Every finding on record at All Valley Hospice, Inc.

Based on interview and record review, the facility failed to provide emergency preparedness training to three of eight sampled employees (Certified Hospice Aide 1 [CHA 1], Medical Social Worker 1 [MSW 1], and Medical Social Worker [MSW 2]) upon hire. This failure resulted in the lack of training for staff on how to respond effectively during an emergency crisis that could negatively affect patient safety. --- During an interview on 6/11/2025 at 10:10 am, with the Director of Patient Care Services (DPCS), the DPCS stated she did not provide emergency preparedness education for CHA 1, MSW 1, and MSW 2 during onboarding orientation. The DPCS stated it was important to educate all employees to facility’s emergency plan so they would know how to protect themselves, patients, and patient families in the event of an emergency. During a review of employee personnel files for CHA 1, MSW 1, and MSW 2, the personnel files did not indicate employees were oriented to the facility’s emergency preparedness plan at the start of their employment. During a record review of the facility’s P&P titled, “Training,” revised 1/3/2025, the P&P indicated, “All new staff will be trained on the Emergency Operation Plan (EOP) in orientation.”

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure pain medication was available for med techs (a caregiver who assists residents with their medications under the supervision of a licensed nurse) to administer to one of five sampled patients (Patient 4) when Patient 4’s acetaminophen (Tylenol, pain medication) and tramadol (pain medication) were not delivered by the hospice pharmacy and when Patient 4’s morphine (an opioid medication that helps relieve pain) was not prepared in a pre-filled syringe. This failure resulted in unmanaged pain and discomfort for Patient 4, which increased the risk of developing agitation that could lead to emergency hospitalization and, subsequently, an avoidable traumatic and undignified death. --- During a review of Patient 4's Face sheet, the Face sheet indicated Patient 4’s SOC date was 11/19/2024 with the primary diagnosis of senile degeneration of the brain (a progressive decline in brain function). During a review of Patient 4’s “Physician Order Details,” dated 11/19/2024, the Physician Order Details indicated Patient 4 had orders Tylenol 500 mg one tablet four times a day as needed for knee pain, and tramadol 50 mg one tablet four times a day as needed for moderate pain. During a concurrent observation and interview on 6/6/2025 at 11:30 am., with Patient 4 in patient's room, Patient 4 was grimacing (facial expression of disgust, or pain) while standing up from sitting on her bed. Patient 4 stated she was having pain that radiated from her abdomen to her right upper leg. During an interview on 6/6/2025 at 11:48 am., with Registered Nurse 2 (RN 2) and Med Tech Supervisor (MT Supervisor), MT Supervisor stated a tramadol 50 mg refill was needed for Patient 4’s pain and was not available. RN 2 stated she would inform the agency of the refill request. During a concurrent observation and interview on 6/6/2025 at 11:54 am., with Med Tech 1 (MT 1) in the medication room, MT 1 had an unopened blister packet of Tylenol 325 mg tablets with a prescription label for Patient 4. MT 1 stated the agency’s pharmacy delivered the Tylenol 325 mg tablets but Patient 4’s order was for Tylenol 500 mg tablets. MT 1 stated there was no Tylenol 500 mg. available to administer to Patient 4. During a concurrent observation and interview on 6/6/2025 at 11:55 am., with MT 1 in the medication room, MT 1 had a bottle of tramadol 50 mg tablets prescribed for Patient 4 with an expiration date of May 2025. MT 1 stated she has called the HA for a refill, but it has not been dispensed yet. MT 1 stated she had no available tramadol 50 mg to administer to Patient 4. During a concurrent observation and interview on 6/6/2025 at 11:57 am with RN 2 and MT 1 in the medication room, MT 1 had a liquid morphine bottle prescribed for Patient 4. MT 1 stated med techs in Patient 4’s assisted living facility were not allowed to administer liquid medications if they were not in prefilled syringes. MT 1 stated that because Patient 4’s liquid morphine was not in prefilled syringes, med techs would not be able to administer it to Patient 4 if Patient 4 needed them. RN 2 stated she was not aware med techs were not allowed to administer liquid medications. During an interview on 6/6/2025 at 12:09 pm with RN 2 and MT 1, RN 2 stated she had never done Patient 4’s medication reconciliation. RN 2 stated she only got Patient 4’s medication list from the MT Supervisor and did not check Patient 4’s available medication containers. RN 2 stated it was her responsibility to do Patient 4’s medication reconciliations. MT 1 stated she has never met RN 2 or seen her in the medication room. During an interview on 6/7/2025 at 1:32 pm with the DPCS, the DPCS stated she was aware that med techs were not allowed to administer liquid medications if not in pre-filled syringes. The DPCS stated RN 2 should have prepared Patient 4’s liquid medication into syringes for the med techs to administer to Patient 4 if needed. During an interview on 6/7/2025 at 1:35 pm., with the DPCS, the DPCS stated RNs are expected to medication reconciliation during every visit to the patients. The DPCS stated the RN should compare the patient’s medication container with the medication list. The DPCS stated if medications were missing or needed to be refilled, the RN should call the HA to order the medication. The DPCS stated she does not know if the RNs are complying with the medication reconciliation process because she has not followed up with them. The DPCS stated RNs should be teaching caregivers about physician-ordered medications with each visit.  During a review of the agency’s policy and procedure (P&P) titled, “Identification of Medication for Administration,” revised April 2021, the P&P indicated, “The nurse will review the written physician’s orders prior to medication administration…The nurse will review the medication label for name, additional patient identifier, drug, dosage, and prescription… All medications will be checked for stability by visualizing the medication and observing for the…expiration date.” During a review of the agency’s policy and procedure (P&P) titled, “Interdisciplinary Group Plan of Care,” revised April 2021, the P&P indicated, “Core hospice services (nursing, social work, physician, and counselors) will be available 24 hours a day, seven (7) days a week, as will drugs, biologicals, and medical supplies.”During a record review of the facility’s policy and procedure (P&P) titled, “Safe/Effective Use of Medications,” revised April 2021, the P&P indicated, “As part of the comprehensive assessment, the patient and family/caregiver will be assessed as to their knowledge and skill required for safe and effective use of medications.”

Based on interview and record review, the facility failed to ensure the medical social worker (MSW) completed the comprehensive assessment within 5 calendar days after election of hospice care for one of five sampled patients (Patient 4). This failure had the potential to result in the lack of emotional and social support for Patient 4 and family members. --- During a phone interview on 6/5/2025 at 4:04 pm., with MSW 3 stated the initial MSW comprehensive assessments must be completed within five days of election into hospice care for every admitted patient. MSW 3 stated patients should be seen within the first five days to provide the patient and their family crucial emotional and social resources and counseling. MSW 3 stated if a patient is not seen within the specified timeframe, the reason for the delay must be documented in the patient’s chart. During a review of Patient 4's Face sheet, the Face sheet indicated Patient 4’s SOC date was 11/19/2024 with the primary diagnosis of senile degeneration of the brain (a progressive decline in brain function). During a review of Patient 4’s “Comprehensive Assessment – Psychological,” dated 12/20/2024, the Psychological Comprehensive Assessment did not indicate a reason for the delay in visitation or assessment by the MSW. During a record review of the facility’s policy and procedure (P&P) titled, “Comprehensive Assessment,” revised April 2021, the P&P indicated, “A comprehensive assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with the attending physician.”

Based on interview and record review, the facility failed to update the comprehensive assessment of the frequency of Spiritual Counselor (SC) visits for two of five sampled patients (Patient 2 and Patient 5). This failure resulted in the SC visiting once every recertification instead of once every month according to physician orders for Patient 2 and Patient 5. --- During a review of Patient 2’s Face sheet, the Face sheet indicated Patient 2’s start of care (SOC) date was 5/2/2024 for the primary diagnosis of cerebral atherosclerosis (a condition where plaque builds up in the blood vessels of the brain). During a review of Patient 2’s “Physician Order Details,” dated 5/2/2024, the Physician Order Details indicated, “Spiritual Care Counselor visit frequency: 1x a month and as needed for spiritual needs and support.” During a review of Patient 5’s Face sheet, the Face sheet indicated Patient 5’s SOC date was 3/28/2025 for the primary diagnosis of senile degeneration of the brain (a progressive decline in brain function). During a review of Patient 5’s “Physician Order Details,” dated 3/25/2025, the Physician Order Details indicated, “Spiritual Care Counselor visit frequency: 1x a month and as needed for spiritual needs and support.” During a phone interview on 6/6/2025 at 2:38 pm., with the SC stated, spiritual counseling for hospice patients was important because it provides spiritual and emotional support for both the patient and their families. The SC stated he visits patients once every recertification period and that he was “not sure where it states I have to visit every month.” During an interview on 6/11/2025 at 10:11 am., with the Administrator (ADM)/Director of Patient Care Services (DPCS), the ADM/DPCS stated the SC must follow the frequency of visits noted in the physician orders. The ADM/DPCS stated if patients or family members declined SC services, it would be the SC’s responsibility to document and communicate such during Interdisciplinary Group (IDG, the team responsible for the holistic care of the hospice beneficiary) meetings so the physician would be able to change the frequency of visits order. During a review of Patient 2’s “Visit Notes,” from the month of 1/2025 to 5/28/2025, the record indicated the SC visited Patient 2 on 2/27/2025 and 4/21/2025. During a review of Patient 2’s “IDT Plan of Care,” from the month of 1/2025 to 5/28/2025, the record did not indicate any changes to the frequency of visits for the SC discussed during the IDG meeting.   During a review of Patient 5’s “Visit Notes,” from the month of 3/2025 to 5/28/2025, the record indicated the SC visited Patient 5 on 3/31/2025. During a review of Patient 5’s “IDT Plan of Care,” from the month of 4/2025 to 5/28/2025, the record did not indicate any changes to the frequency of visits for the SC discussed during the IDG meeting.   During a record review of the facility’s policy and procedure (P&P) titled, “Comprehensive Assessment,” revised April 2021, the P&P indicated, “The comprehensive assessment is updated by the interdisciplinary group as frequently as the patient’s condition requires but at a minimum every 15 days… The interdisciplinary group is required to only update those sections that require updating.”

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the condition of participation (CoP-a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Organizational Environment were met as follows: --- 1.      1. The facility failed to provide documented evidence that the Medical Social Worker (MSW) and Spiritual Counseling (SC) collaborates with the facility's Interdisciplinary Group (IDG, the team responsible for the holistic care of the hospice beneficiary) meeting for five of five sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5).2.     2.  The facility failed to ensure the MSW developed a written individualized plan of care (POC, a written document that outlines the specific needs and services provided to a hospice patient and their family/caregiver) that addressed the patients and the family's psychological and spiritual needs for five of five sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5).These failures had the potential to result in hospice patients and their family experiencing difficulty in coping with the illness and dying with dignity; to suffer from reduced quality of life, increased distress, and can lead to emergency hospitalization that may contribute to an avoidable traumatic death. (Refer to L543)The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (relating to rules or laws which have been formally written down) mandated compliance with the Federal regulations for Interdisciplinary Group (IDG), Care Planning (CP) , and Coordination Service to ensure provision of the highest quality of care for Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5 who were assessed to receive hospice care services.

Based on observation, interview, and record review, the hospice agency’s (HA, agency providing care to terminally ill patients who have six months or less to live) facility failed to provide documented evidence that the Medical Social Worker (MSW) and Spiritual Counselling (SC) collaborates with the facility’s Interdisciplinary Group (IDG, the team responsible for the holistic care of the hospice beneficiary) meeting and the MSW developed individualized written plan of care (POC, a written document that outlines the specific needs and services provided to a hospice patient and their family/caregiver)  that addressed the patients and the family’s psychosocial and spiritual needs for five of five sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5).This failure had the potential to result for hospice patients and their family to experience difficulty in coping with the illness and dying with dignity, to suffer from reduced quality of life, increased distress, and can lead to emergency hospitalization that may contribute to an avoidable traumatic death. On 6/9/2025 at 12:56 pm, the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Administrator (ADM)/Director of Patient Care Services (DPCS) for failing to ensure that the MSW and the SC collaborates with the facility’s IDG meeting and MSW to develop individualized plan of care that addressed the patients and the family’s psychosocial and spiritual needs.On 6/11/2025 at 11:48 am, the HA submitted an IJ removal plan (IJRP-includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely), but was not accepted. On 6/11/2024 at 2:49 pm, the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the ADM/DPCS with the IJ situations not removed. --- During a review of Patient 1’s “Patient Face Sheet,” the record indicated Patient 1’s Start of Care (SOC) was 9/19/2023, with primary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a condition where the heart cannot pump enough blood to meet the body’s needs). During a review of Patient 1’s “Comprehensive Assessment – Psychosocial,” dated 9/22/2023, the initial Medical Social Worker (MSW) assessment indicated Patient 1 and family requires psychosocial support and community resources.  The assessment did not include an individualized POC was developed to address Patient 1 and the family’s psychosocial needs.   During a review of Patient 1’s record from SOC to current recertification period (a period when a doctor re-evaluates patient receiving hospice care to see if they continue to meet the requirements for it) #10 (5/11/2025 - 7/09/2025), the record has no documented evidence that an individualized POC was developed by the MSW, addressing the patient and the family’s psychosocial and emotional needs. During a review of the “IDT Plan of Care,” from the month of 1/2025 to 5/28/2025, the record did not indicate documented evidence that the MSW and Spiritual Counselor (SC) participated and collaborated in the IDG meeting.  During a review of Patient 2’s “Patient Face Sheet,” the record indicated Patient 2 SOC was 5/2/2024 with primary diagnosis of chronic obstructive respiratory disease (a lung and airway diseases that restrict your breathing) and essential hypertension (refers to high blood pressure where no specific underlying cause is identified). During a review of Patient 2’s “Comprehensive Assessment – Psychosocial,” dated 5/6/2024, the record indicated Patient 2 and the family required emotional counseling. The assessment did not indicate an individualized POC was developed to address Patient 2 and the family’s psychosocial needs.  During a review of Patient 2’s record from SOC to current recertification period #6 (4/27/2025-6/25/2025), the record did not indicate documented evidence that an individualized POC was developed by the MSW to address Patient 2 and family’s psychosocial and emotional needs. During a review of the “IDT Plan of Care,” from the month of 1/2025 to 5/28/2025, the record did not indicate documented evidence that the MSW and SC participated and collaborated in the IDG meeting.  During a review of Patient 3’s “Patient Face Sheet,” the record indicated Patient 3 SOC was 3/29/2025 with primary diagnosis of Alzheimer’s Disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline) with late onset.   During a review of Patient 3’s “Comprehensive Assessment – Psychosocial" dated 4/3/2025, the initial MSW assessment under “Social/Emotional Functioning” did not indicate MSW’s assessment of the emotional status of the Patient 3.  The record did not include an individualized POC was developed to address Patient 3 and family’s psychosocial needs.  During a review of the “IDT Plan of Care,” from the month of 4/2025 to 5/28/2025, the record did not indicate documented evidence that the MSW and SC participated and collaborated in the IDG meeting.   During a review of Patient 4’s “Patient Face Sheet,” the record indicated Patient 4 SOC was 11/19/2024 with primary diagnosis of senile degeneration of the brain (a decline in mental abilities, particularly memory, thinking, and reasoning, often associated with old age). During a review of Patient 4’s initial “Comprehensive Assessment – Psychosocial,” dated 12/20/2024, the record did not indicate an individualized POC was developed to address Patient 4 and Patient 4’s family’s psychosocial needs.  During a review of Patient 4’s record from SOC to current recertification period #8 (5/18/2025-7/16/2025), the record did not indicate documented evidence that an individualized POC was developed by the MSW to address the patient and the family’s psychosocial and emotional needs. During a review of the “IDT Plan of Care,” from the month of 1/2025 to 5/28/2025, the record did not indicate documented evidence that the MSW and SC participated and collaborated in the IDG meeting. During a review of Patient 5’s “Patient Face Sheet,” the record indicated Patient 5, SOC was 3/28/2025 with primary diagnosis of senile degeneration of the brain (a decline in mental abilities, particularly memory, thinking, and reasoning, often associated with old age). During a review of Patient 5’s initial “Social Worker Assessment/Care Plan,” dated 4/1/2025, the record indicated Patient 5, Patient 5’s Caregiver, and Patient 5’s family required psychosocial support and community resources.  The record did not indicate an  individualized POC was developed to address Patient 5 and Patient 5’s family’s psychosocial needs.   During a review of the “IDT Plan of Care,” from the month of 4/2025 to 5/28/2025, the record did not indicate documented evidence that the MSW and SC participated and collaborated in the IDG meeting. During an interview on 6/8/2025 at 12:01 pm with the ADM/DPCS, the ADM/DPCS stated the IDG only discusses current patient issues during IDG meetings. The ADM/DPCS stated because the MSW and SC are often driving during IDG meetings, the ADM/DPCS reads the MSW and SC written assessments for each patient instead of discussing with them verbally. The ADM/DPCS stated if there are no documented issues written by the MSW and SC, she will document “No visit made” under their sections in the IDG POC. The ADM/DPCS stated she cannot validate if there are issues from a MSW or SC standpoint by reading their assessments because that is not her specialty. The ADM/DPCS stated she was not aware the MSW or SC were not signing in during the IDG meeting to confirm their participation. The ADM/DPCS stated it was her responsibility to ensure each member of the IDG sign-in with each of the IDG POC meetings.  During an interview on 6/9/2025 at 9:31 am with MSW 1, MSW 1 stated the focus of the MSW assessment is providing emotional support to the patient and their family, ensuring patient safety by providing the proper equipment at their homes, and focused on appropriate community resources.  After assessing and identifying the emotional and psychosocial needs of the patients and family, MSW 1 stated she develops the care plan, because care plan is important for MSWs to help support and guide the patients and family.   MSW 1 stated she was not able to see care plans were developed for Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5 addressing the psychosocial and emotional needs of the patients. During a review of the hospice agency’s policy and procedure (P&P) titled, “Psychosocial Services” revised April 2021, the P&P indicated:3.  Psychosocial assessments and interventions will be documented in the patient’s clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care.  Documentation will include:A.            Goals of careB.             Observations of the psychosocial needs or problems of the patient and family/caregiver, including counseling needs, assistance with planning for wills, funeral arrangements, financial planning, etc.C.             Interventions provided to address the psychological needs or problems of the patient and family/caregiver and the patient’s response and progress towards goalsD.            Plans and/or referrals made to address the psychosocial needs or problems of the patient and family/caregiver in accordance with the plan of careDuring a review of the hospice agency’s policy and procedure (P&P) titled, “Interdisciplinary Group Plan of Care” revised April 2021, the P&P indicated:8.  The interdisciplinary group (in collaboration with the attending physician, if any) will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every15 calendar days.  The attending physician will receive a copy of the care plan updates.9.  All interdisciplinary group members, including those providing contracted services, will have access to the plan of care to ensure coordination and continuity.10.  Contract personnel will participate in preparation of the plan of care; submit documentation of services provided, including clinical notes, schedule of visits, and patient evaluations at least twice a week; and participate in interdisciplinary group meetings.  Care provided by contracted services will be monitored by the interdisciplinary group to ensure compliance with the plan of care.

Based on observation, interview, and record review the hospice failed to ensure caregivers for two of five sampled patients (Patient 2 and Patient 3) were able to safely self-administer medications when Patient 2’s Caregiver and Patient 3’s Caregiver were not educated on how to safely administer comfort pack medications (morphine [an opioid medication that helps relieve pain], lorazepam [Ativan, used to treat anxiety], atropine sulfate [used under the tongue to reduce salivation], bisacodyl [used to treat constipation], ondansetron [used to prevent nausea and vomiting], acetaminophen [Tylenol, used to relieve pain], and ipratropium bromide/albuterol [DuoNeb, a combination of inhalation medications used to treat and prevent shortness of breath]), as ordered by the physician. These failures had the potential to result in medication errors for Patient 2 and Patient 3. These failures also increased the risk of adverse drug reactions and poor symptom management such as unmanaged pain, distress, or agitation that could lead to emergency hospitalization and contribute to an avoidable undignified death. --- During a review of Patient 2’s Face sheet, the Face sheet indicated Patient 2’s start of care (SOC) date was 5/2/2024 for the primary diagnosis of cerebral atherosclerosis (a condition where plaque builds up in the blood vessels of the brain).During a review of Patient 2’s “Physician Order Details,” dated 5/2/2024, the Physician Order Details indicated Patient 2 had orders for morphine, Ativan, atropine sulfate, bisacodyl, ondansetron, Tylenol, and DuoNeb as needed by the patient.During a concurrent observation and interview on 6/5/2025 at 1:56 pm., with Patient 2’s Caregiver and Registered Nurse 1 (RN 1) in patient’s home, Patient 2’s Caregiver and RN 1 checked Patient 2’s available medications. Patient 2’s Caregiver stated new medications (morphine, Ativan, atropine sulfate, ondansetron, bisacodyl, and Tylenol) were just delivered in the morning (6/5/2025). Patient 2’s Caregiver stated she has never seen any of the new medications before in the three years she has been working with Patient 2. Patient 2’s Caregiver stated she was not aware Patient 2 had orders for the new medications, and she was never taught how to administer them. RN 1 stated she has never seen those medications before, and she did not teach Patient 2’s Caregiver how to safely administer the new medications. During a review of Patient 3’s Face sheet, the Face sheet indicated Patient 3’s start of care (SOC) date was 3/29/2025 for the primary diagnosis of Alzheimer’s disease with late onset (a progressive brain disease that destroys memory).During a review of Patient 3’s “Physician Order Details,” dated 3/29/2025, the Physician Order Details indicated Patient 3 had orders for morphine, Ativan, atropine sulfate, bisacodyl, ondansetron, Tylenol, and DuoNeb as needed by the patient.During a concurrent observation and interview on 6/6/2025 at 4:10 pm., with Patient 3’s Caregiver and Registered Nurse 2 (RN 2) in patient’s home, Patient 3’s Caregiver and RN 2 checked Patient 3’s available medications. Patient 3’s Caregiver stated new medications (morphine, Ativan, atropine sulfate, ondansetron, bisacodyl, and Tylenol) were just delivered the day before (6/5/2025). Patient 3’s Caregiver stated he has never seen any of the new medications since the patient was admitted under hospice care. Patient 3’s Caregiver stated RN 1 visited the day before and informed Patient 3’s Caregiver that education on the new medications would be provided during RN 1’s visit next week. During a record review of the facility’s policy and procedure (P&P) titled, “Safe/Effective Use of Medications,” revised April 2021, the P&P indicated, “As part of the comprehensive assessment, the patient and family/caregiver will be assessed as to their knowledge and skill required for safe and effective use of medications.”

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide at least 12 hours of in-service in 12-months period for two of two sampled certified hospice aides (CHA, [CHA 1 and CHA 2]). This failure had the potential to expose patients to staffs that do not have the skills and qualifications to meet the needs of the patients. --- During a review of “2025 In-services,” dated 1/24/2025 to 5/27/2025, the record indicated the Administrator (ADM)/Director of Patient Care Services (DPCS) provided one-hour monthly in-service to the Registered Nurses (RNs) and the CHAs.  Both CHA 1 and CHA 2 only attended the one-hour in-service on 4/25/2025 and 5/27/2025. During an interview with the ADM/DPCS on 6/10/2025 at 2:50 pm, the ADM/DPCS stated she did not write the dates and times of the in-services she provided in 2024 because the HA staffs was in serviced at different dates and times. The in-service sign-in sheets were placed under the monthly tab from January to October 2024. The ADM/DPCS stated that she is responsible for providing the in-service to the RNs and CHAs. During a review of the HA’s document, titled, “Job Descriptions:  Certified Hospice Aide,” revised November 2020, the Job Descriptions indicate: "position qualification:  Meets the training requirements of the State. Effective August 14, 1990, a person who has successfully completed a state established or other training program that meets the requirements of § 484.36(a) and a competency evaluation program, or state licensure program that meets the requirements of § 484.36(b), or a competency evaluation program or state licensure program that meets the requirements of § 484.36(b). Understands hospice philosophy, comfortable providing specialized care to the terminally ill."

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the condition of participation (CoP-a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Organization and administration of services was met as follows: --- 1. The HA failed to ensure that the HA’s governing body (GB-a group of individuals who have responsibility for the overall management and operations, such as the legal, financial aspects of the organization, including oversight of the patient care, fiscal operations, and quality improvement activities) was able  to demonstrate and provide evidence of their (GB) knowledge and involvement in the agency’s quality assessment performance improvement (QAPI – a data-driven approach that combines quality and performance improvement to enhance healthcare quality, safety, and compliance) program to ensure continuous care assessment of patient health status and hospice services (a specialized form of end-of-life care that provides comfort, and support to terminally ill patients and their families that focuses on improving the quality of life and easing suffering during the final stages of life) were provided to five of five sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5.This failure resulted in the GB’s lack of responsibility and oversight in the HA’s  QAPI program that resulted in Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5 not having  continued assessment of care provided and had the potential to not identify changes in patients’ conditions which could result in unsafe patient care; increased risk of medical errors; and adverse event that can lead to emergency hospitalization and death. (Refer to L651). 2. The HA failed to ensure medications were available for patient’s use and as physician order for two of five sampled patients (Patient 2 and Patient 4).For Patient 2, Patient 2’s magnesium oxide (a medication used to treat heartburn) was not available.For Patient 4, the following medications were not available as ordered by the physician for Patient 4, ipratropium bromide/albuterol (DuoNeb, a combination of inhalation medications used to treat and prevent shortness of breath),atropine sulfate (a medication used under the tongue to reduce salivation), acetaminophen (Tylenol, for pain), tramadol (for pain). This failure resulted in Patient 2 and Patient 4 not having available medication as needed for patient use that could lead to unmanaged pain and discomfort and serious side effect if medication not administered to the patient as ordered by the physician that could lead to hospitalization and, and death. (Refer to 653). 1.      The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (relating to rules or laws which have been formally written down) mandated compliance with the Federal regulations for Organization and Administration of Services to ensure quality of care provided to Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5 who were assessed to receive hospice care services.

Based on interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that the HA’s governing body (GB, a group of individuals who have responsibility for the overall management and operations, such as the legal, financial aspects of the organization, including oversight of the patient care, fiscal operations, and quality improvement activities) was able  to demonstrate and provide evidence of their (GB) knowledge and involvement in the agency’s quality assessment performance improvement (QAPI, a data-driven approach that combines quality and performance improvement to enhance healthcare quality, safety, and compliance) program to ensure continuous care assessments of patient health status and hospice services (a specialized form of end-of-life care that provides comfort, and support to terminally ill patients and their families that focuses on improving the quality of life and easing suffering during the final stages of life) were provided to five of five sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5. This failure resulted in the agency’s  governing body lack of responsibility and oversight in their QAPI program that resulted in Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5 not having  continuous assessment of the care being provided, and had the potential to not identify changes in patients’ conditions that could result in unsafe patient care, increased risk of medical errors, and adverse event that can lead to emergency hospitalization and death. On 6/10/2025 at 3:47 pm, the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Administrator (ADM)/Director of Patient Care Services (DPCS) for failing to ensure the governing body demonstrated and provided documented evidence of knowledge and involvement in the hospice agency’s quality assessment performance improvement (QAPI) program to ensure care, services, and continuous assessment of patient health status were provided to five of five sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5). On 6/11/2025 at 12:26 pm, the HA submitted an acceptable IJ removal plan IJ removal plan  (IJRP, includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) but had not implemented the IJRP.On 6/11/2025 at 2:49 p.m., the Department completed the survey tasks and conducted an exit conference while onsite in the prices of the ADM/DPCS with the IJ situation not removed. --- Findings:During a review of Patient 1’s “Patient Face Sheet,” the Patient Face Sheet indicated Patient 1’s Start of Care (SOC) date was 9/19/2023, with primary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a condition where the heart cannot pump enough blood to meet the body’s needs). During a review of Patient 1’s “Comprehensive Assessment – Psychosocial,” dated 9/22/2023, the initial Medical Social Worker (MSW, a healthcare worker that provides psychosocial support to patients and their families facing medical conditions, including chronic, acute, or terminal illnesses) assessment indicated Patient 1 and family requires psychosocial support and community resources.  The assessment did not include a plan of care (POC, a written document that outlines the specific needs and services provided to a hospice patient and their family/caregiver) that addressed Patient 1 and the family’s psychosocial needs.   During a review of Patient 1’s record from SOC to current recertification period (a period when a doctor re-evaluates patient receiving hospice care to see if they continue to meet the requirements for it) #10 dated from 5/11/2025 - 7/09/2025, there was no documented evidence that POCs were developed by the MSW, addressing the patient and the family’s psychosocial and emotional needs. During a review of Patient 1’s “Interdisciplinary  (IDT) Plan of Care,” from 1/2025 to 5/28/2025, the IDT plan of care  did not indicate that the MSW and Spiritual Counselor (SC) participated and collaborated in the Interdisciplinary group (IDG, the team responsible for the holistic care of the hospice beneficiary) meeting.   2.  During a review of Patient 2’s “Patient Face Sheet,” the Patient Face Sheet indicated Patient 2’s SOC date was 5/2/2024 with primary diagnosis of chronic obstructive respiratory disease (COPD-a lung and airway diseases that restrict your breathing) and essential hypertension (refers to high blood pressure where no specific underlying cause is identified). During a review of Patient 2’s “Comprehensive Assessment – Psychosocial,” dated 5/6/2024, the Comprehensive Assessment – Psychosocial indicated Patient 2 and the family required emotional counseling. The assessment did not indicate a care plan that addresses Patient 2 and the family’s psychosocial needs.  During a review of Patient 2’s SOC to current recertification period #6 (4/27/2025-6/25/2025), the record did not indicate documented evidence that POCs were developed by the MSW, addressing the patient and the family’s psychosocial and emotional needs.  During a review of the “IDT Plan of Care,” from the month of 1/2025 to 5/28/2025, Patient 2’s IDT Plan of Care did not indicate documented evidence that the MSW and SC participated and collaborated in the IDG meeting.   2.  During a review of Patient 2’s “Patient Face Sheet,” the record indicated Patient 2 SOC was 5/2/2024 with primary diagnosis of chronic obstructive respiratory disease (a lug and airway diseases that restrict your breathing) and essential hypertension (refers to high blood pressure where no specific underlying cause is identified).  During a review of Patient 2’s “Comprehensive Assessment – Psychosocial,” dated 5/6/2024, the record indicated Patient 2 and the family required emotional counseling. The assessment did not indicate a care plan that addresses Patient 2 and the family’s psychosocial needs.   During a review of Patient 2’s record from SOC to current recertification period #6 (4/27/2025-6/25/2025), the record did not indicate documented evidence that POCs were developed by the MSW, addressing the patient and the family’s psychosocial and emotional needs.  During a review of the “IDT Plan of Care,” from the month of 1/2025 to 5/28/2025, the record did not indicate a documented evidence that the MSW and SC participated and collaborated in the IDG meeting.   3. During a review of Patient 3’s “Patient Face Sheet,” Patient Face Sheet indicated Patient3’s SOC date was 3/29/2025 with primary diagnosis of Alzheimer’s Disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline) with late onset.    During a review of Patient 3’s “Comprehensive Assessment – Psychosocial" dated 4/3/2025, the initial MSW assessment under “Social/Emotional Functioning” did not indicate MSW’s assessment of the emotional status of the Patient 3. Patient 3’s “Comprehensive Assessment – Psychosocial did not include POCs that addressed Patient 3 and the family’s psychosocial needs.   During a review of the “IDT Plan of Care,” from the month of 4/2025 to 5/28/2025, the record did not indicate documented evidence that the MSW and SC participated and collaborated in the IDG meeting.  4. During a review of Patient 4’s “Patient Face Sheet,” Patient Face Sheet indicated Patient 4 SOC was 11/19/2024 with primary diagnosis of senile degeneration of the brain (a decline in mental abilities, particularly memory, thinking, and reasoning, often associated with old age). During a review of Patient 4’s initial “Comprehensive Assessment – Psychosocial,” dated 12/20/2024, Patient 4’s initial “Comprehensive Assessment – Psychosocial did not indicate a care plan addressing Patient 4 and Patient 4’s family’s psychosocial needs.   During a review of Patient 4’s SOC to current recertification period #8 (5/18/2025-7/16/2025), the record did not indicate documented evidence that POCs were developed by the MSW, addressing the patient and the family’s psychosocial and emotional needs. During a review of the “IDT Plan of Care,” from the month of 1/2025 to 5/28/2025, the record did not indicate documented evidence that the MSW and SC participated and collaborated in the IDG meeting. 5. During a review of Patient 5’s “Patient Face Sheet,” the Patient Face Sheet indicated Patient 5, SOC was 3/28/2025 with primary diagnosis of senile degeneration of the brain (a decline in mental abilities, particularly memory, thinking, and reasoning, often associated with old age).  During a review of Patient 5’s initial “Social Worker Assessment/Care Plan,” dated 4/1/2025, the Social Worker Assessment/Care Plan indicated Patient 5’s Caregiver, and Patient 5’s family required psychosocial support and community resources.  The record did not indicate a POC that addressed Patient 5 and Patient 5’s family’s psychosocial needs.    During a review of the “IDT Plan of Care,” from the month of 4/2025 to 5/28/2025, the record did not indicate documented evidence that the MSW and SC participated and collaborated in the IDG meeting.  During a review of the HA Minutes of Governing Body Meeting dated 1/4/2024, 1/3/2024, 10/4/2023, 7/5/2023, and 4/4/2023, the Minutes of Governing Body Meeting indicated there were no documented evidence of discussion of QAPI reports and no documentation of QAPI result reports on 1/4/2023, 1/3/2024, 7/5/2023, and 4/4/2023. During an interview on 6/10/2025 at 10:58 am, with the Administrator/DPCS, the Administrator/DPCS stated she is a member that leads the governing body.  The Administrator/DPCS stated there was no governing body meeting held for 2025, and the last GB meeting was held on 1/4/2024.  The Administrator/DPCS stated the members of the GB comprised of the Administrator/DPCS and the Chief Financial Officer only. The Administrator/DPCS stated, during the governing body meeting, the agenda consist of discussion on patient census, who will be discharged, patient issues, but quality of care and performance are not part of the agenda. The Administrator/DPCS stated the last governing body meeting was held on 1/4/2024 and in that meeting, the QAPI results for 2023 was presented. The Administrator/DPCS stated that there was no governing body meeting that had occurred after 1/2024 that discussed the QAPI result for 2024 through June 2025.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure medications were available for patient’s use and as physician order for two of five sampled patients (Patient 2 and Patient 4).For Patient 2, Patient 2’s magnesium oxide (a medication used to treat heartburn) was not available.For Patient 4, the following medications were not available as ordered by the physician for Patient 4, ipratropium bromide/albuterol (DuoNeb, a combination of inhalation medications used to treat and prevent shortness of breath), atropine sulfate (a medication used under the tongue to reduce salivation), acetaminophen (Tylenol, for pain), tramadol (for pain).  This failure resulted in Patient 2 and Patient 4 not having available medication as needed for patient use that could lead to unmanaged pain and discomfort and serious side effect if medication not administered to the patient as ordered by the physician that could lead to hospitalization and, and death. On 6/8/2025 at 12:40 pm, the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) presence of the Administrator (ADM)/Director of Patient Care Services (DPCS) for failing to ensure physician-ordered medications were made routinely available to meet the needs of two of five sampled patients (Patient 2 and Patient 4).   On 6/11/2025 at 10:21 am, the hospice agency (HA) was able to submit an IJ removal plan (IJRP, includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) and was not accepted.  On 6/11/2025 at 10:21 am, the hospice agency (HA) was able to submit an IJ removal plan (IJRP, includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) and was not accepted.   On 6/11/2024 at 2:49 pm, the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the ADM/DPCS with the IJ situations not removed. --- Findings: 1.During a review of Patient 2’s Face sheet, the Face sheet indicated Patient 2’s start of care (SOC) date was 5/2/2024 for the primary diagnosis of cerebral atherosclerosis (a condition where plaque builds up in the blood vessels of the brain). During a review of Patient 2’s “Physician Order Details,” dated 5/2/2024, the Physician Order Details indicated Patient 2 had an order for magnesium oxide 240 mg 1 tablet daily. During a joint home visit observation on 6/5/2025 at 1:46 pm., with Registered Nurse 1 (RN 1), at Patient 2’s home, Patient 2’s Caregiver provided RN 1 with Patient 2’s medication containers to perform medication reconciliation (the process of comparing a patient's medication orders to all the medications that the patient has been taking to ensure accuracy and prevent errors). RN 1 was observed looking at containers for magnesium oxide, losartan (a medication used to treat high blood pressure), atorvastatin (a medication used to treat high cholesterol), and amlodipine (a medication used to treat high blood pressure).  RN 1 did not compare the containers against Patient 2’s ordered medication list. RN 1 stated the medications looked okay and returned the containers to Patient 2’s Caregiver. During a concurrent observation and interview on 6/5/2025 at 1:54 pm., with RN 1 and Patient 2’s Caregiver, Patient 2’s Caregiver had a bottle of magnesium oxide 400 milligram (mg, unit of measurement) tablets prescribed for Patient 2. Patient 2’s Caregiver stated she has been administering one tablet of magnesium oxide 400 mg daily to Patient 2 as dispensed from the pharmacy. RN 1 stated “I did not know that the magnesium oxide being given (to Patient 2) was different from the order.” 2. During a review of Patient 4's Face sheet, the Face sheet indicated Patient 4’s SOC date was 11/19/2024 with the primary diagnosis of senile degeneration of the brain (a progressive decline in brain function).  During a review of Patient 4’s “Physician Order Details,” dated 11/19/2024, the Physician Order Details indicated Patient 4 had orders for DuoNeb via nebulizer every six hours as needed for congestion or shortness of breath, atropine sulfate under the tongue every 3 hours as needed for excessive secretions, Tylenol 500 mg one tablet four times a day as needed for knee pain, and tramadol 50 mg one tablet four times a day as needed for moderate pain. During a concurrent observation and interview on 6/6/2025 at 11:30 am., with Patient 4 in Patient 4’s room, Patient 4 was grimacing while standing up from sitting on her bed. Patient 4 stated she was having pain that radiated from her abdomen to her right upper leg. During an interview on 6/6/2025 at 11:48 am., with Registered Nurse 2 (RN 2) and Med Tech Supervisor (MT Supervisor), MT Supervisor stated a tramadol 50 mg refill was needed for Patient 4’s pain and was not available. RN 2 stated she would inform the agency of the refill request. During a concurrent observation and interview on 6/6/2025 at 11:54 am., with Med Tech 1 (MT 1) in the medication room, MT 1 had an unopened blister packet of Tylenol 325 mg tablets with a prescription label for Patient 4. MT 1 stated the agency’s pharmacy delivered the Tylenol 325 mg tablets but Patient 4’s order was for Tylenol 500 mg tablets. MT 1 stated there was no Tylenol 500 mg. available to administer to Patient 4. During a concurrent observation and interview on 6/6/2025 at 11:55 am., with MT 1 in the medication room, MT 1 had a bottle of tramadol 50 mg tablets prescribed for Patient 4 with an expiration date of May 2025. MT 1 stated she has called the hospice agency for a refill, but it has not been dispensed yet. MT 1 stated she had no available tramadol 50 mg to administer to Patient  4. MT 1 stated she did not receive a physician’s order for Patient 4’s DuoNeb and atropine sulfate. MT 1 stated the hospice pharmacy has not delivered DuoNeb or atropine sulfate for Patient 4. During an interview on 6/6/2025 at 12:09 pm with RN 2 and MT 1, RN 2 stated she had never done Patient 4’s medication reconciliation. RN 2 stated she only got Patient 4’s medication list from the MT Supervisor and did not check Patient 4’s available medication containers. RN 2 stated it was her responsibility to do Patient 4’s medication reconciliations. MT 1 stated she has never met RN 2 or seen her in the medication room. During a review of the agency’s policy and procedure (P&P) titled, “Identification of Medication for Administration,” revised April 2021, the P&P indicated, “The nurse will review the written physician’s orders prior to medication administration…The nurse will review the medication label for name, additional patient identifier, drug, dosage, and prescription… All medications will be checked for stability by visualizing the medication and observing for the…expiration date.” During a review of the agency’s policy and procedure (P&P) titled, “Interdisciplinary Group Plan of Care,” revised April 2021, the P&P indicated, “Core hospice services (nursing, social work, physician, and counselors) will be available 24 hours a day, seven (7) days a week, as will drugs, biologicals, and medical supplies.”

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the condition of participation (CoP, a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Drugs, Biologicals, Medical Supplies, and Durable Medical Equipment (DME, medical devices used for an extended period of time) were met as follows: --- The facility failed to ensure caregivers for three of five sampled patients (Patient 2, Patient 3, and Patient 4) were able to safely self-administer medications when:1. Patient 2’s Caregiver and Patient 3’s Caregiver were not educated on how to safely administer comfort pack medications (morphine [an opioid medication that helps relieve pain], lorazepam [Ativan, used to treat anxiety], atropine sulfate [used under the tongue to reduce salivation], bisacodyl [used to treat constipation], ondansetron [used to prevent nausea and vomiting], acetaminophen [Tylenol, used to relieve pain], and ipratropium bromide/albuterol [DuoNeb, a combination of inhalation medications used to treat and prevent shortness of breath]), as ordered by the physician.2. Med Tech 1 (MT 1) was not able to administer morphine, Ativan, or atropine sulfate as needed by Patient 4 because the medications were not prepared in pre-filled syringes.These failures had the potential to result in medications errors for Patient 2, Patient 3, and Patient 4. These failures also increased the risk of adverse drug reactions and poor symptom management such as unmanaged pain, distress, or agitation that could lead to emergency hospitalization and contribute to an avoidable undignified death. (Refer to L692)

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure caregivers for three of five sampled patients (Patient 2, Patient 3, and Patient 4) were able to safely self-administer medications when:1. Patient 2’s Caregiver and Patient 3’s Caregiver were not educated on how to safely administer comfort pack medications (a set of medicines kept at home used for fast relief when pain, fear or sickness become worse in hospice patients; including morphine [an opioid medication that helps relieve pain], lorazepam [Ativan, used to treat anxiety], atropine sulfate [used under the tongue to reduce salivation], bisacodyl [used to treat constipation], ondansetron [used to prevent nausea and vomiting], acetaminophen [Tylenol, used to relieve pain], and ipratropium bromide/albuterol [DuoNeb, a combination of inhalation medications used to treat and prevent shortness of breath]), as ordered by the physician.2. Med Tech 1 (MT 1) was not able to administer morphine, Ativan, or atropine sulfate as needed by Patient 4 because the medications were not prepared in pre-filled syringes.These failures had the potential to result in medications errors for Patient 2, Patient 3, and Patient 4. These failures also increased the risk of adverse drug reactions and poor symptom management such as unmanaged pain, distress, or agitation that could lead to emergency hospitalization and contribute to an avoidable undignified death. On 6/7/2025 at 4:37 pm, the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the Administrator (ADM)/Director of Patient Care Services (DPCS) for failing to ensure caregivers for three of five sampled patients (Patient 2, Patient 3, and Patient 4) were able to safely self-administer medications.On 6/9/2025 at 3:54 pm, the Hospice Agency (HA) was able to submit an IJ removal plan (IJRP-includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) and was not accepted.  On 6/11/2024 at 2:49 pm, the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the ADM/DPCS with the IJ situations not removed. --- 1. During a review of Patient 2’s Facesheet, the Facesheet indicated Patient 2 was an 89-year-old female with a start of care date (SOC) on 5/2/2024 for the primary diagnosis of cerebral atherosclerosis (a condition where plaque builds up in the blood vessels of the brain).During a review of Patient 2’s “Physician Order Details,” dated 5/2/2024, the Physician Order Details indicated Patient 2 had orders for morphine, Ativan, atropine sulfate, bisacodyl, ondansetron, Tylenol, and DuoNeb as needed by the patient.During a review of Patient 3’s Facesheet, the Facesheet indicated Patient 3 was an 87-year-old female with a SOC on 3/29/2025 for the primary diagnosis of Alzheimer’s disease with late onset (a progressive brain disease that destroys memory).During a review of Patient 3’s “Physician Order Details,” dated 3/29/2025, the Physician Order Details indicated Patient 3 had orders for morphine, Ativan, atropine sulfate, bisacodyl, ondansetron, Tylenol, and DuoNeb as needed by the patient.During a concurrent observation and interview on 6/5/2025 at 1:56 pm with Patient 2’s Caregiver and Registered Nurse 1 (RN 1) in Patient 2’s home, Patient 2’s Caregiver and RN 1 checked Patient 2’s available medications. Patient 2’s Caregiver stated new medications (morphine, Ativan, atropine sulfate, ondansetron, bisacodyl, and Tylenol) were just delivered in the morning (6/5/2025). Patient 2’s Caregiver stated she has never seen any of the new medications before in the three years she has been working with Patient 2. Patient 2’s Caregiver stated she was not aware Patient 2 had orders for the new medications and she was never taught how to administer them. RN 1 stated she has never seen those medications before, and she did not teach Patient 2’s Caregiver how to safely administer the new medications.During a concurrent observation and interview on 6/6/2025 at 4:10 pm with Patient 3’s Caregiver and Registered Nurse 2 (RN 2) in Patient 3’s home, Patient 3’s Caregiver and RN 2 checked Patient 3’s available medications. Patient 3’s Caregiver stated new medications (morphine, Ativan, atropine sulfate, ondansetron, bisacodyl, and Tylenol) were just delivered the day before (6/5/2025). Patient 3’s Caregiver stated he has never seen any of the new medications since the patient was admitted under hospice care. Patient 3’s Caregiver stated RN 1 visited the day before and informed Patient 3’s Caregiver that education on the new medications would be provided during RN 1’s visit next week.2. During a review of Patient 4’s Facesheet, the Facesheet indicated Patient 4 was a 90-year-old female with a SOC on 11/19/2024 for the primary diagnosis of senile degeneration of the brain (a progressive decline in brain function).During a concurrent observation and interview on 6/6/2025 at 11:30 am with Patient 4 in Patient 4’s room, Patient 4 was grimacing while standing up from sitting on her bed. Patient 4 stated she was having pain that radiated from her abdomen to her right upper leg.During a concurrent observation and interview on 6/6/2025 at 11:57 am with RN 2 and MT 1 in the medication room, MT 1 had liquid morphine and liquid Ativan bottles prescribed for Patient 4. MT 1 stated med techs in Patient 4’s assisted living facility were not allowed to administer liquid medications if they were not in prefilled syringes. MT 1 stated that because Patient 4’s liquid morphine and liquid Ativan were not in prefilled syringes, med techs would not be able to administer them to Patient 4 if Patient 4 needed them. RN 2 stated she was not aware med techs were not allowed to self-administer liquid medications.During an interview on 6/6/2025 at 12:09 pm with RN 2 and MT 1, RN 2 stated she has never done Patient 4’s medication reconciliation (the process of comparing a patient's medication orders to all the medications that the patient has been taking to ensure accuracy and prevent errors). RN 2 stated she only gets Patient 4’s medication list from the MT Supervisor and does not check Patient 4’s available medication containers. RN 2 stated it was her responsibility to do Patient 4’s medication reconciliations. MT 1 stated she has never met RN 2 or seen her in the medication room.During an interview on 6/7/2025 at 1:08 pm with the Director of Patient Care Services (DPCS), the DPCS stated Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5 had orders for comfort pack medications upon admission into hospice care. The DPCS stated she called their contracted pharmacy on 6/4/2025 to deliver the comfort pack medications to all five patients’ homes by 6/5/2025 to comply with the regulations. The DPCS stated comfort pack medications should have been made available to the patients when they were initially ordered. The DPCS stated not having the comfort pack medications available had the potential to cause pain exacerbations in Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5.During an interview on 6/7/2025 at 1:32 pm with the DPCS, the DPCS stated she was aware that med techs were not allowed to administer liquid medications if not in pre-filled syringes. The DPCS stated RN 2 should have prepared Patient 4’s liquid medication into syringes for the med techs to administer to Patient 4 if needed.During an interview on 6/7/2025 at 1:35 on with the DPCS, the DPCS stated RNs are expected to medication reconciliation during every visit to the patients. The DPCS stated the RN should compare the patient’s medication container with the medication list. The DPCS stated if medications were missing or needed to be refilled, the RN should call All Valley Hospice to order the medication. The DPCS stated she does not know if the RNs are complying with the medication reconciliation process because she has not followed up with them. The DPCS stated RNs should be teaching caregivers about physician-ordered medications with each visit.During a review of the facility’s “Pharmacy (Rx) Delivery Receipt,” dated 6/4/2025, the Rx Delivery Receipt indicated morphine, Ativan, atropine sulfate, bisacodyl, ondansetron, Tylenol, and DuoNeb were to be delivered stat by 6/5/2025 11 am for Patient 2 and Patient 3.During a record review of the facility’s policy and procedure (P&P) titled, “Interdisciplinary Group Plan of Care,” revised April 2021, the P&P indicated, “Core hospice services (nursing, social work, physician, and counselors) will be available 24 hours a day, seven (7) days a week, as will drugs, biologicals, and medical supplies.”During a record review of the facility’s policy and procedure (P&P) titled, “Safe/Effective Use of Medications,” revised April 2021, the P&P indicated, “As part of the comprehensive assessment, the patient and family/caregiver will be assessed as to their knowledge and skill required for safe and effective use of medications.”