The nursing documentation identifying the patient’s diet was downgraded to mechanical soft 4/27/26. There was no evidence the plan of care was updated to add the problems, goals, and interventions related to the issue. Patient 12,15: The plan of care contained initial assessment problems, goals, and interventions for the social worker and spiritual care provider. There was no evidence the plan of care was updated to resolve the issues after the initial assessments. Patient 13: The plan of care contained UTI 2/10/26 problems, goals, and interventions. There was no evidence the plan of care was updated to resolve the issues after treatment. The nursing documentation 5/12/26 identifying patient issues with dysphagia and need for oxygen. There was no evidence the plan of care was updated to add the problems, goals, and interventions related to the issues. Patient 14: The nursing documentation 5/12/26 identifying patient history of aspiration pneumonia. There was no evidence the plan of care was updated to include problem, goals, and interventions related to risk for aspiration. Patient 16 The plan of care contained initial assessment problems, goals, and interventions for the RN and social worker, . There was no evidence the plan of care was updated to resolve the issues after the initial assessments. Patient 18: The plan of care contained initial assessment specific problems, goals, and interventions for the social worker. There was no evidence the plan of care was updated to resolve the issues after the initial assessment. An order 5/28/26 to downgrade patient diet to mechanical soft. There was no evidence the plan of care was updated to include problems, goals, and interventions related to the need for special diet.”

“Upon client record review, 4 of 23 (Patients #1,#8,#10,#12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained an order for nurse visits twice weekly. There was no evidence of a second visit completed the week of 5/31/26. Patient 8: The medical record contained nursing documentation 6/9/26 identifying wound care was given to a skin tear on the right hip. There was no evidence of an order for wound care. Patient 10: The medical record contained an order for nurse visits twice weekly. There was no evidence of a nurse visit completed the week of 5/24/26. Patient 12: The medical record contained an order for nurse visits twice weekly. There was no evidence of a nurse visit completed the week of 5/3/26.”

“Upon patient record review, 2 of 23 (Patients #5,#11) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 5: The medical record contained nursing documentation 6/8/26 identifying the facility was planning to have an X-ray completed on the patient’s left shoulder due to patient complaint of facility staff being too aggressive. There was no evidence of follow up by the hospice regarding X-ray results. Patient 11: The medical record indicated the patient’s daughter is a high risk for bereavement. There was no evidence of sharing the information between disciplines.”

“Upon patient record review, 1 of 23 (Patient #20) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 20: The medical record contained a bereavement note from the chaplain 12/29/25 stating bereaved will be contacted by phone twice per month; however, there was no evidence of follow up until 1/27/26 in which the chaplain states the bereaved will be contacted once per month. There was no evidence of follow up until 6/9/26.”

“Upon patient record review, 6 of 23 (Patients #2,#5,#10,#11,#14,#18) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 2: The aide care plan contained no instructions for management of the peg tube insertion site during bathing. Patient 5: The aide care plan contained no instructions for patient use of wheelchair. Patient 10: The aide care plan did not contain parameters for reporting the temperature, blood pressure, or pain to the RN. Patient 11: The aide care plan did not contain parameters for reporting blood pressure to the RN. Patient 14,18: The aide care plan did not contain parameters for reporting the temperature, blood pressure, respirations, pulse, or pain to the RN.”

“Upon patient record review 5 of 23 (Patients #1,#5,#10,#11,#14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1: The medical record contained an order for aide visits twice weekly. There was no evidence of a second visit completed the week of 5/31/26. Patient 5: The medical record contained aide documentation 6/9/26 identifying the aide brushed hair, cut and cleaned nails, brushed teeth, cleaned ears, and dressed the patient. There was no evidence of these tasks assigned on the care plan. Patient 10: The medical record contained aide documentation 5/26/26 and 6/2/26 identifying a bed bath was given instead of the tasked shower for every visit. There was no evidence the aide received instructions to alter bath type from the RN. Patient 11: The aide care plan contained the task to give a shower unless patient unable to transfer to shower chair. There was no evidence a shower was given in May or June until time of review 6/17/26. Patient 14: The medical record contained an order for aide visits three times weekly. There was no evidence of a third visit completed the week of 5/24/26.”

“Upon patient record review 1 of 23 (Patient #10) did not have evidence in the patient record that the hospice aides report: • Changes in the patient’s medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice’s policies and procedures Patient 10: The medical record contained aide documentation 6/4/26 identifying patient reported a pain level of 8 out of 10. There was no evidence of communication with the RN regarding patient’s pain.”

“Upon client record review, 2 of 23 (Patients #2,#11) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 2: The medical record contained peg-tube site care 4/22/26 and 4/27/26, and catheter order 5/4/26 that does not specify hospice and facility responsibilities. Patient 11: The medical record contained an order for wound care 5/1/26 that did not specify facility responsibility.”

“Upon patient record review, 2 of 23 (Patients #2,#18) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice’s 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient 2: During home visit review of facility’s hospice binder, there was no evidence the agency provided the recertification of terminal illness in May, updates to the plan of care, and an advance directive. Patient 18: During home visit review of facility’s hospice binder, there was no evidence the agency provided the certification of terminal illness, updates to the plan of care, and election form.”

“Based on policy review, medical record review, observation and interview, the agency failed to ensure medication profiles were accurately assessed and documented for 3 of 6 (Patient #1, #2, and #5) sampled patients with home visits. The findings included: 1. Review of the agencys policy titled, “;Medication Profile” revealed, “;...Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record...the medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications. 2. Observations on 7/8/2024, during the home visit for Patient #1, revealed the following medications were not listed on the medication report provided by the hospice: Lantanoprost (used to treat glaucoma) eye drops- one drop in both eyes at bedtime, Pepcid (used to treat acid-reflux) 40 milligrams (mg) one time per day, and Metformin (used to treat diabetes) 850 mg one tablet three times per day. Further observation revealed the following medications listed on Patient #1’s medication report that were not being taken by the patient and were not in the home: Alendronate (used to treat or prevent osteoporosis) 10 mg one tablet par day, Buspirone (used to treat anxiety) 10 mg tablet two times per day, Diphenoxylate- Atropine (used to treat diarrhea) 2.5 mg- 0.025 mg 2 tablets by mouth four time a day and Morphine Concentrate (used to control pain)100 mg/ 5 milliliters (ml) take 0.5 ml every 4 hours. In an interview on 7/8/2024 at 2:20 PM, Patient #1 stated she was taking the eye drops, Pepcid, and Metformin. Patient #1 further stated she was not taking the other medications listed on the profile identified above. 3. Observations on 7/8/2024, during the home visit for Patient #2, revealed the following medications were not listed on the medication report provided by the hospice: Gabapentin (used to treat seizures and pain) 100 mg by mouth two times a day and an additional Furosemide (used to remove fluid from the body) 20 mg tablet by mouth once a day as needed. Further observations revealed Pantoprazol (used to treat gastric reflux and a damaged esophagus) 40 mg two times a day intravenously was listed on the medication report provided by the hospice, but it was being given by mouth. In an interview on 7/8/2024 at 1:45 PM, Hospice Nurse #1 verified the medications were not on the medication report and Pantoprazole was not administered intravenously. 4. Observations on 7/9/2024, during the home visit for Patient #5, revealed the following medications listed on Patient #5’s medication report that were not being taken by the patient and were not in the home: Aspirin 81 mg two tablets per day, Alprazolam (used for anxiety and panic disorder) 0.25 mg tablet one tablet every six hours as needed, Codeine 10 mg- Guaifenesin (combination of the two medications to treat cough) 100 mg/5 ml oral liquid take 2.5- 5 ml every 6 hours as needed, Meclizine (used to treat dizziness and motion sickness)25 mg one tablet three times per day, as needed, and Prochlorperazine Maleate (used to treat nausea and vomiting; or used to treat anxiety and schizophrenia) 10 mg tablet every six hours for pain, as needed. In an interview on 7/9/2024 at 9:03 AM, Hospice Nurse #2 stated Patient #5 was no longer taking the above medications and verified the medications were not in the home.”