Valor Hospice

“Based on observation, record review and interview, the agency failed to ensure the right of a patient to receive effection pain management for 1 (Patient #1) of 3 records reviewed of patients with a diagnosis of cancer. The failure resulted in Patient #1 having increased pain. Patient #1:Record review of Patient #1’s clinical record revealed a Plan of Care dated 7/15/2026 to 10/12/2026. The Plan of Care indicated that Patient #1 started on the agency’s services on 7/15/2026. The Plan of Care listed Malignant Neoplasm of Prostate (prostate cancer- tumor started in the prostate gland (organ in men that makes fluid for semen. Cancer occurs when cells grow out of control and can spread to other parts of the body) as the terminal diagnosis. The Plan of Care listed Secondary Malignant Neoplasm of Bone (cancer started in another body part and spread to the bone), Pathological Fracture in Neoplastic Disease (cancer has grown inside a bone and made it weak. The bone can break from a normal, everyday action or a very small bump that would not break a healthy bone), Spinal Stenosis Thoracic Region (narrowing of the open space of the spine between the neck and the abdomen), and Displacement of Internal Fixation device of Vertebrae (a medical complication when surgical hardware—such as rods, screws, or plates placed to stabilize the spine—shifts or moves out of its correct position) as other terminal/pertinent diagnoses. The Plan of Care contained orders for:Methadone 10 milligrams every 8 hours by mouth (used to treat severe chronic pain),Oxycodone 30 milligrams (used to treat moderate to severe pain) every 4 hours as needed by mouth,Methocarbamol (used short-term to treat muscle pain, stiffness, and spasms) 750 milligrams twice a day routinely and once as needed daily by mouth,Acetaminophen 650 milligrams (used for mild pain or fever) per rectum (last portion of the large intestine ending at the opening where solid waste leaves the body),Morphine 20 milligrams/Milliliter. 0.25 milliliters - 1 milliliter, (used for moderate for severe pain) every hour for pain or shortness of breath as needed by mouth. Review of Patient #1’s clinical health history documentation revealed, prior to starting on hospice services: Progress notes dated 7/6/2026 that indicated that Patient #1 went to the hospital with worsening back pain and was admitted for cancer-related pain; Patient #1 had new T11 (the eleventh thoracic vertebra (small, irregular bones that stack on top of each other to form the spine, or backbone), located in the lower part of the mid-back, spine, a transitional bone that helps support upper body weight and protects the spinal cord-a long tube of nerve tissue running from the base of the brain down through the center of the spine, It acts as a main message highway between the brain and the rest of the body); Patient #1 presented with worsening pain and lower extremity (legs) weakness; Patient #1 received palliative radiation (targeted cancer treatment using high-energy rays to shrink tumors, ease pain, and control symptoms in advanced cancer cases; Fentanyl (50 to 100 times stronger than morphine and used to treat severe pain for advanced cancer) Patch 100 micrograms was discontinued; started on Oxycodone 30-45 milligrams every 4 hours as needed; continue steroids; and mood was normal. MR (Magnetic Resonance Imaging (MRI), a safe, non-invasive scan using strong magnets and radio waves to make clear pictures of soft tissues, organs, and bones inside the body) Thoracic Spine (middle part of the back) and Lumber Spine (lower part of the back) with and without intravenous contrast, dated 6/23/2026, impression indicated widespread metastatic (spread) disease in the thoracolumbar spine (mid and lower back), Pathologic compression fractures of L2, L4, T4, and T9; and T11 ventral epidural metastatic disease (cancer that spreads to the front part of the spine from inside the spinal canal located between the bones of the spine). CT (uses X-rays and a computer to make detailed pictures of the inside of the body showing cross-sectional “slices” of bones, organs, and blood vessels) without contract of Cervical Spine (the neck part of the backbone has seven vertebrae, labeled C1 to C7. These bones hold up the head, allow movement of the neck in all directions and protects the spinal cord), Thoracic Spine, and Lumbar Spine. dated 6/23/2026, impression: Widespread osseous (bone) metastatic disease involving the cervical, thoracic, and lumbar spine; noted positioning of screws. XR Myelogram, 2 or more levels (a diagnostic imaging test that injects a special contrast-dye into the fluid-filled space around the spinal cord. Real-time X-rays, called fluoroscopy, are then used to view the spinal canal, nerve roots, and spinal cord to find compression, tumors, or herniated discs), dated 6/29/2026. Impression Successful fluoroscopically quided lumber puncture for entire spine myelography. Impression - Diffuse bone metastases (cancer that spread widely throughout the skeleton from a primary tumor located in another part of the body) of the axial skeleton (the central core of the human skeleton with 80 bones forming the long middle axis of the body that includes the head, neck, chest, and back), and appendicular skeleton (part of the human body that contains 126 bones of the arms, legs, shoulders, and hips). Findings of widespread osseous metastatic disease and could not exclude a couple of borderline pulmonary nodules. Record review of Xray (medical test using invisible radiation beams to take black-and-white pictures of the inside of the body) of the chest, dated 6/27/2026, impression Widespread osseous metastatic disease. Record review of the interim physician orders:7/27/2026- Methadone 10 milligrams every 8 hours by mouth discontinued; Methocarbamol 750 milligrams twice daily routinely and once daily as needed by mouth discontinued; Oxycodone 30 milligrams every 4 hours as needed by mouth discontinued. Reason Duplicate medications 7/31/2026- Trazodone 50 milligrams every hour sleep by mouth for insomnia (trouble sleeping); Buspirone (depression/anxiety) 5 milligram daily by mouth; Fentanyl Patch 12 micrograms every 72 hours, topical; Discontinue Oxycodone 30 milligrams by mouth. 8/1/2026- Oxycodone 15 milligrams every 4 hours as needed by mouth for pain 8/6/2026-Fentanyl Patch 12 micrograms, 2 patches every 72 hours topical; Discontinue Dexamethasone (steroid- stops swelling and slows down an overactive immune system) by mouth; Discontinue Fentanyl patch 12 micrograms 1 patch topical; 8/7/2026- Discontinue Buspirone 5 milligrams daily by mouth; Start Buspirone 5 milligrams three times a day by mouth. 8/12/2026- Discontinue Fentanyl Patches, 2 patches, 12 micrograms topical effective 8/12/2026; Start Fentanyl patch 50 micrograms, 2 patches every 72 hours topical- effective 8/13/2026. Registered Nurse C conducted a start of care/ initial comprehensive assessment on 7/15/2026. Registered Nurse C documented that Patient #1 had recently completed palliative radiation therapy and Patient #1 had reported some improvement with pain; Patient #1’s pain was currently managed on high-dose Methadone and as needed Oxycodone; Patient #1’s pain was presently controlled but Patient #1 remained at high risk for worsening pain due to extensive metastatic disease; Patient #1 had significant generalized pain, takes Methadone, Oxycodone, Dexamethasone, and Methocarbamol; Patient #1’s current pain was scaled as a 3 on 0-10 pain scale, and scaled pain at its worse as level 5; and Patient #1’s emergency contacts were Witness 1 and Witness 2. Registered Nurse D conducted a skilled nurse visit on 7/16/2026. Registered Nurse D documented that Patient #1’s pain level was 2 and pain was controlled with medication. Registered Nurse D conducted a skilled nurse visit on 7/21/2026. Registered Nurse D documented that Patient #1’s pain was 0 and pain was controlled with medication. Registered Nurse D conducted a skilled nurse visit on 7/27/2026. Registered Nurse D documented that Patient #1 had no signs/symptoms of pain; Patient #1 was not requesting pain medication until today and it had not been working; Patient #1 was taking pain medication every 4 hours and the pain has become worse; Patient #1 requesting an increase in Oxycodone dosage from 30 milligrams to 45 milligrams; Registered Nurse D informed Patient #1 that the hospice physician would need to be notified; Skilled Nurse Facility staff reported Patient #1 set an alarm for every 4 hours and asked for Oxycodone every 3-4 hours routinely; Physican X was notified and would need to review Patient #1’s record. Patient #1’s pain was 0 and pain was well controlled with medication. Social Worker E conducted a social work visit on 7/27/26. Patient #1 reported pain, scaled at 3, and requested as needed pain medication. Social Worker E notified Facility Y staff. Registered Nurse D conducted a skilled nurse visit on 7/31/2026. Registered Nurse D documented that Patient #1 received an as needed dose of Oxycodone during the visit; Patient #1 taking the as needed Oxycodone every 4 hours; Patient #1 was asked about starting a low-dose Fentanyl patch and decreasing Oxycodone to 15 milligrams; New order to start Patient #1 on Fentanyl patch 12 micrograms every 72 hours and 12 hours after starting Fentanyl, reduce Oxycodone to 15 milligrams every 4 hours as needed; Facility physician started Patient #1 on Trazodone and Buspar daily; Provider wanted a follow up with Patient #1 over the weekend; and Patient #1’s pain was 0 and controlled with medication. Registered D conducted a skilled nurse visit on 8/4/2026. Registered Nurse D documented the facility had Methocarbamol listed as needed every 8 hours and the order was changed to reflect the current order listed in March (sic); Patient #1 started on Fentanyl patch and it had helped but continued to take Oxycodone every 4 hours; Medication order change written for the Facility Y nurse; Patient #1’s pain was 0 and controlled with medication. Registered Nurse D conducted a skilled nurse visit on 8/6/2026. Registered Nurse D documented Patient #1 requested an increase in Fentanyl patch dose; Provider increased the Fentanyl patch to 25 micrograms but due to pharmacy not having the 25 microgram patch in stock, (2) 12 microgram patches were ordered every 72 hours; Patient #1 requested Oxycodone to be scheduled instead of as needed because having issues with Facility Y staff administering the Oxycodone in a timely manner when it was requested; Facility Y Staff reported that Patient #1 was requesting Oxycodone every 3-4 hours and used a timer set for every 4 hours, that Patient #1 would request medication and not allow them more than a few minutes to check when last dose was given before Patient #1 was calling again; Patient #1 was keeping a notebook of notes of times when medication was administered and any issues when the medication was administered; When Patient #1 was informed that Oxycodone would remain as needed, Patient #1 wanted Fentanyl patch increased to 50 micrograms; Patient #1 stated that Patient #1 used to be on 150 micrograms of Fentanyl; and Patient #1’s pain was 0. Registered Nurse D conducted a skilled nurse visit on 8/11/2026. Registered Nurse D documented that Patient #1 called the afterhours/on-call number over the weekend multiple times including having a family friend call multiples times; Patient #1 called skilled nurse over the weekend reporting excessive pain and reporting wanting to go the emergency room if medication was not increased; Patient #1 reported pain as 7; Patient #1 had signs of pain; Facility staff nurse reported Patient #1 had been chasing the nurse down, attempting to get pain medication, following into other Patient rooms, Patient #1 has set alarms to notify when the next dose was needed; Facility nurse reported that Patient #1 would have family call and report that Patient #1 was crying in pain; Patient #1 voiced attempting to find a pain management physician to take over as Patient #1 does not feel that Patient #1’s pain was understood or being managed effectively; Provider was notified with no new orders; Patient #1 reported pain as 7 now because Patient #1 had Oxycodone about 15 minutes ago and that Patient #1 would wait an hour and ask for Morphine; and Patient #1’s pain was 0 and was controlled with medication. Registered Nurse D conducted a skilled nurse visit on 8/14/2026. Registered Nurse D documented that Patient #1 had Witness 1 bring a Fentanyl 100 microgram patch from home and Patient #1 put it on; The facility staff and hospice staff were unaware that Patient #1 had a Fentanyl 100 microgram patch on; the hospice had increased Fentanyl patch to 100 microgram patch -(2) 50 microgram patches, due to the Patient calling after hours, the office and skilled nurse frequently reporting uncontrolled pain; the new patch was applied on 8/13/2026 while Patient was wearing the 100 microgram patch brought by Witness 1; Patient #1 applied the patch out of medical necessity because pain was not being managed and asked when the physician would increase the Fentanyl to 150 micrograms; Patient #1 scaled pain as 8; Patient #1 stated that it was the doctors legal duty to get Patient #1 out of pain; Facility nurse removed the 100 microgram patch (brought by Witness 1); Facility called Witness 1 to not bring outside medication to the facility; Patient #1 was informed a medication contract (agreement to take pain medications as prescribed by the hospice) would need to be signed; and Patient #1’s pain was 0. Registered Nurse D conducted a skilled nurse visit on 8/17/2026. Registered Nurse D documented Patient #1 had called the office several times over the weekend to report uncontrolled pain; Patient #1 reported how pain was not being managed and not receiving pain medication as Patient #1 should; Patient #1 wanted Fentanyl patch increased to 150 micrograms and Oxycodone scheduled routinely; Patient #1 reported not needing pain medication when Patient #1 had the fentanyl 200 micrograms on; Provider notified of Patient #1’s request; Patient #1 reported pain as 8 and requested Morphine; Patient #1 reported being able to get up, move around, and use computer; Patient #1 stated that pain was not being controlled and needed Oxycodone scheduled; hospice was taking too long to make changes and Patient #1 was staying in pain; and Patient #1’s pain was 0 and controlled with medications. Record review of Facility Y’s medication/treatment records indicated the dosage, applied, and removal dates of Patient #1’s Fentanyl Patches; Fentanyl 12 micrograms, 1 patch, applied at 10:00 PM on 7/31/2026, removed on 8/3/2026 at 9:59 PMFentanyl 12 micrograms, 1 patch applied at 10:00 PM on 8/3/2026, removed on 8/6/2026 at 4:46 PM Fentanyl 12 micrograms, 2 patches applied at 9:34 PM on 8/6/2026, removed on 8/9/2026 at 9:12 PMFentanyl 12 micrograms, 2 patches applied at 9:12 PM on 8/9/2026, removed on 8/12/2026 at 9:00 PMFentanyl 12 micrograms, 2 patches applied at 9:00 PM on 8/12/2026, removed on 8/15/2026 at 10:11 PMFentanyl 12 micrograms, 2 patches applied at 10:12 PM on 8/15/2026, removed on 8/16/2026 at 9:48 PM Fentanyl 100 micrograms applied at 1215PM on 8/13/2026, removed 8/15/2026 at 9:45 PMFentanyl 100 micrograms applied at 10:00 pm on 8/15/2026, removed on 8/18/2026 at 8:53 PM During an interview on 8/12/2026 with the Alternate Administrator/Director of Nursing, the Surveyor was informed that the agency used Lippencott (reference manual for nursing) for clinical procedures. During an interview on 8/18/2026 at 8:11 AM with Witness 2, the Surveyor asked about Patient #1’s pain. Witness 2 informed the Surveyor that Patient #1 and Witness 2 called the hospice about Patient #1’s pain and the hospice never called back until Monday, when the nurse from the Hospice came to see Patient #1. Witness 2 informed the Surveyor that over the weekend Patient #1 was having strong pain; Witness 1 brought a Fentanyl patch from home that was prescribed to Patient #1 previously; Patient #1 had been on Fentanyl patches 150 microgram prior to hospitalization in 6/2026; Patient #1 told Facility Y about putting on the other patch; this was what Patient #1 had to do to get out of pain; that the hospice nurse talked about increasing Patient #1’s medication, they are worried about increasing the medications; Witness 2 listened to Patient #1 be in excruciating pain; when the Hospice put Patient #1 on a Fentanyl patch, they reduced the dosage of the breakthrough medications; Patient #1 was keeping a log of when Patient #1 received medications. During an interview on 8/18/2026 at 5:24 PM with Witness 1, that Surveyor asked about Patient #1’s pain. Witness 1 stated, “(Patient #1) has not been getting pain controlled, (Patient #1) was in tears. They want (Patient #1) to ask for Morphine every hour around the clock. (Patient #1) was having tremendous issues with pain. When (Patient #1) was requesting pain medication, (Patient #1) would have to wait an hour or more for the medication to be given.” The Surveyor asked about Patient #1’s history with Fentanyl patches for pain relief. Witness 1 informed the Surveyor that Patient #1 was using Fentanyl Patches 150 micrograms; the hospice was only giving 30 micrograms (24 micrograms, Patient #1 would call it 30 micrograms); and the hospice wanted Patient #1 to use Morphine, and the Morphine was not effective. The Surveyor asked if anyone from the Hospice spoke with Witness 1 about Patient #1’s pain medications. Witness 1 said, “No, but (Patient #1) had.” Witness 1 informed the Surveyor that Witness 1 had been instructed not to bring medications to Facility Y but thought it was from Facility Y. The Surveyor asked if Witness 1 brought a Fentanyl Patch to Patient #1. Witness 1 stated, “Yes I did.” During a home visit with concurrent interviews on 8/19/2026 at 9:37 AM to visit Patient #1 at Facility Y, the Surveyor asked about pain history, pain medication history, and hospice services. Patient #1 informed the Surveyor that Patient #1 had an increase in pain and went to the local hospital, that hospital transferred Patient #1 to Hospital Z. Patient #1 stated, “My pain was so high, I was taking Oxycodone 45 milligrams every 4 hours and was on a Fentanyl patch, 150 micrograms.” The Surveyor asked how the palliative radiation had affected Patient #1’s pain. Patient #1 stated, “It cut the pain dramatically for a few weeks.” Patient #1 informed the Surveyor that when Patient #1 arrived at Facility Y pain was good and then the pain started to come back. Patient #1 informed the Surveyor that when Patient #1 would call for pain medication (facility staff), it was taking them a while to bring the medication, some wouldn’t give it for several reasons. Patient #1 informed the Surveyor that Patient #1 was on Fentanyl Patch 150 micrograms every 48 hours prior to palliative radiation; the Hospice decided to go back to the patch. Patient #1 stated, “I thought it was a great idea to get back on Fentanyl, it helped, prior to palliative radiation, I was driving, going to rehabilitation, had energy and was free of pain.” Patient #1 informed the Surveyor that the hospice started the Fentanyl patch at 12 micrograms every 72 hours. Patient #1 stated, “The hospice made me go 6 days without an increase, finally went up to Fentanyl 24 micrograms. I went -Friday, 12 micrograms, Monday, another 12 micrograms. Then they went up to Fentanyl 12 micrograms, 2 patches for two applications. The Hospice got another Doctor and agreed to go back up to Fentanyl 150 micrograms but wanted to start with Fentanyl 100 micrograms which was done on 8/11/2026 and it had not been increased since then.” Patient #1 informed the Surveyor that the patch was due last night, the pharmacist never delivered it, “now it’s additional time before I can get it.” Patient #1 informed the Surveyor that they let Patient #1 know that Patient #1 could take Morphine every hour, that there was a range of how much to give; Patient #1 would ask for the higher amount; Patient #1 asked for 1 milliliters of Morphine, Facility Y nurse only gave 0.25 milligrams of Morphine; Facility Y nurse had told Patient #1 that the hospice could provide a nurse; and Patient #1 spoke to Registered Nurse D about it. Witness 2, who was on the phone, informed the Surveyor that was during the first pain problem started 7/22/2026 or 7/24/2026, the second problem was in August. Witness 2 informed the Surveyor that the hospice was called on 8/6/2026, 8/8/2026, 8/9/2026- twice, and 8/10/2026. The Surveyor asked Patient #1 how Patient #1 would scale pain today. Patient #1 scaled it at 8 out of 10, pain was in Patient #1’s back and spine. Patient #1 stated, “Its metastasized (spread) all over the spine. Doctors had put in a bunch of screws to support the spine.” Patient #1 showed the Surveyor a picture of a scan of Patient #1’s back, which Patient #1 informed the Surveyor that the bright spots were cancer. The Surveyor noted bright spots along the back, sternum, and jaw. The Surveyor asked how Patient #1 would describe the pain. Patient #1 stated, “Intractable (severe, constant form of chronic pain that does not respond to standard medical care, surgeries, or typical medications) is how I would describe it. This has been traumatizing. I’m dying.” Patient #1 informed the Surveyor that Patient #1 didn’t want to be “doped up,” was not depressed but was frustrated from pain and not sleeping. The Surveyor asked about the Fentanyl 100 microgram patch brought to Patient #1 by Witness 1. Patient #1 stated, “I asked (Witness 1) to bring it to me. I put it on, It took care of my pain. It was done out of medical necessity. The (Facility Y nurse) came in and gave me a patch. I wore both patches. I never got euphoria (abnormal state of physical and mental well-being, intense happiness, and excitement that is often disproportionate to real-life events). I have opiod tolerance (response in which one or more of a drugs effects, such as analgesia or sedation decreases over time).” The hospice wanted to use it against me, told me I could get kicked off hospice all together.” Patient #1 informed the Surveyor that Patient #1 was supposed to get new patches last night. The Surveyor asked if Patient #1 had patches on now. Patient #1 stated, “No.” The Surveyor asked how much break through pain medicine Patient #1 was taking. Patient #1 informed the Surveyor that Patient #1 didn’t call for it; Morphine doesn’t work; and having to wait too long for breakthrough pain medication. During an interview on 8/19/2026 at 11:05 AM with the Facility Y’s (a skilled nursing facility) Alternate Director of Nursing, the Surveyor asked about Patient #1’s pain. Alternate Director of Nursing informed the Surveyor that Patient #1 was on hospice; Patient #1 was expressing a lot of pain; some disconnect with the hospice and Patient #1’s pain; Patient #1 had to change hospice physician; the hospice had to change physicians because the current physician would not change pain medications; new hospice physician increased the pain medications. The Surveyor asked who was responsible for the pain medications. The Alternate Director of Nursing stated, “Hospice.” The Surveyor asked when was the last time Patient #1 received a Fentanyl patch. The Alternate Director of Nursing wanted to review the medication administration record. The Alternate Director of Nursing informed the Surveyor that the Fentanyl would be on the treatment medication administration record and requested a co-worker to print it out. The Surveyor asked how often Patient #1 was taking breakthrough pain medications. The Alternate Director of Nursing said, “(Registered Nurse D) had said that they were trying to wean (Patient #1) off Oxycodone. I told (Registered Nurse D) they needed to come up with a better system, because Patient #1 didn’t like Morphine.” The Surveyor asked whether Patient #1 was wearing Fentanyl patches. The Alternate Director of Nursing said, “They were waiting for Fentanyl patches, they didn’t come in and (Patient #1) was due last night” The Surveyor asked if there had been a case conference with the facility, hospice, and Patient #1. The Alternate Director of Nursing informed the surveyor that a conference was scheduled at 3:00 PM. During an interview on 8/20/2026 at 11:55 AM with the Alternate Administrator/Director of Nursing the Surveyor discussed Patient #1’s pain. The Alternate Administrator/Director of Nursing informed the surveyor that Patient #1 had extensive metastatic cancer and Hospice Physician X was the hospice physician. The Alternate Administrator/Director of Nursing stated, “To my understanding, (Patient #1) was asking for pain medication. I believe they made some adjustments to (Patient #1’s) pain medication. (Hospice Physician X) was not comfortable with increasing pain medications for (Patient #1). (Hospice Physician X didn’t want to care for (Patient #1) and (Patient #1)did not want (Hospice Physician X). The Surveyor asked if the Medical Director was consulted about Patient #1’s pain and Hospice Physician X not wanting to increase Patient #1’s pain medication. The Alternate Administrator/Director of Nursing did not know if the Medical Director had been consulted. During an interview on 8/20/2026 at 3:11 PM with Executive Director 1, of Hospice Alternate Delivery Site 1, the surveyor asked Executive Director 1 when Executive Director 1 was told about Patient #1’s pain and that Hospice Physician X was uncomfortable prescribing pain medications. Executive Director 1 stated, “8/11/2026. We switched physicians to (Hospice Physician W).’ The Surveyor asked if the Medical Director had been consulted. Executive Director 1 informed the surveyor that Executive Director did not know. The Surveyor asked why Facility Y did not have Fentanyl patches to put on Patient #1 for 8/18/1026. Executive Director 1 informed the Surveyor that Executive Director 1 would have to talk with Registered Nurse D. During an interview on 8/20/2026 at 3:48 PM with Registered Nurse D, the Surveyor discussed Patient #1’s pain. Registered Nurse D informed the Surveyor; Patient #1 wanted Oxycodone increased from 30 to 45 milligrams; Hospice Physician X said no, asked if Patient #1 wanted to start on a Fentanyl patch, Patient #1 agreed; Hospice Physician X started Patient #1 on Fentanyl patch 12 micrograms and decreased the Oxycodone to 15 milligrams; Patient #1 said that was not enough; Fentanyl patch was increased to 24 micrograms and Hospice Physician X would not increase from there; Patient #1 was taking Morphine sometimes 9 times per day; Patient #1 was calling frequently after hours; We had Hospice Physician W take over and Hospice Physician W increased the Fentanyl patch to 100 micrograms; The Surveyor asked how many Fentanyl patches would ordered. Registered Nurse D informed the Surveyor that Registered Nurse D would order 4 Fentanyl patches at a time so the facility wouldn’t have to destroy them. The Surveyor asked why Patient #1 did not have Fentanyl patches. Registered Nurse D informed the Surveyor that Registered Nurse D called Facility Y on 8/12/2026 to let them know that the Fentanyl patch was increasing to 100 micrograms; and the Fentanyl patches didn’t arrive at Facility Y until Thursday, 8/13/2026. The Surveyor asked why the increased Fentanyl patches (50 microgram, 2 patches) took two days to get to the facility. Registered Nurse D informed the Surveyor that the order to increase Fentanyl 100 micrograms was received on Wednesday night, 8/13/2026. (order dated 8/12/2026- Discontinue Fentanyl Patches (2) 12 micrograms effective 8/12/2026; Start Fentanyl patch 50 micrograms, 2 patches, every 72 hours- effective 8/13/2026). Registered Nurse D informed the Surveyor that Facility Y did not discontinue the Fentanyl 12 micrograms patches on 8/12/2026. Registered Nurse D informed the Surveyor that Facility Y staff pulled off the initial Fentanyl 50 micrograms patches (2) on Saturday when it wasn’t due. Registered Nurse D informed the Surveyor that Registered Nurse D confirmed with Facility Y that the Fentanyl 50 microgram patches (2) were applied on Thursday, 8/13/2026. Facility Y pulled the patches off on Saturday, but it should have been pulled off on Sunday. The Surveyor discussed that Facility Y was documenting pain. Registered Nurse D stated, “To me, (Patient #1) doesn’t appear to have pain. (Patient #1) would be doing other things. (Patient #1) had (Witness 1) bring in another Fentanyl patch and (Patient #1) had Fentanyl 200 micrograms on. The Surveyor asked could a Patient have pain and still do other things. Registered Nurse D stated, “Absolutely. I told (Patient #1) that I was trying my best to help (Patient #1). Hospice Physician X refused to go up (on dosage). Before we started with Fentanyl, he wasn’t complaining until the oxycodone was cut down, (Patient #1) started having trouble with pain. We switched Hospice Physicians. I looked over the narcotic sheets (Facility Y) and (Patient #1) was taking less Oxycodone and Morphine when (Patient #1) was on the Fentanyl 200 micrograms.” During an interview on 8/20/2026 with Director of Nursing 1 at Hospice Alternate Delivery Site 1, the Surveyor asked Director of Nursing 1 informed the Surveyor that Director of Nursing 1 was on personal time off July 21-29, 2026 and August 1-9, 2026. The Surveyor asked when Director of Nursing 1 was aware of the issues regarding Patient #1’s pain. Director of Nursing 1 informed the Surveyor that Registered Nurse D called about Hospice Physician X was not taking care of Patient #1’s pain management; Patient #1 requested a new physician; Spoke to Hospice Physician W, Hospice Physician W reviewed Patient #1’s record; Hospice Physician W accepted Patient #1 and increased the Fentanyl patch to 100 micrograms due to other medication Patient #1 was on, and needed to wait a week to increase the dose; Notified Registered Nurse D. Director of Nurse 1 informed the Surveyor the hospice was notified by Facility Y that Patient #1 had 2 100 microgram patches on; Witness 1 brought the patch in; and we had Patient #1 sign a drug contract. The Surveyor asked if the Medical Director had been notified. Director of Nursing 1 stated, “Not by myself. I don’t believe that (Medical Director) is aware.” The Surveyor asked about the physician order written on 8/12/2026 for Fentanyl, order had for Fentanyl. 12 micrograms, 2 patches, was discontinued on 8/12/2026 and had to start Fentanyl patch 50 micrograms, 2 patches, on 8/13/2026. Director of Nursing 1 stated, “I guess they (Facility Y) could have misinterpreted it.” The Surveyor asked if patients always present the same with pain. Director of Nursing 1 stated, “No. Everyone does not present the same way with pain.” Record review of the agency’s policy titled “Patient’s Rights and Responsibilities RI.10,” last reviewed on 10/1/2021 read in part; “Purpose To ensure the patient, their representative (if any), and the Hospice staff acknowledge, protect, observe, and implement the patient’s rights and responsibilities...Policy...Procedure I. The Hospice staff will be responsible for knowing, observing, and implementing the patient’s rights and patient responsibilities on an ongoing basis. The staff will also be responsible for protecting and promoting these rights...IX. Regarding the patient’s rights, the patient has the right to the following: A. To receive effective pain management and symptom control from the Hospice for conditions related to the terminal illness...”[ Record review of documents, undated, received from the Alternate Administrator/Director of Nursing titled “Pain Management,” the agency’s clinical procedures were from Lippincott (a major global publisher of medical, nursing, and health science information that produce professional journals, textbooks, and digital clinical and educational tools for students and healthcare workers). The document read in part; “Pain Management...The patient’s report of pain is the most reliable indicator of the existence of pain...Special considerations...Be aware that patients receiving o pioid analgesics may be at risk for addiction, physical dependence, or tolerance...Tolerance is a neuroadaptive response in which one or more of a drugs effects, such as analgesia or sedation decreases over time...” Record review of the agency’s policy titled “Pain and Symptom Management PC.135,” last reviewed on 9/1/2024 read in part; “Purpose To establish a process with guidelines for pain and symptom assessment, reassessment, prevention and management in order to respond appropriately and timely to the patient’s pain and symptoms. Policy I. The Hospice staff are committed to pain and symptom prevention and management and will respond quicly to provide effective management. II. The Hospice will respect the patient’s right to receive effective pain managment and symptom control for conditions related to the terminal illness...Procedure...3. Impact of pain on quality of life such as sleeping, functioning, appetite and mood...X. When the IDG/IDT determines that the patient’s pain and symptoms cannot be adequately managed in the home, appropriate referrals will be made, including general inpatient care, if necessary...””

“Based on record review and interview, the hospice agency failed to ensure the right of a patient to receive effective pain management and symptom control for conditions related to the terminal illness, in that Patient #4 received ineffective pain management when Patient #4’s pain levels scaled 7-8, on a pain scale 0-10, at the last three skilled nursing visits and constipation for 1 (Patient #4) of 2 patient records reviewed where the patients lived in their homes. The failure resulted in Patient #4 having increased pain. Patient #4: Record review of Patient #4’s clinical record revealed a Plan of Care dated 7/29/2023 to 10/26/2023. The Plan of Care indicated that Patient #4 started on the agency’s services on 4/30/2023. The Plan of Care listed Malignant Neoplasm of Unspecified site of Unspecified Female Breast (breast cancer- aggressive, abnormal, uncontrolled growth of cells in the breast tissue which could spread to other parts of the body) as the terminal diagnosis. The Plan of Care listed Hydromorphone (used to treat moderate to severe pain) 4 milligrams every three hours by mouth as needed and Morphine (used to treat moderate to severe pain) concentrate 20 milligrams/milliliter as needed for pain/shortness of breath- frequency not listed as pain medications. The Plan of Care contained an order for skilled nurse visits once each week for 13 weeks. Registered Nurse C conducted telephone or telehealth visits on 9/1/23, 9/7/2023, 9/12/2023, and 9/18/2023. Registered Nurse C documented on 9/18/2023 that Patient #4 rated pain as an 8/10 pain scale; advised Patient #4 to use the as needed Hydromorphone liquid, Patient #4 voiced being hesitant to use due to making Patient #4 sleep all day; Patient #4’s last bowel movement was on 9/11/2023; and Patient #4 requested an increase in pain medications to Oxycodone IR(immediate release- fast acting) (used to treat moderate to severe pain) three times each day; and Patient #4 continued to have nausea (sensation that contents of the stomach were going to empty out through the mouth). Registered Nurse C documented receiving orders for Patient #4 to take Oxycodone ER (extended release) (used to treat severe pain) twice a day. Registered Nurse C and Nurse Practitioner D conducted a joint visit on 9/27/2023, 9 days after Patient #4 reported a pain level of 8 on a 0-10 pain scale, and no bowel movement in 7 days. Nurse Practitioner D documented on 9/27/2023, that Patient #4 reported uncontrolled pain, nausea with vomiting (expulsion of stomach contents from the stomach through the mouth); new order to stop “Oxy ER”(Oxycodone extended release); add Fentanyl (50 to 100 times stronger than Morphine, used to treat severe chronic pain) 50 micrograms every 3 days, take “Oxy IR” (Oxycodone Immediate Release) twice a day as needed and to continue with Dilaudid as needed for pain; Zofran (used to treat nausea and vomiting) was administered by Registered Nurse C; Patient #4 reported not having a bowel movement for a few days; Patient #4 had distended left upper quadrant and left lower quadrant of the abdomen, had hypoactive bowel sounds and absent bowel sounds to left lower quadrant of the abdomen; refilled suppositories (used for constipation); ordered Lactulose (used to treat constipation); and fleets enema (laxative) administered by Registered Nurse C. Registered Nurse C documented on 9/27/2023, that Patient #4 scaled pain as 8/10; had a bowel movement on 9/26/2023; Fleets enema administered, Patient #4 had small hard bowel movement after fleets enema; Patient #4 reported taking Oxycodone ER (extended release) (used to treat pain) and Oxycodone IR (Immediate release) (used to treat pain) due to pain being severe; compliancy issues with pain medications by Patient #4; new orders for Fentanyl 50 micrograms per hour, change every 3 days, begin Senna (Laxative) twice a day, discontinue Miralax (laxative), Oxycodone ER (extended release) (used to treat pain) , Oxycodone IR (Immediate Release) (used to treat pain). Registered Nurse E conducted a skilled nurse visit on 10/5/2023, 8 days after Patient #4 reported pain as 8 on a pain scale 0-10, had abnormal bowel sounds, and bowel movements. Registered Nurse E documented on 10/5/2023 that Patient #4 scaled pain as 8/10; was vomiting; complained of constipation- family reported last bowel movement was on 9/29/23. Registered Nurse C documented a discharge note on 10/6/2026. Registered Nurse C documented that Patient #4 was a live discharge. Patient #4 went to the hospital. During an interview on 6/6/2026 at 4:27 PM with Patient #4’s Family Member 1 and Family Member 2. The Surveyor asked what had transpired with the hospice and Patient #4. Family Member 1 informed the surveyor that the hospice nurse was not coming to the home. Family Member 1 informed the Surveyor that the home had cameras and that was how Patient #4’s family knew the hospice nurse was not coming. Family Member 1 informed the Surveyor that the nurse was doing visits by phone. Family Member 1 stated, “(Patient #4) was getting worse and had terrible pain.” Family Member 1 informed the Surveyor that Family Member 3 and Family Member 4 took Patient #4 to the hospital. Family Member 2 informed the Surveyor that Patient #4 was in severe pain. Family Member 1 informed the Surveyor that Patient #4’s family called Registered Nurse C because they wanted Registered Nurse C to come see Patient #4. Family Member 1 stated, “(Registered Nurse C) started tripping out.” Family Member 1 informed the Surveyor that Registered Nurse C had decided to do phone visits, not Patient #4. Family Member 1 stated, “I asked (Patient #4) why the nurse was doing phone visits.” Family Member #1 informed the surveyor that (Patient #4) had told Family Member 1 that Patient #4 did not know why, that Registered Nurse C had set Patient #4 up for phone visits. During an interview on 6/10/2026 at 12:15 PM with the Administrator, Alternate Supervising Nurse, and the Alternate Administrator, the Surveyor discussed Patient #4, phone visits, pain, and bowel movements. The Surveyor asked the Alternate Supervising Nurse what the agency’s expectation would be for a nurse to follow-up with a patient when the patient had elevated pain levels and no bowel movement in a week. The Alternate Supervising Nurse stated, “Within 24 hours.” The Surveyor asked what the agency’s expectation would be for a nurse to follow-up with a patient when the patient had elevated pain level and no bowel sounds in left abdominal quadrant. The Alternate Supervising Nurse stated, “Within 24 hours.” The Alternate Supervising Nurse could not say why Registered Nurse C did not follow-up in an in-person visit with Patient #4. The Alternate Supervising Nurse stated, “I was not in this position (Alternate Supervising Nurse position).” (The agency was in process of hiring a new alternate supervising nurse and would be moving the Alternate Supervising Nurse into the role of Supervising Nurse). The surveyor asked if Registered Nurse C worked at the hospice. The Alternate Supervising Nurse and Administrator informed the Surveyor that Registered Nurse C no longer worked at the hospice. The Surveyor attempted to contact Registered Nurse C on 6/11/2026 at 4:08 PM. Registered Nurse C did not answer the phone and the Surveyor was unable to leave a message. Review of the agency’s policy titled “Patient Rights and Responsibilities RI.10,” last reviewed on 10/2/2021, read in part; “Purpose To ensure the patient, their representative (if any), and the Hospice staff acknowledge, protect, observe, and implement the patient’s rights and responsibilities...Policy...Procedure I. The Hospice staff will be responsible for knowing, observing, and implementing the patient’s rights and patient responsibilities on an ongoing basis, The staff will also be responsible for protecting and promoting these rights...IX. Regarding patient’s rights, the patient has a right to the following: A. To receive effective pain management and symptom control from the Hospice for conditions related to the terminal illness...” Review of the agency’s policy titled “Pain and Symptom Management PC.135,” last reviewed on 9/1/2024 read in part; “Purpose To establish a process with guidelines for pain and symptom assessment, reassessment, prevention and management in order to respond appropriately and timely to the patient’s pain and symptoms. Policy I. The Hospice staff are committed to pain and symptoms prevention and management and will respond quickly to provide effective management. II. The Hospice will respect the patient’s right to receive effective pain management and symptom control for conditions related to the terminal illness. III. The Hospice will educate direct patient care staff and the patient regarding pain assessment, reassessment, prevention, and management...Procedure...VI. When pain is assessed to be at a level greater than the patient’s goal, the patient will be reassessed within a timely manner following this pain intervention...IX. When medication changes occur in relation to pain and symptom management, timely follow up by the nurse will be made to determine the effectiveness of those changes...””

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 20 (10%) clinical records with hospice aide services reviewed revealed that the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s plan of care. Clinical Record 1: The Aide Care Plan dated 02/23/2023 revealed ambulatory with assistance every visit, apply barrier cream every visit, apply deodorant every visit, apply lotion to all extremities every visit. assist to the bathroom every visit, assist with dressing, every visit, change linens every visit, clean nails every visit, comb or brush hair every visit, document last BM every visit notify RN if no BM in 3 days or longer, foot care every visit, full infection control precautions for COVID-19 required every visit, make bed every visit, mouth care with oral swab every visit, partial bed bath two times weekly, perineal care every visit, shower with chair three times a week, and wash hair two times weekly. The Aide Regular Visit note dated 03/06/2023 documented, “clean nails every visit refused and mouth care with oral swab every visit refused.” The Aide Regular Visit dated 03/21/2023 documented, “mouth care with oral swab, refused, “refused to let me oral swab... mouth; and shower with chair three times weekly, refused, refused shower but... was able to get a bed bath.” The Aide Care Plan dated 06/28/2024 revealed apply barrier cream every visit, apply deodorant every visit, apply lotion to all extremities every visit, assist with dressing every visit, bed bath three times a week, change linens every visit, clean nails every visit, comb or brush hair every visit, document last BM every visit notify RN if no BM in 3 days or longer, make bed every visit, partial bed bath three times weekly, perineal care every visit, and wash hair two times weekly. The Aide Regular Visit notes dated 07/08/2024 and 07/09/2024 documented change linens every visit, not performed, “no clean clothes, linens, towels available all dirty.” There was no documented evidence that the registered nurse was notified of changes to the plan of care. Clinical Record 3: The Aide Care Plan dated 05/28/2024 revealed ambulatory with assistance every visit, apply deodorant every visit, apply lotion to all extremities every visit, assist to the bathroom every visit, assist with dressing every visit, brush teeth every visit, change linens every visit, clean nails every visit, comb or brush hair every visit, document last BM every visit notify RN if no BM in 3 days or longer, dress patient every visit, file nails every visit, full Infection Control Precautions for COVID-19 required every visit, make bed every visit, may remove oxygen during bath/shower and replace every visit, shower every visit, and take out trash every visit. The Aide Regular Visit note dated 5/31/2024 documented, “ambulatory with assistance refused, apply deodorant refused, apply lotion to all extremities refused, assist to bathroom refused, assist with dressing refused, brush teeth refused, change linens refused, clean nails refused, comb or brush hair refused, document last BM refused, dress patient refused, file nails refused, full Infection Control Precautions for COVID-19 required every visit refused, may remove oxygen during bath/shower and replace refused, and shower refused.” The Aide Regular Visit note dated 06/03/2024 documented, “ambulatory with assistance refused, apply deodorant refused, apply lotion to all extremities refused, assist to bathroom refused, assist with dressing refused, brush teeth refused, clean nails refused, comb or brush hair refused, document last BM refused, dress patient refused, file nails refused, may remove oxygen during bath/shower and replace refused, and shower refused.” The Aide Regular Visit note dated 06/04/2024 documented, “ambulatory with assistance refused, assist to bathroom refused, assist with dressing refused, brush teeth refused, clean nails refused, document last BM refused, dress patient refused, may remove oxygen during bath/shower and replace refused, and shower refused.” There was no documented evidence that the registered nurse was notified of changes to the plan of care. During a joint clinical record review and interview on 09/19/2024, the Director of Nursing confirmed that the hospice aide documentation lacked notification to the registered nurse of the changes in plan of care.”