Every finding on record at Absolute Hospice & Palliative Care, Inc.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure patient care plan was developed and completed that included identified problems, interventions, monitoring, and management of the patient's related condition for one of six sampled patients (Patient 8). This deficient practice had the potential to affect the necessary care and services needed to maintain the highest practicable physical, mental, and psychosocial well-being of Patient 8 certified to receive hospice care services. --- A review of Patient 8's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated Patient 8 was admitted to the hospice agency on 2/1/2024, with a terminal diagnosis of hepatic failure (loss of liver function). A review of Patient 8s POC (Plan of Care)/IDG (Interdisciplinary Group) Review, indicated an order for visits dated 2/14/2024, for routine level of care (routine visits from a home provided by licensed medical professionals under the direct supervision of a physician) by a skilled nurse (SN) twice a week, Social Worker (MSW) to evaluate and assess for needs within five days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within five days of admission to identify spiritual needs. A review of Patient 8's Physician's order dated 2/1/24, indicated to administer Sertraline (Zoloft, an anti-depressant medication [any drug that affects mental function, behavior, and mood]) 50 milligram (mg, a unit of measurement) one tablet daily for anxiety and agitation. The common side effects of Seroquel included dry mouth, akathisia (a feeling of muscle quivering, restlessness, and inability to sit still), weight gain, and dizziness. On 2/17/2024, at 1:00 p.m., a home visit was conducted at Patient 8's residence. Patient 8 was observed sitting on a chair at dining area looking sleepy and weak. During an interview and concurrent record review with the DPCS on 2/18/2024, at 1:00 p.m., the DPCS stated that there was no plan of care developed for the anti-depressant medication management (Zoloft) for Patient 8. Further review of Patient 8s clinical record indicated there was no plan of care developed that included management of the identified psychological problem, monitoring of the effects and side effects of the medication (Zoloft), and interventions necessary in the palliation (relieve symptoms) and management of the terminal illness and related condition. A review of the agency's undated policy and procedure titled, "Plan of Care", indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on observation, interview, and record review, the hospice agency (HA) failed to notify the attending physician regarding a low blood pressure reading for one out of six sampled patients (Patient 8). These failures had the potential to result in poor quality care that can affect the affected patients' quality of life. --- A review of Patient 8's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated Patient 8 was admitted to the hospice agency on 2/1/2024, with a terminal diagnosis of hepatic failure (loss of liver function). A review of Patient 8s POC (Plan of Care)/IDG (Interdisciplinary Group) Review, indicated an order for visits dated 2/14/2024, for routine level of care (routine visits from a home provided by licensed medical professionals under the direct supervision of a physician) by a skilled nurse (SN) twice a week, Social Worker (MSW) to evaluate and assess for needs within five days of admission, and the Spiritual Care Coordinator (SC) for spiritual assessment within five days of admission to identify spiritual needs. On 2/17/2024, at 1:00 p.m., a home visit was conducted at Patient 8's residence. Patient 8 was observed sitting on a chair at dining area looking sleepy and weak. On 2/18/2024, at 11:00 a.m., during a review of Patient 8's LVN (license vocational nurse) note dated 2/15/2024, indicated a blood pressure reading of 96/59 (a normal blood pressure reading is 120/80), however there was no documented evidence the physician was notified of low blood pressure reading. A further review of Patient 8's clinical record indicated no documented evidence of a communication note that the physician was notified of the low blood pressure reading. On 2/18/2024, at 1:30 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated the blood pressure reading was low and the visiting nurse should have notified the physician about it. A review of the facilitys undated policy and procedure titled, "Monitoring Patient's Response/Reporting To Physician," indicated during each hospice visit, the clinician will notify the patient's physician or the hospice medical director on the same day when there are changes in the patient's condition

Based on record review and interview, the hospice agency (HA) failed to ensure one of six sampled patients (Patient 1) received monthly spiritual counseling assessments as prescribed by the physician to meet patient's spiritual needs. The deficient practice had the potential to result in patients not receiving spiritual and emotional support as necessary to cope with the terminal diagnosis and disease process. --- Findings: During a review of Patient 1s admission record indicated start of care date of 2/18/2023 with a terminal diagnosis of unspecified heart disease. During a review of Patient 1's POC (Plan of Care) Summary form, indicated there was an order, dated 2/19/2023, for the Spiritual Counselor (SC) to visit patient once a month and one prn (pro re nata, which means ";as needed") visit for spiritual support, needs, and concerns. During a joint home visit, on 2/17/2024 at 2:56 p.m. with the licensed vocational nurse (LVN 1), Patient 1 was observed laying in bed, awake, alert, oriented to place only, and forgetful. During a concurrent interview with Patient 1s family member (FM 1), FM 1 stated Patient 1 and her family spoke with the agencys SC only a couple of times during admission and none after that. During a review of Patient 1s clinical record indicated there was only one spiritual assessment conducted and dated 2/19/2023. During a concurrent interview and record review on 2/18/2024 at 11:10 a.m., with the Director of Nursing Service Designee (DPCSD), DPCSD stated and acknowledged there was only one spiritual assessment conducted for Patient 1 since the start of care. DPCSD stated hospice care and service should be in accordance with the plan of care. During a review of the agencys policy and procedure titled, ";Spiritual Services", revised March 2013, indicated the Chaplain/Spiritual Counselor is designed to oversee the spiritual care of the patient, family and caregivers and to ensure that the patients needs are met and rights preserved. The Chaplain/Spiritual Counselor provides spiritual counseling and services for patients, families and caregivers, as requested to meet needs in a manner consistent with patient/familys beliefs and desires. During a review of the agencys policy and procedure titled, ";IDG Care Planning Process", revised 2014, indicated hospice has designated an interdisciplinary group (IDG, a team responsible for the holistic care of the hospice beneficiary) which, in consultation with the patients attending physician, prepares a written plan of care for each patient. The care plan specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions.

Based on interview and record review, the agency failed to ensure clinical records were completed and documented timely for one of six sampled patients (Patient 17) when the Hospice Aide (HA) visit notes were incomplete. This failure had the potential to result in inadequate provision of care and undocumented missed visits by the aide. --- Findings: During a review of Patient 17's admission records indicated a start of care (SOC) date of 10/5/2023, with a terminal diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 17s POC (Plan of Care)/IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) form dated 1/3/2024, indicated the frequency of visits of hospice aide to three times per week to perform ADL (or activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating) care and assistance as assigned by the registered nurse (RN) supervisors plan of care. During a review of Patient 17s History of HA Visits indicated the last HA visit note submitted was on 1/31/2024. During a concurrent interview and record review on 2/18/2024 at 11:10 a.m., with the Director of Nursing Service Designee (DPCSD), DPCSD stated agencys nursing staff visit notes should be submitted and documented on the patients electronic medical records on a Monday of the following week after the visit per the agencys policy and procedure. DPCSD stated that in the case of Patient 17, there was a delay in the submission of visit notes by the hospice aide for the month of February 2024. During a review of the agencys policy and procedure titled, ";Timely Submission of Patient Documentation", revised 2014, indicated hospice will ensure the timely and proper submission of patient documentation. Itineraries, plan of care (POC) and all visit reports must be submitted every Monday of the following week. All patient visit reports from contract personnel must be submitted within three (3) business days from the date of the visit.

Observed in Individual Tracer. It was found on review of the patient folder in the home on HSHV#2 that the POC and Medication profile was not present. Organization policy and discussion with the DON stated that these items were to be in the home. These forms are considered education for the patient and caregivers.

Observed in Record Review. In 8 of 10 patient records reviewed, It was found in review of HSNHVRR#1, HSNHVRR#2. #3, #4, #6 and also HSHV#1 and HSHV#2 and HSHV #3 that Goals on the POC were not measurable and were without time frames. Examples: Pt/Pcg will verbalize/express understanding of medication/treatment orders and side effects was found on these records reviewed. They were also found on every IDG update. This was discussed with the DON/Administrator.

Observed in Individual Tracer. It was observed on HV#2 that the nurse placed her bag on the floor in the patient's home. Organization policy for bag technique stated that the bag should not be placed on the floor. This was verified with the Administrator who was also on the visit.

Observed in Infection Control System Tracer. It was found during the infection control tracer that the organization based their risk assessment only on current patient population. It was not based on geographic location, community, and population served. This was verified with the QAPI Coordinator and Administrator.

Based on an interview and record review, the hospice agency failed to ensure the Condition of Participation for Initial and Comprehensive Assessment of Patients was met as follows: The hospice agency failed to ensure interventions and reassessment for pain were implemented for one of 14 sampled patients (Patient 10). Refer to L524. The hospice agency failed to maintain the current medication profiles for two of 14 sampled patients (Patient 1 and Patient 9). Refer to L 530. The hospice failed to ensure appropriate professionals assess, evaluate, educate caregiver, and make referrals to meet the hospice needs for one of 14 sampled patients (Patient 1). Refer to L532. The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily (right or legal way) mandated compliance with the Federal regulations for Initial & Comprehensive Assessment of Patients to ensure the highest quality of care is being provided to patients certified to receive the Medicare hospice benefits. --- .

Based on interview and record review, the hospice agency (HA) licensed staff failed to ensure the patient's pain was identified comprehensively and it must be based on accepted clinical standards of practice by gathering the characteristic of pain, treatment including non-pharmacological /pharmacological (relating to treatment that uses drugs) treatment, pain re-assessment, and intervention implemented for one of 14 sampled patients (Patient 10). This deficient practice has the potential to result in an ineffective pain management causing uncontrollable pain, discomfort, and distress to the patient receiving hospice care and services. --- Findings: A review of Patient 10's clinical record indicated he was admitted to the hospice agency on 2/16/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 10s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 9/27/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus one PRN (pro re nata, which means ";as needed") for clinical care and support and as needed for any change of patients condition visit. The POC indicated on 8/17/2023, Patient 10 had manifested symptoms of chronic pain at times with a 10 level (worst pain). The POC included a goal for the patient will have a level of comfort maintained as evidenced by bring down pain to less than 3/10 (mild pain) or stated comfort level of pain by patient after nursing intervention/medication; The intervention included for the SN to assess/monitor pain and severity of pain every visit, teach caregiver on proper use and effectiveness of medication prescribed and assess compliance, monitor and assess effectiveness of new medication. A review of Patient 10s medication profile indicated the following medications for pain: -Diclofenac Sodium 1%, Topical Gel( treat pain of arthritis joints), one tube, 4 grams (unit of measure) topical, two times a day, apply 4 grams to affected area(s) as needed for pain. (Do not exceed 32 grams in 24 hours). -Norco (hydrocodone-acetaminophen)(relieve moderate to severe pain),10-325 milligrams one tab, oral, every six hours as needed for moderate (4-6) to severe pain (7-10). A review of Patient 10s SN Visit note dated 8/17/2023, indicated Patient 10 manifested (show) a pain level of 10/10 (most severe or worst pain), expressed by having severe back pain, and described it as a dull pain (gnawing sensation ranged from mild to severe). The note indicated Patient 10 took her pain medication Norco, 10-325 milligram, however, there was no documented evidence of pain re-assessment (re-evaluate) after taking the pain medication. There was no documented evidence the SN notified the physician of the patient's severe pain of 10/10 level. There was no documented evidence the patient's severe pain was mitigated (reduce) after the pain medication was taken. During a concurrent interview and record review on 10/1/2023 at 3:06 p.m., with the Director of Patient Care Services (DPCS), Patient 10s SN visit note dated 8/17/2023 was reviewed and indicated Patient 10 reported a pain level of 10. DPCS stated that Patient 10s pain level was not reassessed after the patient took her pain medication and it should have been documented in the narrative of the note. The DPCS further stated that if it was not documented, it did not happen and that it was important to make the patient comfortable. A review of the agency's policy titled, "Pain Assessment", revised in 2014, indicated that the appropriate hospice staff will assess and reassess the patients pain and that each patient will receive effective pain management and symptom control for conditions related to the terminal illness.

Based on observation, interview and record review, the hospice staff failed to review all medications the patients are taking and update the medication profiles with the currently used medications for 2 of 14 sampled patients (Patients 1 and 9). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. --- Findings: A review of Patient 9's clinical record indicated a start of care (SOC) date of 3/7/2022, with a terminal diagnosis of heart disease (a range of conditions that affect the heart). A review of Patient 9s POC (Plan of Care) form dated 9/29/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus PRN (pro re nata, which means ";as needed") visits for clinical care and support and as needed for any change of patients condition. A review of Patient 9s Medication Profile indicated the following: -Oxygen, 2-5 liters per minute, nasal cannula (a device that delivers extra oxygen through a tube and into the nose), as needed for shortness of breath or wheezing. On 9/30/2023at 10:30 a.m., a joint home visit was conducted at Patient 9s home residence with the Licensed Vocational Nurse (LVN 2). Patient 9 was observed awake, alert and oriented, breathing room air, and sitting in a wheelchair in the living room. LVN 2 performed vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), skilled assessment and checked medications. During an interview and record review on 9/29/2023 at 11:00 a.m. with Patient 10s family member (FM 2), the medication profile was reviewed and indicated for oxygen. FM 2 stated that Patient 10 has never had a breathing problem or shortness of breath, has never used oxygen, and never received oxygen from the hospice agency. During an interview on 10/1/2023 at 3:17 pm, the Director of Patient Care Services (DPCS) stated that no oxygen was ordered for Patient 10 and that is why it was not delivered. The DPCS further stated that the oxygen order should not have been on the Medication Profile. A review of the hospice agencys policy titled, ";Medication Profile", revised in 2015, indicated that the registered nurse checks all medications a patient may be taking and documents on the medication profile. The policy indicated that the nurse will add all new/changed medication(s) to the medication profile. The medication action profile will be reviewed every home visit, updated as changes occur and reviewed by the Interdisciplinary group (IDG, a group of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families). On 9/30/23, at 11:00 a.m., during a joint home visit with Registered Nurse 2 (RN2), Patient 1 was observed lying in a bed and Family member 2 (FM2) was next to the Patient. During Patient 1's medication review with both RN 2 and FM 2, compared with the medication profile, following discrepancies were noticed. Tylenol Arthritis Pain extended release gel tab 650 milligrams 1 tablet three times a day. FM 2 stated that she changed to Advil 200 mg 1 tablet as needed for pain two weeks ago. Advil was not listed on the medication list. Aspercreme Topical cream 10% apply to affected area four times as needed for pain not available at home. FM 2 stated the patient ran out of supply. Robitussin Adult Cough plus chest congestion dextromethorphan Sugar free solution 20 milligrams give 10 milliliters by mouth every six hours as needed for cough and congestion. There was no bottle in the home. FM 2 stated the patient ran out of supply also. During an interview of the RN 2 at the same date and time, RN 2 stated that there should be continuous education to the patient caregiver every home visit when RN 2 during refill of the medication and when there are new medications. RN 2 further stated to call the doctor for an order or discontinuation of medication orders and update the medication profile every home visit. During an interview with the director of patient care services (DPCS) on 10/1/23 at 11:30 a.m., DPCS stated the skilled nurse (SN) should have physically checked the patients' medication comparing with the medication profile, and should have called and clarified with the physician, and provided education to the patient/caregiver. A review of the agency's policy titled " Medication profile " revised on April 2015, indicated hospice provides a mechanism for documentation of patient prescriptions, non-prescriptions (over the counter) medications and home remedies, including vitamins and herbs. The RN checks all medications a patient may be taking and documents on the medication profile. The nurse will add all new/changed medications to the medication profile. Discontinued medications will be documented and dated. The medication profile will be reviewed every home visit, updated as changes occurs and reviewed by the interdisciplinary group (IDG).

Based on observation, interview and record review, the hospice failed to ensure appropriate professionals assess, evaluate, educate caregiver, and make referrals to meet the hospice needs for one of 14 sampled patients (Patient 1). This deficient practice has the potential to result in not meeting the patient's hospice needs affecting their quality of care. --- Findings: A review of Patient 1's Patient Profile indicated, a start of care (SOC) date of 2/18/2023, with a diagnosis that included heart disease( heart condition that affects the major blood vessels and muscle of the heart) and left side paralysis (complete or partial loss of muscle function). During a review of Patient 1's Plan of Care Summary (POC), created 2/18/2023, included musculoskeletal (muscles, bones, joints, and tissues of the body) stiffness, weakness and left sided hemiplegia (loss of muscle function of one side of the body). The patient care goal included for the patient will have strength/energy for functional (useful) activities (action) as evidenced by patient participate to perform daily activities within the limit of her disease without feeling excessive fatigue or weakness. The goal for Pain included patient and family will verbalize confidence (belief) in management (control) of pain. The care plan intervention included to educate the family about increase in patient's weakness and fatigue due to expected decline, identify barriers to effective pain management and provide support and educational resources. Teach patient and caregiver on safe transfer techniques, range of motion (ROM) exercises and gentle massaging for relief measures. On 9/30/2023 at 11:00 a.m., during a joint home visit, concurrent observation and interview with Registered Nurse 2 (RN 2) and Family Member 2 (FM 2). FM2 stated Patient 1 complained of pain on her left arm. Patient 1 was observed with her left arm contracted(decrease in size). RN 2 attempted to stretch Patient 1's left arm to assess for pain, Patient 1 stated that it was difficult for her to move her left arm because of the pain. FM 2 also stated they would want physical therapy, but the agency and the nurse told them they do not provide physical therapy. FM 2 stated that her husband provided range of motion exercises for the patient. When asked if they were provided a physical therapy evaluation and teaching, FM 2 stated "No" During an interview with RN 2 on 9/30/2023 at 11:00a.m., RN 2 stated " the program does not provide physical therapy services only evaluation." During an interview with the director of nursing (DON) on 10/1/23 at 11:40 a.m., the DON stated they do offer physical therapy evaluation and home visits." DON stated we need to educate and remind our staff that our agency offers these services and can be offered to patients when needed. A review of the HA policy titled " Initial Assessment/Comprehensive Assessment" revised 2015, stipulated that each patient admitted will receive a comprehensive assessment. The comprehensive assessment will identify the patients need for hospice care and identify the patient's need for: physical care, psychosocial and emotional care, spiritual care, all areas of hospice care related to palliation and management of the terminal illness and related conditions.

Based on observation, interview, and record review, the Condition of Participation for Organization and Administration of Services was not met as follows: 1. The Hospice agency failed to provide care and services identified in the plan of care for one of 14 sampled patients (Patient 1) with left sided paralysis (the loss of muscle function in part of the body) and on pain management. (Refer to L652). 2. The Hospice agency failed to furnish services and care in a safe and effective manner by the qualified personnel to ensure the continuity in the provision of care and deliver these services in accordance with the patient's plan of care for one of 14 sampled residents (Patient 6). (Refer to L655). The cumulative effect of these deficient practices resulted in the failure of the hospice to deliver statutorily mandated compliance with the Federal regulations for Organization and Administration of Services to ensure highest quality of care are being provided to patients certified to receive hospice services. --- .

Based on observation, interview, and record review, the hospice agency (HA) failed to provide care and services identified in the plan of care for one of 14 sampled patients (Patient 1) with left sided paralysis and on pain management. This deficient practice has the potential to result in not meeting the identified needs of the hospice patient that could affect the patient's quality of care. --- Findings: A review of Patient 1's undated Patient Profile indicated, a start of care (SOC) date of 2/18/2023, with a diagnosis that included heart disease and left side paralysis (inability to move one side of the body). A review of Patient 1's Plan of Care Summary (POC), created 2/18/2023, Musculoskeletal care plan indicated Patient 1 had stiffness (tightness in the muscle), weakness, and left sided hemiplegia (paralysis of one side of the body). Goal section indicated Patient 1 will have strength /energy for functional activities as evidenced by patient to participate in performing daily activities within the limit of her disease without feeling excessive fatigue or weakness. The care plan indicated interventions to educate family about increase in patient's weakness and fatigue due to expected decline, teach patient/caregiver on safe transfer techniques, range of motion (ROM, exercises done to preserve flexibility and mobility of the joints to reduce and prevent stiffness) exercises, and gentle massaging for relief measures. A review of Patient 1's Plan of Care Summary (POC), created 2/18/2023, Pain care plan indicated Patient 1 had chronic pain at times. The care plan indicated interventions to instruct on non-pharmacological (any intervention intended to improve the health or the well-being of individual that do not involve the use of drugs or medicine) methods of pain and symptom relief of repositioning, muscle therapy, and/or calm quiet environment, identify barriers to effective pain management, and provide support and educational resources. Patient 1's care goal for Pain indicated patient/family will verbalize confidence in the management of pain. A review of Patient 1's Current Treatment/Medication/DME (DME, durable medical equipment) List, indicated Tylenol ER (ER, extended release, medication forms designed to make them last longer in the body) 650 milligram (mg, a unit if mass) three times a day for pain. During a joint home visit with Registered Nurse 2 (RN 2) on 9/30/2023 at 11 a.m., Family Member 2 (FM2) stated that Patient 1 complained of pain on her left arm. Observed Patient 1's left arm was contracted (stiffening of muscles due to disease or lack of use). During a concurrent interview with FM 2, FM 2 stated that Patient 1's pain was 4/10 (a pain numerical scale, in which zero means no pain, one to three means mild pain, four to seven means moderate pain) and she would give Advil (pain medication) medication instead of Tylenol ER which was ordered in the POC. Observed RN 2 attempted to stretch Patient 1's left arm to assess for pain, Patient 1 stated that it was difficult for her to move her left arm because of the pain. FM 2 stated they informed the hospice staff of the patient's need for physical therapy services; however the hospice nurse told them "No, they do not provide physical therapy". FM 2 further stated that her husband performed range of motion exercises for Patient 1. Further record review indicated no further instruction/education was provided to the patient's care givers to safely perform range of motion exercises. During an interview with RN 2 on 9/30/2023 at 11 a.m., the RN 2 stated, "The program does not provide physical therapy services, only evaluation." During an interview with the director of nursing (DON) on 10/1/2023 at 11:40 a.m., the DON stated they do offer physical therapy evaluation and home visits." DON stated we need to educate and remind our staff that the hospice agency offers these services and can be offered to patients when needed." A review of the HA policy titled " Initial Assessment/Comprehensive Assessment" revised 2015, indicated that each patient admitted will receive a comprehensive assessment. The comprehensive assessment will identify the patients need for hospice care and identify the patient's need for: physical care, psychosocial and emotional care, spiritual care, all areas of hospice care related to palliation and management of the terminal illness and related conditions.

Based on observation, interview, and record review, the hospice agency (HA) failed to furnish services and care in a safe and effective manner by the qualified personnel to ensure the continuity in the provision of care and deliver these services in accordance with the patient's plan of care for one of 14 sampled residents (Patient 6). This deficient practice had resulted in the delay of care and services at the time the patient and family needed assistance during an emergency crises when the patient suffered respiratory distress and eventually died. --- Findings: A review of Patient 6's "Personal Information" indicated Patient 6 was admitted for hospice care on 6/19/2023 with the diagnosis of malignant neoplasm of the pancreatic duct (also called "Pancreatic ductal adenocarcinoma" (PDAC) is a highly aggressive lethal malignancy due to the lack of early diagnosis and limited response to treatments). A review of Patient 6's "Certification of Death" dated 7/12/2023, indicated the immediate cause of death was respiratory distress (breathing becomes difficult and oxygen cannot get into the body). During a telephone interview with Patient 6's Family Member (FM 3) on 9/29/2023, at 2:45 p.m., FM 3 stated that he called the agency multiple times between the hours of 1:00 a.m. to 7 a.m. FM 3 stated he called the agency because Patient 6 was having gurgling sounds (sounds heard when the patient is is no longer able to swallow or cough effectively to clear their saliva) and respiratory distress. FM 3 stated he wanted to ask for a hospice nurse to come and assess Patient 6 to alleviate his symptoms and make him comfortable. FM 3 stated he did not receive any return calls from the hospice agency until 7:15 a.m. FM 3 stated Patient 6 had expired around that time and the hospice nurse finally arrived at 7:40 a.m. and pronounced Patient 1's death without checking the vital signs. A phone call was conducted on 9/30/2023 at 11:45 p.m. to test the agency's answering service and the caller did not receive a return call from the on-call nurse. A second phone call test was conducted again on 10/1/2023 at 5:45 a.m. The agency's on-call nurse returned the call at 7:15 a.m. During an interview with the Director of Nursing (DON) on 10/1/2023, at 11:40 a.m., DON stated she was the on-call nurse after office hours. The DON stated that she had the on-call phone and calls were forwarded from the on-call phone to her alternate phone if not answered. The DON stated she did not check that the phone was on silent mode the night Patient 6's family was calling. The DON stated, "She felt very bad this happened and that this was an isolated incident." The DON stated the agency contracted an answering service to receive all calls after office hours after the incident happened. The agreement or contract for the answering service was requested to be reviewed. The DON stated they don't have a contract or agreement with the answering service. DON stated the answering service were given Agency 1 to triage the agency's call. The DON stated the answering service will call the on-call staff if the client mentions any of the following: concern related to a patient condition, emergency, urgent, sever pain or pain issue, question on medication or medication issues, will talk to the patient immediately. DON stated she will receive the concerns via an email and a recording of the phone call will be received. A review the HA's policy titled "After Hours Accessibility" revised 2014, indicated at the time of initial assessment, each patient and family will receive a written information about the hours that care and services are available (normal business hours) and how to obtain care after hours. To provide care to patients 24 hours a day, seven days a week. The Registered Nurse (RN) on call is available at all times by telephone or pager. All calls are documented on an on-call form. The director and/or manager of Patient Services is on call 24 hours per day on a rotating weekly basis. Office hours are 9:00 a.m. to 5:00 p.m. Monday thru Friday. Telephone calls, after office hours, are answered by Hospice answering service. The on-call nurse is available and may be contacted by the answering service 24 hours a day seven days a week.