Heritage Hospice of Texarkana LLC

“It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by clinical record review, personnel record review, and interviews which revealed issues with the hospice organizing, managing, and administering its resources to provide hospice care and services to patients, families, and caregivers in the following areas: Failure to ensure that on-call nursing services responded with professional judgement to make sure the patient’s needs were met twenty-four hours a day, seven days a week {HCDT.4.I/L653}; Failed to ensure that the competencies were documented annually as per agency policy {HSRM.14.I/L663}; Failed to ensure agency that the registered nurse provided coordination of care, ensured continuous assessment of the patient and family needs and that hospice care and services provided followed the individualized plan of care{HCPC.19.I/L540}. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.100: Organization and Administration of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.”

“It is required that the hospice designates a registered nurse member of the IDG to: Provide coordination of care; Ensure continuous assessment of each patient’s and family’s needs; Ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care. This standard was not met as evidenced by clinical record review and document review. In 1 of 21 (5%) clinical records reviewed revealed the agency did not ensure that the registered nurse provided coordination of care, ensured continuous assessment of the patient and family needs and that hospice care and services provided followed the individualized plan of care. The hospice’s policy “Plan of Care Process (PC.30)” dated 09/01/2024 included in part that “... The Hospice staff will review the patient care at each visit to identify needs that may have changed in order to make adjustments to the POC. All written changes to the POC will be incorporated into the patient’s medical record...” Clinical Record 21: The patient, who resided at home with family, elected the hospice benefit on 11/29/2023 with the diagnosis of senile degeneration of the brain. A review of the plans of care for 05/27/2024 to 07/25/2024 and 07/26/2024 to 09/23/2024 was performed. A Patient Communication Note was documented on 07/22/2024 and included in part that the nurse “Received call from ... POA/daughter/caregiver for patient stating she was out of town but her spouse reported mom was vomiting and needed a visit. PRN visit scheduled and SN notified. Caregiver voiced understanding. “ A PRN Licensed Vocational/Practical (LVN/LPN) Skilled Nurse Visit was performed on 07/22/2024 and it was noted the patient’s temperature was 99.1 degrees (temporal). The patient’s heart rate was 105, with a respiratory rate of 22. Her oxygen saturations were measured at 88% room air, and she was noted to be lethargic with lungs clear to auscultation bilaterally. Additionally, it was noted in part that “...PRN LVN visit due to calling on call for pt vomiting. Upon arrival patient lying in bed with eyes closed. O2 sat 88 , pt son in law with pt. and states he heard her gagging and vomit from the other room. Called and spoke with Dr ... and orders noted for O2 PRN. O2 was applied at @2lnc; sats returned to 92 after 5 mins. On 07/26/2024, another PRN LVN/LPN Skilled Nurse Visit was documented and noted that the patient’s temperature was 100.8 degrees (temporal), her heart rate was 121, respiratory rate was 22 with oxygen saturations of 90% on oxygen at two liters per minute by nasal cannula. The nurse documented crackles auscultated in the patient’s lungs in the bilateral upper lobes, and neurologically, the patient remained lethargic. Further noted in part was that “...PRN LVN visit due to patient’s daughter calling and requesting nurse visit because ‘momma isn’t acting right.” Upon arrival patient lying in bed with eyes closed. O2 sat at 90% with wheezing to upper bil lobes. Called and spoke with Dr. ... and orders noted for Rocephin 1GM IM QD x7 days... Daughter is a NP and can give injection ... IDT updated. Discussed visit with RNCM.” A physician’s order documented on 07/26/2024 read for Rocephin 1 gram to be administered per intramuscular injection for seven days. The LPN/LVN documented on 07/29/2024 that the patient had crackles to bilateral upper lobes of the lungs and an oxygen saturation reading of 93% on two liters of oxygen administered by nasal cannula. When the oxygen was removed, the patient’s oxygen saturation dropped to the mid-eighties. The nurse included in part that “... Spoke with (daughter) about the Rocephin injections she states she never started and just started the Bactrim pills . There was a problem identified on 11/29/2023 for oxygen therapy, but the only documentation was dated 07/26/2024 and read, “Respiratory system assessed q visit. “ There was a care plan problem for chronic urinary tract infections initiated on 05/13/2024, with the last documentation on 06/10/2024. The next IDG on 08/12/2024 included no RN note, no new problems added, no new planned interventions, and no updated patient/family goals related to the updated assessment findings and new orders documented in the clinical record. The plans of care for 05/27/2024 to 07/25/2024 and 07/26/2024 to 09/23/2024 did not include the identification of a respiratory infection, signs and symptoms of nausea and vomiting, lethargy, and lack of appetite. There were no new planned interventions and no updated patient/family goals of care. There was no documented evidence that an RN ensured continuous assessment that led to the implementation of the interdisciplinary plan of care updates.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and document review. In 1 of 21 (5%) clinical records reviewed revealed the agency did not ensure that the patient’s plan of care reflected updated assessment data with patient-specific planned interventions and patient/family goals. The hospice’s policy “Plan of Care Process (PC.30)” dated 09/01/2024 included in part that “... The Hospice staff will review the patient care at each visit to identify needs that may have changed in order to make adjustments to the POC. All written changes to the POC will be incorporated into the patient’s medical record...” Clinical Record 21: The patient, who resided at home with family, elected the hospice benefit on 11/29/2023 with the diagnosis of senile degeneration of the brain. A review of the plans of care for 05/27/2024 to 07/25/2024 and 07/26/2024 to 09/23/2024 was performed. A Patient Communication Note was documented on 07/22/2024 and included in part that the nurse “Received call from ... POA/daughter/caregiver for patient stating she was out of town but her spouse reported mom was vomiting and needed a visit. PRN visit scheduled and SN notified. Caregiver voiced understanding. “ A PRN Licensed Vocational/Practical (LVN/LPN) Skilled Nurse Visit was performed on 07/22/2024 and it was noted the patient’s temperature was 99.1 degrees (temporal). The patient’s heart rate was 105, with a respiratory rate of 22. Her oxygen saturations were measured at 88% room air, and she was noted to be lethargic with lungs clear to auscultation bilaterally. Additionally, it was noted in part that “...PRN LVN visit due to calling on call for pt vomiting. Upon arrival patient lying in bed with eyes closed. O2 sat 88 , pt son in law with pt. and states he heard her gagging and vomit from the other room. Called and spoke with Dr ... and orders noted for O2 PRN. O2 was applied at @2lnc; sats returned to 92 after 5 mins... Pt usually consumes 1-2 boosts daily, but for the last 2 days, pt. has only taken sips of any fluids ... IDT updated. Discussed visit with RNCM.” A physician’s order was documented on 07/23/2024 for Bactrim DS 800/170mg by mouth twice a day for ten days. Then, on 07/26/2024, another PRN LVN/LPN Skilled Nurse Visit was documented and noted that the patient’s temperature was 100.8 degrees (temporal), her heart rate was 121, respiratory rate was 22 with oxygen saturations of 90% on oxygen at two liters per minute by nasal cannula. The nurse documented crackles auscultated in the patient’s lungs in the bilateral upper lobes, and neurologically, the patient remained lethargic. Further noted in part was that “...PRN LVN visit due to patient’s daughter calling and requesting nurse visit because ‘momma isn’t acting right.” Upon arrival patient lying in bed with eyes closed. O2 sat at 90% with wheezing to upper bil lobes. Called and spoke with Dr. ... and orders noted for Rocephin 1GM IM QD x7 days... Daughter is a NP and can give injection ... IDT updated. Discussed visit with RNCM.” A physician’s order documented on 07/26/2024 read for Rocephin 1 gram to be administered per intramuscular injection for seven days. The LPN/LVN documented on 07/29/2024 that the patient had crackles to bilateral upper lobes of the lungs and an oxygen saturation reading of 93% on two liters of oxygen administered by nasal cannula. When the oxygen was removed, the patient’s oxygen saturation dropped to the mid-eighties. The nurse included in part that “... Spoke with (daughter) about the Rocephin injections she states she never started and just started the Bactrim pills ... Pt still not consuming a whole can of boost a day ...” The Interdisciplinary Group (IDG) Meeting held on 07/29/2024 included a note from the RN that read, “84 yr. old ... terminal diagnosis of senile degeneration of the brain. Plan of care discussed with IDG team, past 2 weeks or changes and future two weeks of needs; admission, resorts, live d/c, POC, bereavement POC, and Optum medication therapy management assessment discussed with IDG team..” There was a problem identified on 11/29/2023 for oxygen therapy, but the only documentation was dated 07/26/2024 and read, “Respiratory system assessed q visit. “ There was a care plan problem for chronic urinary tract infections initiated on 05/13/2024, with the last documentation on 06/10/2024. The next IDG on 08/12/2024 included no RN note, no new problems added, no new planned interventions, and no updated patient/family goals related to the updated assessment findings and new orders documented in the clinical record. The plans of care for 05/27/2024 to 07/25/2024 and 07/26/2024 to 09/23/2024 did not include the identification of a respiratory infection, signs and symptoms of nausea and vomiting, lethargy, and lack of appetite. There were no new planned interventions and no updated patient/family goals of care.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 9 of 21 (43%) clinical records reviewed revealed the agency did not ensure that the patient’s progress toward the specific goals identified in their plan of care was documented in accordance with agency policy. The hospice’s policy “Interdisciplinary Group Roles and Responsibilities (PC.40)” dated 09/01/2024 read in part that “... The IDG/IDT will update the Comprehensive Assessment no less frequently than every 15 days. A revised interdisciplinary POC will include information from the patient’s updated Comprehensive Assessment and will note the patient’s progress toward outcomes and goals specified in the plan of care...” The agency policy dated 09/01/2024 entitled “Patient Assessments (PE.5)” included in part that “...Updates to the comprehensive assessment will be accomplished by the IDG/IDT ... to include but limited to: changes that have taken place since the initial assessment or last comprehensive assessment, including the patient’s progress toward desired outcomes...” The hospice’s policy “Medical Record Content (IM.30)” dated 09/01/2024 included in part that “...the medical record will contain ... Interdisciplinary POC, including problems, interventions, goals, and progress toward goals...” Clinical Record 1: The patient, who resided at home, elected the hospice benefit on 09/25/2020 with the diagnosis of hypertensive heart disease. The Interdisciplinary Group Meetings documented on 07/11/2024, 07/25/2024, 08/08/2024, 08/22/2024, 09/05/2024, and 10/03/2024 did not include any documentation of the patient’s progression toward the goals specified in the patient’s plans of care for 07/06/2024 to 09/03/2024 and 09/04/2024 to 11/02/2024. Clinical Record 2: The patient, who resided in an assisted living facility, elected the hospice benefit on 07/15/2024 with the diagnosis of senile degeneration of the brain. The Interdisciplinary Group Meetings documented on 07/11/2024, 07/25/2024, 08/08/2024, 08/22/2024, 09/05/2024, 09/19/2024, and 10/03/2024 did not include any documentation of the patient’s progression toward the goals specified in the patient’s plans of care for 07/04/2024 to 09/01/2024 and 09/02/2024 to 10/31/2024. Clinical Record 3: The patient, who resided in an assisted living facility, elected the hospice benefit on 09/08/2021 with the diagnosis of hypertensive heart disease. The Interdisciplinary Group Meetings documented on 07/11/2024, 07/25/2024, 08/08/2024, 08/22/2024, 09/05/2024, 09/19/2024, and 10/03/2024 did not include any documentation of the patient’s progression toward the goals specified in the patient’s plans of care for 06/24/2024 to 08/22/2024 and 08/23/2024 to 10/21/2024. Clinical Record 4: The patient, who resided in a nursing facility, elected the hospice benefit on 08/16/2024 with the diagnosis of Alzheimer’s disease. The Interdisciplinary Group Meetings documented on 08/28/2024, 09/11/2024, 09/25/2024, and 10/09/2024 did not include any documentation of the patient’s progression toward the goals specified in the patient’s plan of care for 08/16/2024 to 11/13/2024. Clinical Record 8: The patient, who resided at home with her spouse, elected the hospice benefit on 06/20/2024 with the diagnosis of anoxic brain damage. The Interdisciplinary Group Meetings documented on 07/15/2024, 07/29/2024, 08/12/2024, 08/26/2024, 09/09/2024, 09/23/2024, and 10/07/2024 did not include any documentation of the patient’s progression toward the goals specified in the patient’s plans of care for 06/20/2024 to 08/18/2024 and 08/19/2024 to 10/17/2024. Clinical Record 10: The patient, who resided at home alone with some paid caregiver assistance, elected the hospice benefit on 06/17/2024 with the diagnosis of renal cancer. The Interdisciplinary Group Meetings documented on 07/01/2024, 07/15/2024, 07/29/2024, 08/12/2024, 08/26/2024, 09/09/2023, 09/23/2024, and 10/07/2024 did not include any documentation of the patient’s progress toward goals specified in the patient’s plans of care for 06/17/2024 to 08/15/2024 and 08/16/2024 to 10/14/2024. Clinical Record 13: The patient, who resided in a nursing facility, elected the hospice benefit on 02/29/2024 with the diagnosis of hemiplegia/hemiparalysis post-cerebrovascular accident. The Interdisciplinary Group Meetings documented on 07/11/2024, 07/25/2024, 08/08/2024, 08/22/2024, 09/05/2024, 09/19/2024, and 10/03/2024 did not include any documentation of the patient’s progress toward goals specified in the patient’s plans of care for 05/29/2024 to 08/26/2024 and 08/27/2024 to 10/25/2024. Clinical Record 16: The patient, who lived at home with her sister, elected the hospice benefit on 11/02/2023 with the diagnosis of chronic obstructive pulmonary disease. She revoked the hospice benefit on 08/29/2024, The Interdisciplinary Group Meetings documented on 06/19/2024, 07/03/2024, 07/17/2024, 08/14/2024, and 08/28/2024 did not include any documentation of the patient’s progress toward the goals specified in the patient’s plans of care for 05/30/2024 to 07/28/2024 and 07/29/2024 to 09/26/2024. Clinical Record 20: The patient, who lived at an assisted living facility, elected the hospice benefit on 05/11/2023 with the diagnosis of senile degeneration of the brain. The Interdisciplinary Group Meetings documented on 07/11/2024, 07/25/2024, 08/08/2024, 08/22/2024, 09/05/2024, 09/19/2024, and 10/03/2024 did not include any documentation of the patient’s progress toward the goals specified in the patient’s plans of care for 07/04/2024 to 09/01/2024 and 09/02/2024 to 10/31/2024. It was confirmed during an interview and joint clinical record review with the Director of Operations (RN) (Personnel Record 2) on 10/17/2024 that the agency did not, as a practice, update the progress listed as a percentage toward the goals identified progress section of the plan of care. Additionally, a unified practice was not in place for an alternative means to update the patient’s progress toward goals.”

“It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including conducting ongoing interdisciplinary comprehensive assessments, developing, and evaluating the plan of care, and contributing to patient and family counseling and education. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 21 (5%) clinical records reviewed revealed the agency did not provide evidence of standards of practice, in that no visit was performed to assess the patient after notification by a facility paraprofessional that a narcotic medication error had been made, the medication error was not communicated to the hospice physician, the patient’s family, or the hospice’s clinical leadership, and no occurrence report was completed as per agency policy. Agency Policy: “Occurrence/Violence Incident Reporting (EC.25)” dated 09/01/2024 read in part that”...The Hospice will document and report all occurrences/violent incidents ... that may result in injury or potential harm to a patient ... Adverse Events include ... Provision of care errors, which results in ... medication errors ... An Occurrence/Violence Incident Report will be completed on all occurrences or incidents, as defined in policy, by the staff member involved or the first person to become aware of the incident. The report will be submitted to the immediate supervisor. The supervisor will review the Occurrence/Violence Incident Report and will document awareness of the occurrence/violent incident ... Follow-up data needed to resolve the occurrence ...(e.g., lab reports, physical exams ...) will be collected by the supervisor and sent to the QAPI Committee ...” The hospice’s policy “Professional Practice Acts (HR.100)” dated 09/01/2024 read in part that “...Professional disciplines will be knowledgeable of and comply with their respective Practice Acts including relating to reporting ... The Hospice’s registered nurses (RN’s) will adhere to the state Nursing Practice Act and Rules and Regulations relating to Professional Nurse Education ... and practice...” The agency policy dated 05/01/2023 entitled “Delegation (HR.101)” included in part that The Clinical Manager will be responsible for knowing the requirement of the (State) Board of Nursing ... The nursing tasks being delegated will not involve the unlicensed person to exercise any nursing judgment...” Clinical Record 17: The patient elected the hospice benefit on 08/13/2024 with the diagnosis of Alzheimer’s and died on 09/09/2024 at the assisted living facility where she resided. A Patient Communication Note dated 09/07/2024, documented by the Registered Nurse (RN), read, “Facility staff reports that pt was given the incorrect dosage of scheduled Dilaudid. Educated staff on Dilaudid 1mg/ml (0.5ml) SL Q6H scheduled order with understanding voiced. Staff voices apology and that pt is stable and being checked on q30 min. Educated that pt may become sleepy and to hold next dose of Dilaudid unless pt is in pain. Staff voices understanding. Educated facility staff to notify staff of any changes or concerns.” The day before the facility reported the medication error, the nurse documented in the Registered Nurse (RN) - Skilled Nurse Visit on 09/06/2024 that the patient was oriented to self only. “...Pt responded to verbal stimuli. Pt was able to open eyes and nodded yes and no to some questions. Pt sleeping most of the time due to decline ...” The next nursing visit after the notification of the medication error was not performed until 09/09/2024 approximately two days after the error. The RN documented that the patient was unresponsive. “...Patient appears to be transitional, bordering on active. Patient’s daughter at bedside is educated on disease progression and the dying process, with understanding verbalized. Facility staff and daughter at bedside educated on signs and symptoms of death and dying ...” A visit was completed on 09/09/2024 by the RN, and the patient’s death was pronounced. A review of the IDG note dated 09/19/2024, there was no documented evidence regarding the medication error. There was no documented evidence that the RN followed up with the patient via an assessment of the patient’s condition or that the medication error was reported to the physician or Administrator/Clinical Director. A review of the Occurrence Book did not present evidence of appropriate incident report documentation and follow-up. In interview was conducted on 10/18/2024 with the Registered Nurse (RN), who took the call on 09/07/2024. She indicated she did not visit the patient as it was the middle of the night, and the facility’s medication aide who called to report the error stated that the patient was stable and was not in pain and that the patient would be checked on every thirty minutes. The nurse received No further calls for this patient over the weekend. The nurse did not make a visit to assess the patient and did not report the medication error to the physician, family, or the clinical supervisor. Further, no Occurrence Report was completed on the incident as per policy. The hospice RN stated that she did not think the assisted living facility had a nurse in the building overnight. The nurse stated that she used poor judgment in the situation. The RN stated during the interview that, although not documented, the facility medication aide reported that the dose that should have been given to the patient was Dilaudid 1mg/ml: 0.5ml, scheduled every six hours. Instead, Dilaudid 1mg/ml: 1 ml was given, which was the PRN dose every three hours as needed. The RN/Branch Manager supervises the branch’s on-call activities and serves as the on-call clinical supervisor resource for the on-call RNs. An interview was conducted with the Branch Manager on 10/18/2024 at 1000. The process/instruction, oversight of on call services, and call were discussed. The Branch Manager, along with the Clinical Supervisors, reviews on-call activities each morning, either from the night before or on Monday morning for the weekend. There was a signature on the faxed on-call log from the phone service company indicating that the call was reviewed, but she stated that this medication error was just not caught. The instructions provided, per the Branch Manager, are for the RN on call for the hospice to make a visit if there is a call. She stated they are not supposed to ask if the patient/family/caregiver wants a visit but to instruct them that a nurse would perform a visit. She stated that the nurse should have made a visit to assess the patient, the appropriate follow-up to the family and physician should have been made, and an occurrence report should have been completed. On 10/17/2024, the Director of Operations (RN) (Personnel Record 2) and the Director of Quality confirmed that no further documentation was located regarding this patient and the reported medication error.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 21 (5%) Clinical records reviewed revealed that the agency did not ensure that the patient’s needs were met as there was no documentation of a nursing assessment and evaluation of findings was presented to the Administrator, Clinical Supervisor, or Hospice Physician following the notification of a medication error by the assisted living facility staff. Document 1: The hospice’s policy “Reporting/Follow-Up of Medication Incidents (PC.105)” dated 09/01/2024 included in part that “... ... A licensed nurse involved in or discovering a medication error will report it immediately to the physician... Internal reporting includes completing an “Occurrence Report” ... and documentation is completed for medication errors as defined in the Hospice’s policy...” The agency policy dated 09/01/2024 and entitled “Coordination of Care (PC.110)” read in part that “... The IDG/IDT will maintain responsibility for directing, coordinating, and supervising the care and services provided by all medical facilities and or residential entities ... All communication and coordination is documented in the clinical record...” And the agency policy “Occurrence/Violence Incident Reporting (EC.25)” dated 09/01/2024 read in part that”...The Hospice will document and report all occurrences/violent incidents ... that may result in injury or potential harm to a patient ... Adverse Events include ... medication errors ... An Occurrence/Violence Incident Report will be completed on all occurrences or incidents ... by the staff member involved or the first person to become aware of the incident... “ Clinical Record 17: The patient elected the hospice benefit on 08/13/2024 with the diagnosis of Alzheimer’s and died on 09/09/2024 at the assisted living facility where she resided. The Initial Plan of Care/Hospice Admission Order 08/13/2024 included that medications may be administered by nurse, patient, or the caregiver. On 08/28/2024, a PRN Registered Nursing Visit was performed with the patient. The nurse noted in part that “Patient with a fall this AM, Patient with shortening of left leg, limited ROM of left leg, and pain. Probable hip fraction. Patient is to be bedbound at this time. Facility staff education on fall prevention, with understanding verbalized. FLACC 8/10 MD notified and pain meds ordered “discussed hospice philosophy with patent daughter at bedside ... is in agreement with POC to manage symptoms of pain and anxiety at this time and to not seek aggressive treatment... Facility staff are educated on medication administration, possible side effects, and medication disposal at this time, with understanding verbalized. Patient to be bedbound at this time due to disease progression. Facility staff educated on fall prevention with understanding verbalized. .. Patient does become anxious with assessment, but calms with withdrawal of stimuli. ... start Dilaudid SL 0.5mg q6h sched start Dilaudid 1mg q3h PRN pain start Ativan SL 1mg q2H PRN anxiety agitation other epack comfort medication order and in place in event of patient decline..” Also, on 08/28/2024, a physician’s order was documented for Hydromorphone HCL Oral Liquid 1mg/ml: 1ml to be administered sublingually every three hours as needed for breakthrough pain and Hydromorphone HCL oral Liquid 1mg/ml: dose 0.5ml sublingually every six hours scheduled for pain. A Patient Communication Note dated 09/07/2024 documented by the Registered Nurse (RN), read, “Facility staff reports that pt was given the incorrect dosage of scheduled Dilaudid. Educated staff on Dilaudid 1mg/ml (0.5ml) SL Q6H scheduled order with understanding voiced. Staff voices apology and that pt is stable and being checked on q30 min. Educated that pt may become sleepy and to hold next dose of Dilaudid unless pt is in pain. Staff voices understanding. Educated facility staff to notify staff of any changes or concerns.” The day before the facility staff notified the hospice of the medication error, the nurse documented in the Registered Nurse (RN) - Skilled Nurse Visit on 09/06/2024 that the patient was oriented to self only. “...Pt responded to verbal stimuli. Pt was able to open eyes and nodded yes and no to some questions. Pt sleeping most of the time due to decline ...” The next nursing visit after the notification of the medication error was not performed until 09/09/2024 at 1000, approximately two days after the error. The RN documented that the patient was unresponsive. “...Patient appears to be transitional, bordering on active. Patient’s daughter at bedside is educated on disease progression and the dying process, with understanding verbalized. Facility staff and daughter at bedside educated on signs and symptoms of death and dying ...” A visit was made on 09/09/2024 by the RN, and the patient’s death was pronounced at 2020. The Interdisciplinary Group Meeting documented 09/19/2024 did not include any information regarding the medication error. There was no documented evidence that the RN followed up with the patient via an assessment of the patient’s condition or that the medication error was reported to the physician or Administrator/Clinical Director. A review of the Occurrence Book did not present evidence of an incident report documentation and follow-up. Personnel Record 2: During a joint clinical record review and interview with the Director of Operations (RN) (Personnel Record 2) and the Director of Quality at the end-of-day meeting on 10/15/2024, they confirmed that no documentation could be found that the medication error was communicated to the physician, that an Occurrence Report was completed in which clinical supervisors would be informed of the incident, nor of a follow-up by a hospice nurse for the assessment of the patient after the hospice was informed of the medication error. An interview was conducted on 10/18/2024 with the Registered Nurse (RN), who took the call on 09/07/2024. She indicated she did not visit the patient as it was the middle of the night, and the facility’s medication aide who called to report the error stated that the patient was stable and was not in pain and that the patient would be checked on every thirty minutes. The nurse received No further calls for this patient over the weekend. The nurse did not make a visit to assess the patient and did not report the medication error to the physician, family, or the clinical supervisor. Further, no Occurrence Report was completed on the incident as per policy. The hospice RN stated that she did not think the assisted living facility had a nurse in the building overnight. The nurse stated that she used poor judgment in the situation. The RN stated during the interview that, although not documented, the facility medication aide reported that the dose that should have been given to the patient was Dilaudid 1mg/ml: 0.5ml, scheduled every six hours. Instead, Dilaudid 1mg/ml: 1 ml was given, which was the PRN dose every three hours as needed.”

“It is required that hospice nursing services, physician services, drugs and biologicals are made routinely available on a 24-hour basis, seven (7) days per week. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 21 (5%) clinical records reviewed revealed the agency did not ensure that on-call nursing services responded with professional judgement to make sure the patient’s needs were met twenty-four hours a day, seven days a week. The hospice’s policy “Responsibilities of the Clinical Manager (LD.30) dated 09/01/2024 read in part that “... The Clinical Manager is the responsible Registered Nurse (RN) for supervising skilled services provided by the Hospice ... The Hospice defines the responsibilities of the Clinical Manager to include ... Ensuring the care offered by the Hospice is consistently available to all patients ... Ensure that the nursing needs of the patient are met ... Ensure that an appropriate health care professional performs a reassessment of a patient’s needs when there is a significant health status change in the patient’s condition...” The agency policy dated 09/01/2024 entitled “On Call for Patient Care (PC.10)” included in part that “To ensure that patient care needs will be met safely and appropriately after the Hospice office hours, during weekends and on holidays... Nursing and physician services will be available 24 hours, seven days a week ... The Hospice will ensure that a registered nurse (RN) is available 24 hours a day, seven days a week to respond to calls ... The on-call RN will respond to all calls and use professional judgement in determining any need to call the Administrative on-call RN ...” Clinical Record 17: The patient elected the hospice benefit on 08/13/2024 with the diagnosis of Alzheimer’s and died on 09/09/2024 at the assisted living facility where she resided. A Patient Communication Note dated 09/07/2024, documented by the Registered Nurse (RN), read, “Facility staff reports that pt. was given the incorrect dosage of scheduled Dilaudid. Educated staff on Dilaudid 1mg/ml (0.5ml) SL Q6H scheduled order with understanding voiced. Staff voices apology and that pt. is stable and being checked on q30 min. Educated that pt. may become sleepy and to hold next dose of Dilaudid unless pt. is in pain. Staff voices understanding. Educated facility staff to notify staff of any changes or concerns.” The day before, the nurse documented in the Registered Nurse (RN) - Skilled Nurse Visit on 09/06/2024 that the patient was oriented to self only. “...Pt responded to verbal stimuli. Pt was able to open eyes and nodded yes and no to some questions. Pt sleeping most of the time due to decline ...” The next nursing visit after the notification of the medication error was not performed until 09/09/2024 two days after the error. The RN documented that the patient was unresponsive. “...Patient appears to be transitional, bordering on active. Patient’s daughter at bedside is educated on disease progression and the dying process, with understanding verbalized. Facility staff and daughter at bedside educated on signs and symptoms of death and dying ...” A visit was made on 09/09/2024 by the RN, and the patient’s death was pronounced . There was no documented evidence that the RN followed up with the patient via an assessment of the patient’s condition or that the medication error was reported to the physician or Administrator/Clinical Director. A review of the Occurrence Book did not present evidence of appropriate incident report documentation and follow-up. An interview was conducted on 10/18/2024 with the Registered Nurse (RN), who took the call on 09/07/2024. She indicated she did not visit the patient as it was the middle of the night, and the facility’s medication aide who called to report the error stated that the patient was stable and was not in pain and that the patient would be checked on every thirty minutes. No further calls were received by the nurse for this patient over the weekend. The nurse did not make a visit to assess the patient and did not report the medication error to the physician, family, or the clinical supervisor. Further, no Occurrence Report was completed on the incident as per policy. The RN/Branch Manager supervises the branch’s on-call activities and serves as the on-call clinical supervisor resource for the on-call RNs. An interview was conducted with the Branch Manager on 10/18/2024. The process/instruction, oversight of on call services, and call were discussed. The Branch Manager, along with the Clinical Supervisors, reviews on-call activities each morning, either from the night before or on Monday morning for the weekend. There was a signature on the faxed on-call log from the phone service company indicating that the call was reviewed, but she stated that this medication error was just not caught. The instructions provided, per the Branch Manager, are for the RN on call for the hospice to make a visit if there is a call. She stated they are not supposed to ask if the patient/family/caregiver wants a visit but to instruct them that a nurse would perform a visit. She stated that the nurse should have made a visit to assess the patient, the appropriate follow-up to the family and physician should have been made, and an occurrence report should have been completed.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview, and personnel record review. In 8 of 10 (80%) applicable personnel records reviewed in which the staff provided direct care revealed the agency did not ensure that the competencies were documented annually as per agency policy. The hospice’s policy “Staff Competency (HR.10),” dated 09/01/2024, read in part that “To ensure the competency of patient care staff is assessed, and improvement needs are identified on an ongoing basis. The Hospice will provide for competency assessments by qualified individuals on hire and annually to assess direct care staff’s basic skill levels for all staff providing care, including volunteers (if applicable), contracted staff, paraprofessionals, and professionals... The Hospice will establish the competency criteria for each job classification. The criteria will be listed on the competency evaluation checklist and/or on the job description. The Hospice may determine initial and ongoing competency in a variety of ways such as: successful completion of a multiple-choice test, specific to the specialty ... competency assessment or self-competency checklist accomplished either by demonstration or verbally, when introducing new procedures, techniques, and/or equipment ... at least annually on-site in a patient’s home for all hospice aides...” The agency’s policy dated 09/01/2024 entitled “Employee Supervision (HR.60)” included in part “To establish employee supervision practices in accordance with applicable federal and state laws and regulations. The Hospice will assign the responsibility for employee supervision to the appropriately qualified individual. Supervision will be performed within the time frame defined by the policy. The Hospice will provide timely supervision of the following employees by qualified individuals ... Hospice Aides ... A RN must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care ... Medical Social Services ... must be provided by a qualified social worker ... A master’s prepared social worker (MSW) will provide supervision as required to the bachelor’s prepared social worker ... Nursing care and services are provided by or under the supervision of a nurse RN... A RN will make an onsite visit, with or without the licensed practical/vocational nurse (LPN/LVN) present, to supervise the LPN/LVN as indicated by the appropriate state practice act .... All offered counseling services must be furnished under the supervision of a qualified professional with relatable experience and/or education. Supervision will be based on the acuity of the patient and/or as frequency as indicated by the state practice act.... Personnel Record 3: The Registered Nurse (RN) Clinical Supervisor was hired on 06/23/2024 and had an initial Hospice Nursing Competency Checklist on 07/26/2023. There was no documented evidence of an On-Site Supervisory Visit or Hospice Nursing Competency Checklist completed for 2024. Personnel Record 4: The Registered Nurse was hired on 06/15/2023 and had an initial Hospice Nursing Competency Checklist on 06/27/2023. There was an On-Site Supervisory Visit for Clinical Staff completed on 06/12/2024. There was no documented evidence of a Hospice Nursing Competency Checklist for 2024. Personnel Record 5: The Registered Nurse was hired on 02/25/2021and had an initial Hospice Nursing Competency Checklist on 02/25/2021. An On-Site Supervisory Visit for Clinical Staff was completed on 02/22/2022, 02/25/2023, and 02/21/2024. There was no documented evidence of a Hospice Nursing Competency Checklists completed for 2022, 2023, or 2024. Personnel Record 7: The Social Worker was hired on 02/04/2019 and had an initial Medical Social Worker Competency Checklist completed on 02/06/2019. An On-Site Supervisory Visit for Clinical Staff was completed on 03/02/2022, 02/02/2023, and 01/29/2024. Additionally, an On-Site Supervisory Visit for Clinical Staff form was completed by the Licensed Master Medical Social Worker for oversight on 10/24/2022, 10/23/2023, and 05/21/2024. There was no documented evidence for a Social Worker Competency Checklists completed for 2022, 2023, or 2024. Personnel Record 8: The Chaplain/Bereavement Coordinator was hired on 02/20/2012 and had a Competency Orientation Skills Checklist - Hospice Chaplain completed on 01/23/2013. An On-Site Supervisory Visit for Clinical Staff form was completed on 02/14/2022, 02/07/2023, and 01/17/2024. There was no documented evidence of a Chaplain/Bereavement Coordinator Competency Checklists completed for 2022, 2023, or 2024. Personnel Record 10: The Nurse Practitioner was hired on 06/01/2021 and completed an initial Nurse Practitioner Competency Checklist on 06/30/2021. An on-site Supervisory Visit for Clinical Staff was completed on 03/15/2024. There was no documented evidence of a Nurse Practitioner Competency Checklists completed for 2022, 2023, or 2024, and no on-site supervisory visit for Clinical Staff for 2023. Personnel Record 11: The Hospice Aide was hired on 05/15/2023 and completed an initial Hospice Aide Skills Competency Checklist on 05/17/2023, 05/18/2023, and 05/19/2023. An on-site Supervisory Visit for Clinical Staff was completed on 05/09/2024. There was no documented evidence of an annual Hospice Aide Skills Competency Checklist completed for 2024. Personnel Record 12: The physical therapist was hired on 01/04/2023 and had an On-Site Supervisory Visit for Clinical Staff completed on 04/04/2023 and 01/02/2024. There was no documented evidence of a skills competency checklists completed in the personnel file. During an interview with the Human Relations Director on 10/17/2024, it was confirmed after a review of the agency’s policy “Staff Competency (HR.10)” dated 09/01/2024 that the hospice has not been completing annual competencies with patient care staff and was unaware of this requirement.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 21 (5%) clinical records reviewed revealed the agency did not ensure orders for care were included in the clinical record. The agency policy “Medical Record Content (IM.30)” dated 09/01/2024 read in part that “To ensure each medical record contains complete, correct information which identifies the patient, describes the problems and needs of the patient ... The content of the medical record will include ... physician orders ... “ The hospice’s policy, entitled “Nutritional Management (PC.115),” dated 09/01/2024, included in part that “physician-ordered diet therapy will be documented in the patient’s medical record ... “ Clinical Record 8: The patient, who resided at home with her husband, elected the hospice benefit on 06/20/2024 with the diagnosis of anoxic brain damage. A review of the patient’s plans of care for 06/20/2024 to 08/18/2024 and 08/19/2024 to 10/17/2024 revealed no documented evidence for orders for the patient’s tracheostomy that included the type and size of the tracheostomy, the care instructions for the tracheostomy or supplies required. Additionally, there were no orders for the gastric tube that included the formula, the method of administration (bolus or by pump), the care and precautions needed in caring for a patient with a gastric tube, checking for residuals (with parameters), or supplies needed. The Registered Nurse (RN) Initial Assessment was dated 06/20/2024 and included in part that “O2 at 4lpm via trach ... 69-year-old... admitted to hospice services with terminal dx Anoxic brain damage PMH: ... other generalized epilepsy and epileptic syndrome ... Does not respond to verbal stimulation .. Patient cannot swallow and is NPO. Jevity infusing via pump @ 55cc/hr. The Nurse Practitioner Face to Face visit on 09/27/2024 read in part that “...Female resting in bed unresponsive to stimuli. Frail and debilitated... Respirations even, rattling to bilateral upper lobes ... Patient is in a vegetative state. She has a trach with O2 via mask ... all feedings via g-tube ...” During an interview with the Director of Operation (RN) (Personnel Record 2) on 10/16/2024, it was confirmed that the chart did not contain any orders for the patient’s tracheostomy, apart from an order for oxygen to be administered via trach or for the patient’s gastric tube feedings.”

“It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies. Persons under contract with the hospice may instruct the patient and/or family. Instruction is documented in the patient record. The patient, family and/or other caregiver must be able to demonstrate the appropriate use of the DME to the satisfaction of the IDG. The IDG documents that the patient, family, and/or caregivers can demonstrate appropriate use. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 21 (5%) clinical records reviewed revealed the agency did not document education and training provided to the family on the use and safety of the Hoyer lift provided for the patient. The agency policy “Interdisciplinary Group Roles and Responsibilities (PC.40)” dated 09/01/2024 read in part that”... The IDG/IDT will ensure that each patient and primary caregiver receives education and training as appropriate to their responsibilities for the care and services identified in the interdisciplinary POC ...” The hospice’s policy dated 09/01/2024 and entitled “Assessment for Patient Education (PF.10)” read in part that “Purpose: To plan, support, and coordinate the provision of patient and/or caregiver education, activities, and resources specific to the patient’s assessed needs, abilities, and readiness to learn as appropriate to the care provided, to promote and maintain health and improve outcomes. The hospice will ensure that each patient and/or caregiver receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the Plan of Care (POC)... An assessment of patient and/or caregiver education needs will be accomplished by providing the patient and/or caregiver with information regarding hospice care ... including but not limited to ... written instructions are provided to the patient and/or family regarding proper use, safety hazards and infection control issues related to the use and maintenance of any equipment provided on the POC ... The patient record will include documentation of all teaching, patient and/or family response to teaching, their level of understanding, and the patient’s level of progress toward meeting goals.” Clinical Record 1: The patient, who resided at home with paid caregiver assistance, elected the hospice benefit on 09/25/2020 with the diagnosis of hypertensive heart disease. A physician order dated 07/29/2024 for DME to deliver Hoyer lift and sling to the patient’s home. During the Skilled Nursing Visit (SNV) on 07/30/2024, the nurse noted in part that “...Patient bed/chair bound and requires max assist with transfers from bed to wheelchair. Pt had a recent fall with injury to left ankle. Swelling and pain noted to ankle. Educated CG to keep extremity elevated and apply ice to site to relieve swelling with understanding voiced. Educated caregiver on fall precautions with understanding voiced. Hoyer lift delivered to pts house during SNV to assist with transfers. All needs met during visit. Educated CG to contact hospice RN for any changes or concerns ...” A follow-up nursing visit on 08/05/2024 included no documentation of education or demonstration of safe use of the Hoyer lift by the paid caregiver. On 08/23/2024, the Registered Nurse (RN) noted “... Hoyer lift being used by CG at this time ...” The IDG dated 8/8/24: “...Patient resides at home with paid sitter ... who is primary caregiver 24/7 and assist with medications and ADLs. Patient is confused at times and has a poor short term memory... Current POC effective ... Mobility/Safety (09/25/2020). G: Pt maintains levels of mobility and participation in ADLs within disease limitations; Pt/cg demonstrate safe, effective use of equipment, Pt/cg demonstrate safe mobility and transfer techniques; Pt will remain free from injury; Progress 0% (by time of death/discharge) I: assess for safety risks; instruct pt/cg on fall and safety precautions; instruct on safe mobility and transfer with assistive devices; instruct on safe use/care of equipment (last update from RN 7/27) The IDG dated 8/22 “...Patient resides at home with paid sitter ... who is primary caregiver 24/7 and assist with medications and ADLs. Patient is confused at times and has a poor short term memory... Current POC effective ... Mobility/Safety (09/25/2020); G: Pt maintains levels of mobility and participation in ADLs within disease limitations; Pt/cg demonstrate safe, effective use of equipment, Pt/cg demonstrate safe mobility and transfer techniques; Pt will remain free from injury Progress 0% (by time of death/discharge); I: assess for safety risks; instruct pt/cg on fall and safety precautions; instruct on safe mobility and transfer with assistive devices; instruct on safe use/care of equipment (last update from RN 7/27). During a joint clinical record review and interview with the Director of Operations (RN) (Personnel Record 2) on 10/14/2024, she confirmed that no documentation could be found that the caregiver was educated on the use and safety of the Hoyer lift.”