Every finding on record at Accentcare Fairview Hospice - West, LLC

Based on interview and document review, the facility failed to develop policy and procedure which included contact information for local emergency, regional, tribal, and state and federal emergency staff. This deficient practice had the potential to affect all 259 patients who currently received hospice services. --- A review of the facility's Emergency Management Plan, dated 4/7/23, was conducted with executive director (ED)-A present with regional business support manager (RBSM)-A and planer specialist of emergency management (PSEM)-A through video conference on 10/3/23 at 2:39 p.m. PSEM-A and ED-A confirmed the findings. The plan format had areas for input of the contact information, however this was not completed and the plan lacked documentation of contact information for federal, state, tribal, regional, and local emergency preparedness staff.

Based on interview and document review, the agency failed to ensure a comprehensive assessment by the interdisciplinary group (IDG) was completed no later than 5 calendar days after the election of hospice for 6 of 20 patients (P1, P2, P4, P7, P8, P11) reviewed in the sample. --- P1s Hospice Certification And Plan Of Care identified P1s start of care was 9/10/23, with a diagnose of malignant neoplasm of unspecified ovary (ovarian cancer). P1s interdisciplinary group (IDG) social work assessment and bereavement assessment was completed on 9/20/23, 9 days after the election of hospice. P7s Hospice Certification And Plan Of Care identified P7s start of care was 8/5/23, with a diagnosis of malignant neoplasm of pancreas (pancreatic cancer). P7s medical record lacked an IDG social work or bereavement assessment ever being completed. P11s Hospice Certification And Plan Of Care identified P11s start of care was 9/12/23, with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer). P11s IDG social work assessment was completed on 9/14/23, however P11s medical record lacked a bereavement assessment ever being completed. During interview on 10/4/23, at 9:08 a.m. executive director (ED)-A and quality specialist (QS)-A by video conference, indicated the registered nurse or social worker was responsible to complete the bereavement initial comprehensive assessment. QS-A reviewed medical records and confirmed P1s initial comprehensive social work and bereavement assessments were not completed within the five-day timeframe, which was the agencys expectation. QS-A stated the agency had a shortage of social workers, so they were unable to meet this expectation. QS-A confirmed P7 had not received an initial comprehensive social work or bereavement assessment. During a follow up interview at 10:43 a.m. ED-A reviewed P11s medical record and confirmed P11 had also not received a bereavement assessment. The agency policy titled Comprehensive Assessment dated 9/12/23, included that the comprehensive assessment identified the physical, psychosocial, emotional, and spiritual needs related to the terminal illness to promote the hospice patients well-being, comfort, and dignity throughout the dying process. The policy identified the hospice interdisciplinary group in consultation with the individuals attending physician, if any, would complete the comprehensive assessment no later than five calendar days after the election of hospice care. The policy identified during the comprehensive assessment, the following information and assessments would include an initial bereavement assessment. The policy identified the comprehensive assessment would include social worker assessment and the initial bereavement assessment within five days of admission completed at nursing admission and social work assessment. P4's Hospice Certification and Plan of Care dated 8/14/23, indicated P4's initial start of care was on 8/14/23, had the following diagnoses: dysarthria (a speech disorder due to weakened muscles) following cerebral infarction (stroke) and had orders for a social worker (SW) to evaluate social, emotional and financial factors related to the patient's illness, the need for additional care and resources, adjustment to care and to develop a plan of care. P4's registered nurse (RN) start of care note dated 8/14/23, indicated a moderate risk for bereavement and a referral was made for a social worker. P4's physician orders dated 8/22/23, indicated an order to add a SW visit. P4's Visit Note report dated 8/23/23, indicated P4 discharged from hospice services on 8/22/23, and P4's progress notes were reviewed, and lacked information a SW assessment was completed during this episode of care and within five days after election of hospice. P4's Hospice IDG Comprehensive Assessment and Plan of Care (POC) Update report dated 8/29/23, indicated P4's reenrolled into hospice on 8/23/23. Further, the report indicated P4 had orders on 8/23/23, for a social worker (SW) to evaluate social, emotional, and financial factors related to the patient's illness, need for additional resources, adjustment to care, and develop a plan of care. P4's Hospice IDG Comprehensive Assessment and Plan of Care Update report dated 9/12/23, indicated an order 9/11/23, for a SW that was rescheduled due to SW availability. Additionally, the report indicated the SW plan for the last two weeks indicated the SW evaluation was to be completed and financial needs, advance directives, ethical/legal issues, community resource identified and shared with the patient, funeral mortuary needs, plan for discharge indicated, "to assess". P4's hospice order dated 9/11/23, indicated the SW was rescheduled due to the SW availability. P4's hospice order dated 9/18/23, indicated the SW visit was moved due to no call back from P4 or the caregiver. P4's Client Coordination Note report dated 9/15/23, indicated the SW called patient's spouse and left a voicemail introducing themselves and explained the role of the hospice SW, requested a return call and indicated the SW evaluation would be rescheduled. P4's SW evaluation note dated 9/20/23, indicated the SW completed the visit on 9/20/23, more than 5 days after P4's start of care. During interview on 10/4/23 between 9:32 a.m. and 9:51 a.m., the quality specialist (QS)-A stated if a patient allowed, the SW would conduct the assessment visit within five days of the start of care, and if a patient declined, it would be documented in a missed visit note. QS-A added they had a shortage of social workers which was why they did not meet the expectation of completion of the comprehensive assessments within five days. QS-A further stated they would not stop admitting patients to hospice due to the shortage, but stated it was absolutely important for the SW to be involved. QS-A verified P4's SW assessment was not completed within five days of hospice enrollment. P2's Hospice Certification and Plan of Care (POC) identified a start of care (SOC) date 8/17/23. Diagnoses included degenerative disease of nervous system, osteoporosis and kidney disease. P2's interdisciplinary group (IDG) social work and bereavement assessment was completed on 8/23/23, 6 days after the election of hospice. P8's POC identified a SOC date 8/18/23, with a primary diagnosis of Alzheimer's disease. P8's IDG social work and bereavement assessment was completed on 9/21/23. A physician order was completed 9/11/23, to delay the social work and bereavement assessment, however, 24 days had elapsed after the election of hospice before the physician was notified of the delay in P8's assessments. When interviewed on 10/4/233 at 9:15 a.m. the quality specialist (QS)-A confirmed P2 and P8 had not received social work or bereavement assessments within the required 5 day time frame due to the agency had a recent shortage of social workers.

Based on interview and document review, the agency failed to comprehensively assess the bereavement needs of family for 3 of 24 patients (P24, P7, P11) reviewed for bereavement services. --- P24's Episode Summary report indicated P24 enrolled into hospice on 1/2/23, and expired on 9/3/23. P24's registered nurse (RN) hospice start of care (SOC) visit note dated 1/2/23, indicated a low risk for bereavement, however, did not identify a bereavement assessment had been completed. P24's chaplain visit note dated 1/3/23, indicated a low risk for bereavement, however, did not identify a bereavement assessment had been completed. P24's Client Coordination Note report dated 1/3/23, indicated a social work visit was declined and P24 requested a return call in two weeks. P24's Hospice IDG Comprehensive Assessment and Plan of Care Update report dated 9/12/23, indicated P24 expired on 9/3/23. The report identified bereavement needs were low risk and under the interdisciplinary group (IDG) team member, Scribe, under the heading details, indicated bereavement plan of care (include who is completing/has completed outreach assessment and identified needs): indicated social worker (SW)/CH (chaplain) to follow up. Under the IDG team member, SW, indicated bereavement services to follow. During interview on 10/2/23 at 3:52 p.m., family member (FM)-A stated the hospice agency had not contacted FM-A or any other FM since P24's death and FM-A stated being very close to P24. During interview on 10/4/23 at 8:33 a.m., the bereavement and integrated therapy manager (BITM) stated the bereavement assessment started on admission and the nurse or the SW would submit a bereavement risk assessment of 15 questions that would then categorize a person being at low, moderate, or high risk for bereavement needs. BITM stated the hospice would have a chaplain or social worker assess the family within seven days following death to see how they were doing, additionally at a bare minimum, bereavement calls were made after one, six, and 12 months post death and the bereavement phone calls were documented in the bereavement activity console. BITM reviewed P24's chart and verified no bereavement phone calls were made and stated this was one of the reasons the hospice was making changes and verified P24 never had a bereavement risk assessment completed and stated none of P24's contacts were ever identified or marked for bereavement needs in the electronic medical record (EMR) and added the bereavement risk assessment needed to be entered in the EMR in order to prompt the follow up phone calls after a patient expired. During interview on 10/4/23 at 9:07 a.m., the executive director (ED) stated the nurse was responsible to complete the bereavement risk assessment at the time of admission to hospice and expected it to be completed at the start of care. During interview on 10/4/23 at 9:14 a.m., the quality specialist (QS) verified the nurse completes the bereavement risk assessment at the time of admission by completing a form that identifies the risk and the SW or chaplain follow up. QS further stated staff should be asking the questions and verified staff did not follow the process and verified P24 did not receive bereavement services and had not been on the hospice's radar for bereavement services. A policy, Bereavement Services 2026 Protocol dated 9/13/23, indicated the initial bereavement risk assessment began at the time of the patient's hospice admission and the evaluation of the risk factors and level of risk was documented in either the nursing or social work assessments by local hospice staff. At the time of death, a bereavement risk assessment will be completed by any member of the site's local clinical team, agency staff, or volunteer deployed to support the chosen family at the bedside. A bereavement plan of care will be initiated for all identified primary bereaved clients. An initial outreach phone call/contact will be made within seven days following every patient death and the assigned local social worker or local psychosocial counselor will call the client and will complete the outreach assessment to determine the client's risk level, identify the client's need, offer bereavement services and indicate the follow up plan and transition to a bereavement center grief counselor, and the staff member will document all attempts interactions, contacts, in the bereavement record. P7s Hospice Certification and Plan of Care identified P7s start of care was 8/5/23, with a diagnosis of malignant neoplasm of pancreas (pancreatic cancer). P7's chaplain visit note dated 8/9/23, identified discipline-specific interventions and team communication related to bereavement risk as none. P7's medical record lacked a bereavement assessment. During interview on 10/4/23, at 9:08 a.m. executive director (ED)-A and quality specialist (QS)-A by video conference, confirmed the above findings that a bereavement assessment had not been completed for P7, which was the agency's expectation. P11s Hospice Certification and Plan of Care identified P11s start of care was 9/12/23, with a diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer). P11's social work visit note dated 9/14/23, identified discipline-specific interventions and team communication related to bereavement risk as anticipatory grief support provided throughout patient decline. P11s entire medical record was reviewed and lacked a bereavement assessment. During an interview on 10/4/23 at 10:43 a.m., ED-A reviewed P11s medical record and confirmed P11 had not received a bereavement assessment.

Based on interview and record review, the agency failed to ensure services were provided in accordance with the plan of care for 2 of 24 patients (P7, P17) reviewed for services planned. --- P7s Hospice Certification And Plan Of Care (POC) identified P7s start of care was 8/5/23, with a diagnosis of malignant neoplasm of pancreas (pancreatic cancer). P7's POC identified medical social work (MSW) visits one a week for one week effective 8/6/23. P7's Interdisciplinary Group (IDG) Comprehensive Assessment And Plan Of Care Update Report dated 8/15/23, social work meeting summary note identified this covering social worker (SW) did not meet the patient or family. P7's Interdisciplinary Group (IDG) Comprehensive Assessment And Plan Of Care Update Report dated 8/29/23, social work meeting summary note identified covering SW did not see patient. P7's Interdisciplinary Group (IDG) Comprehensive Assessment And Plan Of Care Update Report dated 9/12/23, social work meeting summary note identified no social work visit made in past two weeks, social work support remains available through patient decline. P7's Interdisciplinary Group (IDG) Comprehensive Assessment And Plan Of Care Update Report dated 8/15/23, social work meeting summary note identified social work support remains available through patient decline. P7s medical record lacked documentation a social work visit was completed. The agency policy titled Interdisciplinary Group Coordination Of Care dated 2/15/23, identified the type and scope of services provided by the IDG was based upon comprehensive and ongoing assessments to meet the needs of the patient and family/caregiver, were unique to each patient and family/caregiver unit and changed as needs of the patient and family/caregiver evolved throughout their involvement in hospice. The policy identified core hospice services (nursing, social work, and counselors) were available twenty-four hours a day, seven days a week. The policy further identified the agency would provide hospice care and services in accordance with accepted standards of care and the plan of care. P17's Hospice Certification and Plan of Care (POC) identified a start of care (SOC) date 7/6/23. Diagnoses included degenerative disease of nervous system, heart disease and diabetes. P17's POC identified medical social work (MSW) visits of one visit a month effective 7/10/23. P17's Visit Note reports identified a MSW visit on 7/10/23, however, no further MSW visits were documented. P17's medical record lacked documentation a MSW had been completed in August or September 2023. When interviewed on 10/4/23, at 9:15 a.m. the quality specialist (QS) stated the agency had been experiencing a shortage with social workers which was partly why they were not meeting the expectation for MSW visits and assessments. The agency would not delay admission of patients due to the lack of social workers employed as the registered nurses (RN) were assessing patient's physical and safety needs and the agency was making an effort to get the MSW visits done timely. QS stated it was important to have a social worker involved with patient care and they were doing an investigation on MSW missed visits and assessments. During interview on 10/4/23, at 12:15 p.m. the executive director (ED)-A stated she was unable to find any documentation of MSW visits had been completed for P17 for the months of August or September. ED stated, if P17 had orders for a MSW to visit monthly then there should have been visits made.

Based on interview and document review, the agency failed to ensure massage therapy was provided for 1 of 1 patient (P18) who was identified as needing massage therapy. --- P18's Patient Information report dated 10/4/23, indicated P18 had the following diagnosis: dysphagia (difficulty swallowing) following cerebral infarction (stroke), hemiplegia (weakness or paralysis on one side of the body), and osteoarthritis. P18's recertification plan of care (POC) update dated 9/7/23, indicated P18 required massage therapy to improve P18's comfort and P18's goal indicated P18 would have improved comfort through massage therapy services. P18 had no additional notes or POC updates that indicated massage therapy was initiated. During interview on 10/4/23 at 11:09 a.m., the executive director (ED)-A verified the POC dated 9/7/23, indicated P18 required massage therapy and added they no longer had massage therapy because the full-time employee no longer worked at the hospice agency. ED-A further stated if a service was listed on the plan of care, the service should be carried out and verified there were no orders to indicate massage therapy was discontinued. A policy, Interdisciplinary Group Coordination of Care, dated 2/15/23, indicated the type and scope of services provided by the interdisciplinary group (IDG) are based upon comprehensive and ongoing assessments to meet the needs of the patient and family/caregiver, are unique to each patient and family/caregiver unit and change as the needs of the patient and family/caregiver evolve throughout their involvement with hospice.

Based on interview and document review, the agency failed to ensure a registered nurse (RN) provided a supervisory visit of home health aide services at least every 14 days for 2 of 20 patients (P18, P16) whose records were reviewed. --- P16's Patient Information report dated 10/4/23, indicated P16 had the following diagnosis: heart failure, chronic kidney disease, lymphedema (swelling caused by lymph), and osteoarthritis. P16's Hospice POC (plan of care) report dated 10/4/23, indicated P16 required a HHA services. P16's nursing visit notes in the electronic medical record were reviewed and indicated a home health aide (HHA) supervisory visit was conducted on 6/21/23, and not again until 8/16/23. Additionally, P16's next HHA supervisory visit was conducted on 9/12/23. In addition, P16s Episode Summary Report indicated R16 had HHA visits during the time between supervisory visits on 7/11/23, 7/14/23, 7/17/23, 7/21/23, 7/24/23, 7/28/23, 7/31/23, 8/4/23, 8/7/23, 8/11/23, 8/14/23, 8/17/23, 8/21/23, 8/24/23, 8/28/23, 8/31/23, 9/5/23, 9/7/23, and 9/11/23. During interview on 10/4/23 at 11:02 a.m., the executive director (ED)-A stated home health aide supervisory visits should be conducted every 14 days per the protocol. P18's Patient Information report dated 10/4/23, indicated P18 had the following diagnosis: dysphagia (difficulty swallowing) following cerebral infarction (stroke), hemiplegia (weakness or paralysis on one side of the body), and osteoarthritis. P18's Hospice POC (plan of care) report dated 10/4/23, indicated P18 required a HHA services. P18's hospice order dated 9/7/23, indicated P18 received a home health aide twice a week. P18's Episode Visit Summary report indicated P18 received 15 HHA visits from 5/13/23 through 7/11/23, 15 HHA visits from 7/12/23 to 9/9/23, and five home health aide (HHA) visits from 9/10/23 to 10/5/23. P18's nursing visit notes in the electronic medical record were reviewed and indicated a home health aide (HHA) supervisory visit was conducted on 6/20/23, and not again until 7/10/23. Additionally, P18's next HHA supervisory visit was conducted on 7/26/23. The nursing visit notes indicated P18 had a HHA supervisory visit on 8/9/23, and not again until 8/30/23. During interview on 10/4/23 at 11:02 a.m., the executive director (ED)-A stated home health aide supervisory visits should be conducted every 14 days per the protocol. A policy, Aide Plan of Care: Coordination, Documentation and Supervision dated 9/2015, indicated hospice aide services were provided under the direction and supervision of a registered professional nurse. The RN makes a supervisory visit at least every 14 days to assess the quality of care and services provided.

Based on interview and document review, the agency failed to provide orientation for hospice services for 1 of 4 volunteers (V-A) reviewed who provided volunteer services with patients. --- Volunteer (V)-A was identified by the agency as an active volunteer with a start date 4/10/23. The agency did not have documentation of orientation to hospice services that included all the required components required. During telephone interview on 10/3/23, at 2:45 p.m. the acting volunteer coordinator (VC)-A stated he was supporting the agency remotely until the volunteer coordinator position could be filled. VC-A stated the volunteers did their initial training with an on-line training program which included 12 hours of video training. The training included introduction to hospice, emergency situations, code status and hygiene protocols among other things. Annual education was also done. When interviewed on 10/4/23, at 12:15 p.m. the executive director (ED)-A confirmed she was unable to locate any additional training completed for V-A. The volunteer coordinator had resigned her position in August and the agency was still trying to obtain access to all of her files. A policy for volunteer orientation and training was requested, however none were provided.

Based on interview and document review, the agency failed to ensure allegations of potential abuse were thoroughly investigated for 1 of 3 patients (P4) reviewed for grievances. Findings include: P4's plan of care (POC) for benefit period 7/14/22 through 10/11/22, indicated a start of care (SOC) date 7/14/22. Diagnoses included malignant neoplasm of pancreas, liver and bile duct, pulmonary embolism, diabetes, hypertension cerebral palsy, pressure ulcers and neuromuscular dysfunction of bladder. Home health aide (HHA) visits were ordered two visits a week for one week then one visit a week for twelve weeks. The HHA was to assist with personal care, hygiene and activities of daily living (ADLs). P4 was identified as orientated and goals included for a nursing POC to be established to meet P4's needs. The agency's Quality Improvement Summary identified the agencies complaints received 3/21/22 through 8/23/22. P4's family member (FM)-B reported to the agency on 7/29/22, HHA-B was rough during cares. Interventions listed on the complaint identified the agency had spoken with the staff involved and had reassigned the staff member to other patients. The grievance investigation did not include observations of HHA-B performing patient cares, interviews with other patients HHA-B was assigned or other staff to ensure abuse did not occur. P4's visits from 7/14/22 through 8/1/22, identfied HHA-B had assisted P4 with a bed bath, shampoo, skin care, perineal care and turning and repositioning on 7/22/22, 7/25/22 and 7/27/22. P4's interdisciplinary summary report dated 8/1/22, indicated P4 had passed away peacefully at her home. There was no documentation of a grievance received. P4's communication notes from 7/14/22 through 8/1/22, identified the record lacked any documentation regarding P4's grievance of rough treatment with cares. When interviewed on 8/24/22, at 8:45 a.m. the hospice director (HD) stated the team director followed up with HHA-B and found he had no history of accusations of rough treatment and stated he did not feel he had been rough when providing care to P4. The agency thought it was best just to reassign HHA-B to other patients. The report in the agency's Quality Improvement Summary documented the entire investigation, interventions and prevention of each complaint. The director stated P4's FM-B complaint investigation consisted entirely of speaking with HHA-B regarding the accusation and to reassign him to a different patient. During a conference call interview on 8/24/22, at 10:45 a.m. the vice president of operations (VP) stated quality incidents were reported to the supervisor. Follow up activities were managed outside of the electronic record and they tracked who was spoken to with in a word document and develop the corrective plan. One of things the agency planned to implement was to have an adverse event meeting to ensure investigations were more robust. The VP could not idenify if FM-B's concern was thoroughly investigated. The agency's Adverse Events revised 1/24/20, indicated the responsible supervisor must initiate an investigation within two working days of receipt of a complaint. If the adverse event was related to abuse or neglect of a vulnerable person, employees should also consult policy 222 Suspected Abuse, Neglect or Exploitation. All components of the investigation must be documented and retained for seven years. The agency's Suspected Abuse, Neglect or Exploitation policy revised 3/20/20, indicated all cases of suspected abuse, neglect, exploitation would be reported to the appropriate protection agency. The executive director or designee would immediately initiate an investigation of all alleged violations. If allegations of abuse or neglect involved employees or volunteers, the executive director or designee would remove the accused employee or volunteer from involvement with care to protect the patient. The decision to allow the employee to return to work would be made by the executive director, administrator, along with members of the national leadership team, once a thorough investigation was completed and the allegations were determined to be unfounded.

Based on observation, interview and document review, the facility failed to complete a comprehensive medication review during a nursing visit 1 of 1 patients (P2) observed on a home visit. Findings include: P2's Hospice Benefit Period Summary Report for certification date 8/4/22 to 11/1/22, indicated a start of care date 5/6/22. P2's diagnoses included malignant neoplasm of lung, hypertension and dementia. The report identified multiple medications including Haldol (an antipsychotic medication) 0.5 milligrams (mg) orally (po) every hour as needed (PRN) for agitation, Lisinopril (to treat blood pressure) 20 mg po two times per day, lorazepam (a psychotropic medication to treat anxiety) 0.5 mg po every hour PRN for anxiety, metoprolol (to treat blood pressure) 100 mg po two times per day, mirtazapine 15 mg po at bedtime, and morphine (narcotic to treat pain) 5 mg po every hour PRN for pain or shortness of breath. P2's plan of care (POC) with problem date 7/6/22, identified nursing interventions to assess the need for medication management and instruction, assess response to current medications, instruct regarding medication purpose, actions, potential side effects and when to report to hospice staff. Goals were patient or caregiver to verbalize understanding of why each medication was prescribed, understanding of the medication schedule, and to understand when to utilize PRN medications and to document each PRN usage. A home visit was conducted on 8/24/22, at 1:00 p.m. registered nurse (RN)-A obtained P2's blood pressure, oxygen saturation, heart, lung and bowel sounds. P2 denied any discomfort or concerns and reported no problems with voiding or bowel movements. The hospice skilled nurse visit concluded with no further assessment. - After exiting P2's room, RN-A asked an unidentified nursing assistant if P2 was incontinent of bladder or if there were any concerns or problems she was aware of. The nursing assistant indicated she was not aware of any issues and stated P2's nurse was currently busy on another wing. RN-A completed a Hospice Communication Note which identified a hospice skilled nursing visit was completed for disease management and vital signs. The written comment included P2 was forgetful but pleasant, had no symptoms of pain or respiratory distress and there were no changes to her plan of care. RN-A included her phone number and noted she wanted to be called to obtain P2's last current weight. RN-A pushed the form under P2's nurses door of her locked office and exited the building. During interview on 5/24/22, at 1:30 p.m. RN-A indicated her visit was completed and she only asked the assistant living nurse to call her as she would like to obtain P2's current weight. She confirmed the assisted living did have a comfort kit (a packet of medications commonly used for terminal patient symptom control, that include psychotropic and narcotic medications) that hospice issued P2 at her SOC. RN-A did not check on the medications, and would just verify none of the medications had expired, as the assisted living staff tracked the medications. Further, RN-A did not review P2's medication or ask the assisted living staff about P2's medication use. She did not know if P2 had required any of her as needed medications for pain or anxiety since the last hospice visit. Asking about the use of PRN medications would be important to see if the patient had experienced any symptoms other than during the time of hospice visits. RN-A stated she should have reviewed P2's medications and PRN medication use. During interview on 6/24/22, at 8:45 a.m., the hospice director stated she would expect medications to be reviewed during each hospice skilled nursing visit. A policy on medication review was requested, however none were provided.

Based on interview and record review, the agency failed to comprehensively reassess and communicate a patients significant change in condition for an increase in services for 1 of 3 patient's (P1) reviewed for patient assessments. Findings include: P1's Hospice Plan of Care (POC) for episode 7/13/22 through 10/10/22, indicated a start of care (SOC) 7/13/22. Diagnoses included Parkinson's disease, dementia with lewy bodies, hallucinations, repeated falls, dysphagia and malignant neoplasm of lung. Hospice nursing visits were ordered two visits per week for eleven weeks, three visits a week for one week, two visits a week for one week and three visits as needed (PRN) for symptom management or crisis management. - The hospice nurse was to assess and evaluate the patient and caregiver which included the following: assess and evaluate for signs and symptoms of anxiety or terminal agitation and provide instruction regarding origin and management, assess medication response and instruct, evaluate patient and develop the POC with the physician, instruct on pain management, perform wound care to the right sacrum and change the dressing as ordered every three days and PRN and instruct on urinary incontinence. - Social Worker visits were ordered one visit a week for one week, one visit every three weeks for three weeks then one visit every four weeks for eight weeks plus two PRN for coping, or crisis management. The social worker was to assess and evaluate the patient and caregiver which included the following: evaluate social, emotional and financial factors; need for additional care or resources, and adjustment to care; assess for emotional and spiritual preparation for imminent death and provide emotional support and counseling. Goals were identified in the POC including establishing a POC that would meet the patient needs, manage medications and pain appropriately, and minimize patients anxiety and agitation. P1's Hospice Recertification Summary Report (HRS) with interdisciplinary Group (IDG) meeting, dated 7/19/22, identified problems of anxiety and terminal agitation, need for medication management and instruction, need for skilled teaching regarding pain, altered comfort, community resources and urinary incontinence and the need for wound care. P1's IDG note dated 7/19/22, indicated P1 had an indicator of red acuity (an internal agency measure of intensity of nursing care required by a patient). Orders and changes were made in relation to the patient's pain and anxiety. P1 had recent increases in medications for ongoing symptom management issues. Registered nurse (RN)-A's notation identified P1 appeared to be in early phases of transitioning to the active dying phase. The skilled nurse plan including progress toward goals, visits planned for the upcoming two week period, including visit frequency and evidence of declining status, these area's were not completed and was blank. P1's care coordination notes identified the following: - 7/13/22, the hospice triage team received a call from family member (FM)-A with concerns P1 was agitated and combative. FM-A was instructed on medications to administer to P1 for symptom control. - 7/14/22, a hospice nurse visit was performed. P1 displayed symptoms of agitation and combativeness. Medications were scheduled every six hours and FM-A was instructed on medication administration. It was noted to assess need to increase dosage or frequency of medications at the next nurse visit and assess signs and symptoms of anxiety and comfort level. - 7/17/22, a hospice nurse visit was performed at the request of FM-A due to P1 was having increase agitation. An assessment and cares were performed and PRN and scheduled medications were increased. FM-A was instructed on the increase in medication dosages and frequency's and questions were answered. - 7/21/22, RN-A phoned FM-A and was updated on P1's general condition. RN-A indicated she planned a nurse visit in two days. - 7/22/22, a home health aide (HHA) visit was made. Prior to starting cares, P1 was observed to have expired. When interviewed on 8/22/22, at 3:40 p.m. FM-A stated she received a document when P1 was admitted to hospice that indicated a nurse visit would be made two to three times per week and more if needed. The agency left her with a booklet with the contact information on the front. FM-A stated she had no help about the dying process and was talking to friends and neighbors for advice along. Also there was no nurse visits without requesting one. The chaplain called her on 7/20/22, and she asked if P1 had used up all her nursing visits, as P1 was having trouble swallowing and no nurse had been out to visit. The chaplain told her someone would reach out to her. Further, the only reason a nurse came out on 7/17/22, was a result of FM-A calling triage on Saturday 7/16/22, and the triage team scheduled an as needed visit. The nurse who visited on 7/17/22, very clearly explained the medications and changes in dose and frequency. FM-A was not aware if the agency had ever assigned a nurse to P1 and no one was providing a scheudle of nursing visits. - When FM-A called the agency with her concerns after P1 passed, she was told P1 had a significant change in status on 7/17/22, and someone should have been out to see her every day. Nobody called or visited to follow up on the 7/17/22, nurse visit and changes with medications. FM-A stated she received no nursing calls or visits after 7/17/22. RN-A called FM-A on the 7/21/22, as the nurse had heard FM-A called and complained about being ingnored. RN-A may have asked about P1, but she never offered to come out and just indicated she would ensure medications would be delivered to P1 that evening. - When FM-A called the agency after P1 died, she was told to call the funeral home herself. Then she called the funeral home as instructed and was told she had to have the hospice agency call them. The the social called her and got it straightened out. FM-A thought that had all been taken care of on admissio and was never given additional information through out the course of her care. During interview on 8/23/22, at 3:14 p.m. HHA-A stated she cared for P1 on two occasions. She was able to assist with P1's bath and felt P1 was comfortable at the time. The aides were not instructed to do P1's dressing changes, as the nurses were to complete the dressing change. FM-A was there during the visits and was very active in P1's cares. HHA-A did not recall FM-A having a lot of questions during her visit. When a patient was nearing the end of life the agency tended to amp up the patient's visits to daily, unless family requests it was not needed. She did not know why P1 did not get increase nurse visits. During a telephone interview on 8/24/22, at 4:00 p.m. RN-A stated when a patient started to transition to the active dying process, the nurse would have a discussion with family regarding transitioning and ask about increase visits. At the time of a patient's death, the hospice agency would verify what funeral home the patient chose and contact the funeral home and notify the medical examiner of the death. She was P1's case manager but only seen her one time as she had time off. She assigned multiple visits for P1 to other nurses because she knew P1 needed to be seen. RN-A knew FM-A had lots of questions and concerns and would need frequent visits. When RN-A performed a nurse visit on 7/14/22, she could tell, based on interactions with the family, that they would need more support. She sent a request to the manager and scheduler to schedule an increase in hospice nurse visits for P1. She was not sure why the nurse visits were note completed as directed. When interviewed on 8/23/22, at 4:45 p.m. RN-B stated she was an as needed nurse, and picked up nurse visits on the weekends. She made a visit to P1 on 7/17/22, after family requested a visit and it was scheduled by the triage team. When RN-B arrived, P1 was unresponsive and lying in bed. RN-B assisted FM-A with hands on care. RN-B instructed FM-A on potential symptoms and medications to try for symptom control. FM-A was very, very anxious, so she discussed end of life care. A call was made to the physician and medications dose and frequency changes were made. - RN-B asked FM-A when she was expecting the nurse and FM-A indicated she expected a nurse visit the next day. RN-B concerned about who would follow up when she made changes or started a medication or treatment on her PRN visits to patients. RN-B would complete a communication note and the then the scheudled nurse would follow up on the note made. RN-B never received any feed back from anyone at the agency following her visits. RN-B was under the impression there was a scheduled visit for 7/18/22, as reported by FM-A. When interviewed on 8/24/22, at 8:45 a.m.. the hospice director stated the agency had received email requests from RN-A to increase P1's nursing visits. She was not sure why the visits were not scheduled. The agency had a color system in each patient's chart. Green was for routine care, yellow was for increase symptoms and possibly a need for increase visits and red was for end of life patents that had more acute needs and need for increase nursing visits. The agency had a call process that consisted of a triage team that answered calls and another team that made the visits. All the call staff were employees of the agency and were registered nurses. The nurse taking the call would give instruction and if needed would deploy one of the team members to make a visit. An on call report was run every morning, Monday through Friday, which identified everything that occurred during call. Each nurse was to review the call log prior to the agency morning huddle, where they discussed cases. Each nurse was to plot patient visits on a calendar in the patient's chart. There is a calendar in the admission packet and the primary nurse would record all the upcoming planned visits on the calendar on the visit that is made after admission. - The director identified it would be important for patients and families to know what to expect and when visits were going to occur. The calendar for visits in P1's chart was blank. The director indicated visits may not be show up on P1's calendar, as it was now a discharged chart. P1 did have orders for nurse visits every three days to perform wound dressing changes. The director indicated the agency was well aware P1 should have had nurse visits scheduled every three days for the dressing changes and felt it the fact the visits had not been scheduled for the dressing changes was part of the problem. There was a breakdown in communication when RN-A the case manager was off the schedule. Further, the agency was in the process of making changes to daily procedures to ensure the same issue did not occur with other patients. The agency's policy Patient and Family Reassessment revised 2/21/20, identified patients and families would be reassessed regularly to determine their response to care and treatment and to determine if significant changes in their condition warranted a change in the plan of care. If there were observed or communicated significant changes in the patients' condition or needs, such findings would be communicated to the caregiver, the attending physician and the interdisciplinary group. The comprehensive assessment would be updated by the hospice IDG in collaboration with the individual's physician with changes that have taken place since the initial assessment, to include information on the patient's progress toward desired outcomes, as well as a reassessment of the patient's response to care and as frequently as the condition of the patient required, including at the time of the change in level of care, when changes in the patient's physical, social, emotional or spiritual status changed and at the time of recertification.