Every finding on record at Caresouth Hospice, LLC

Based on a review of clinical records and staff interviews, it was determined that the Hospice failed to effectively provide appropriate interventions for symptom management at the end of life for one patient (P) (P#2) of three patients reviewed. --- Findings include: Review of the document titled "Hospice Certification and Plan of Care," dated 5/14/25 revealed orders for Morphine Concentrate 100 mg/5ml oral solution to be given sublingual (under the tongue) every three hours as needed for pain and Lorazepam 0.5mg every six hours as needed for anxiety. The agency failed to provide medications ordered for pain and anxiety for comfort. During an interview with the family member of P#2 on 7/7/25 at approximately 6:30 p.m. who stated P#2 was being discharged on 5/14/25 from the hospital and was to pick up the hospice comfort medications, Morphine (pain medication) and Lorazepam (anxiety medication), which are standard in end-of-life care. Upon receiving the bag of medications for pain and comfort, the family member of P#2 immediately checked and discovered neither Morphine (for pain) nor Lorazepam (for anxiety) was included. The family member of P#2 called the Hospice agency right away to report this. During an interview on 7/7/25 at 2:30 p.m., with the Director of Operations stated she aware that the pain and anxiety medications were missing but did not ensure those medications were delivered prior to P#2's discharge home from the hospital. She stated that these medications were supposed to be included or made available that night. A policy on obtaining pain and comfort medications for hospice patients was requested but not received.

Based on record reviews, staff and family interview, it was determined that the agency failed to promote the right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness. Specifically, the Registered Nurse (RN) AA failed to manage pain and control symptoms for one patient (P) (P#2) of three patients reviewed. --- Findings include: Review of the nursing note dated 5/15/25 revealed that P#2 was unresponsive with cool clammy skin and posturing. No documentation on whether the pain and anxiety medications were in the home and no documentation of instructions to family member on how to continue to care for P#2 in this condition. No other documentation was available for 5/15/25 on P#2 until the pronouncement of death over 12 hours later. During an interview with the family of P#2 on 7/7/25 at approximately 6:30 p.m. states that Registered Nurse (RN) AA made a visit. RN AA assessed her mother and administered Glucagon 1mg. P#2 blood sugar level was read at 23. The family member of P#2 stated that P#2 continued to be unresponsive at the time RN AA concluded the visit. She states RN AA said give us call when she passes and left. During an interview with RN AA states that P#2 was unresponsive and posturing but did not seem to be in pain. She stated that she was unaware that the pain and anxiety medications had not been obtained. She stated that she offered comfort to the family and left. She was unaware that P#2 needed pain medications. RN AA did not offer a reason as to why there was no follow up with the family of P#2 while her condition was declining.

Based on record review, and staff interviews, it was determined that the hospice failed to organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions for one patient (P) (P#2) of three patients reviewed. Specifically, the agency failed to ensure that P#2 received medication for pain and comfort. --- Findings include: Review of document "Medical Record Coordination Notes Reports," dated 5/14/25 revealed that E-kit (a collection of prescribed medications for pain and comfort management for the hospice patient) would be in the home before P#2 arrives. It was to be ordered from hospital pharmacy and picked up by family member of P#2 on 5/14/25 in the a.m. During an interview on 7/7/25 at 2:00 p.m., the Director of Operations (DOO) stated she was aware that P#2 did not have Morphine (pain medication) and Valium (anxiety medication) in their E-kit. She states because P#2 was discharged from the hospital, it should have been provided by them. She states the hospice did not assist with procuring the medications that were ordered by the hospice physician for pain management and comfort.   During and an interview on 7/7/25 at 2:30 p.m. Registered Nurse (RN) AA stated that during the visit with P#2 she did not assist with getting the Morphine and Lorazepam as ordered by the hospice physician.

Based on record review, staff and family interviews, it was determined that the agency failed to ensure that nursing services and drugs were routinely available on 24-hour basis 7 days a week when reasonable and necessary to meet the needs of the patient and family for one patient (P) (P#2) of three patients reviewed. --- Findings include: Review of the document titled "Hospice Certification and Plan of Care," dated 5/14/25 revealed orders for Morphine Concentrate 100 mg/5ml oral solution to be given sublingual (under the tongue) every three hours as needed for pain and Lorazepam 0.5mg every six hours as needed for anxiety.Review of the nursing note dated 5/15/25 revealed that P#2 was unresponsive with cool clammy skin and posturing. No documentation on whether the pain and anxiety medications were in the home and no documentation of instructions to family member on how to continue to care for P#2 in this condition. No other documentation was available for 5/15/25 on P#2 until the pronouncement of death over 12 hours later.An interview on 7/7/25 at 2:00 p.m. with the Director of Operations, who stated that hospice did not assist with obtaining pain and comfort medications as they were to be provided by the hospital pharmacy at discharge.During an interview on 7/7/25 at 6:24 p.m. with a family member of P#2 stated that several requests were made to the hospice agency to obtain pain and comfort medications. The family member of P#2 states the medications were not received until the day after admission. The family of P#2 further stated that Registered Nurse (RN) AA made a visit. RN AA assessed her mother and administered Glucagon 1mg. P#2 blood sugar level was read at 23. The family member of P#2 stated that P#2 continued to be unresponsive at the time RN AA concluded the visit. She states RN AA said give us call when she passes and left. The clinical record failed to reveal documented interventions to assist P#2 in achieving pain management.

Based on record review, staff and family interviews, and review of policy “Medication S07,” it was determined that the agency failed to provide drugs related to the palliation and management of the terminal illness and related conditions for one patient (P) (P#2) of three patients reviewed. --- Findings include: Writing Complete | Last Updated by Terry Burks 07/16/2025 7:37 AMReview of the undated policy titled "Medication S07," revealed the following:1.0 Purpose1.1 Establish guidelines for the appropriate administration and management of medication for patients and establish guidelines for appropriate personnel to administer medication.2.0 Definitions2.4 Medication profile is a listing of the medications2.4.1 Prescribed by a physician for the patient, identifying, the name, dose, route, frequency and date drug was started or changed or discontinued. Review of the document titled "Hospice Certification and Plan of Care," dated 5/14/25 revealed orders for Morphine Concentrate 100 mg/5ml oral solution to be given sublingual (under the tongue) every three hours as needed for pain and Lorazepam 0.5mg every six hours as needed for anxiety. During an interview on 7/7/25 at 2:00 p.m., with the Director of Operations, states that she was aware that P#2 did not receive the Morphine (pain medication) and Lorazepam (anxiety medication) in the Comfortpak (a collection of medications prescribed for the hospice patient for comfort) from the hospital. These medications were listed on the patient's drug profile. She states that the hospice did not assist in obtaining the medications.  The agency failed to provide medications that were ordered in the Comfortpak for pain and comfort while under hospice care.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy "Admission Process and Patient Assessment" (Reviewed 10/18/2023) stated in part, "The plan of care will reflect patient and family goals and interventions based on the problems identified..." In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that the patient's plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 6: The patient elected hospice care on 01/25/2024 with the primary diagnosis of chronic obstructive pulmonary disease (COPD). On 04/09/2024, the Registered Nurse (RN) documented that the patient was having dysuria, flank pain, and discharge. An order was documented on 04/09/2024 (#11572217) for Cipro 250 mg by mouth every other day for three doses to be completed over six days. On 05/07/2024, the RN documented that a call was made to the doctor and an order was documented the same day (#116814406) for a urine culture and for Cipro 500 mg by mouth twice a day for five days for a urinary tract infection. The plan of care did not identify a planned intervention to address the urinary tract infection. Clinical Record 7: The patient elected hospice care on 08/24/2023 with the primary diagnosis of breast cancer. On 04/23/2024, the RN documented that the patient complained of a sore throat and had a "raspy voice and cleared her throat frequently" during the visit. Also documented was a dry cough. An order was documented on the same day (#11623864) for Doxycycline Hyclate 100 mg by mouth twice daily for an upper respiratory tract infection. In addition, there was an order documented on 04/30/2024 (#11649533) for Guaifenesin 600 mg by mouth twice daily for seven days for a cough. On 04/11/2024, the RN documented that the patient's daughter reported that her mother had diarrhea for a week. The daughter gave Imodium twice a day for one week without improvement, and the patient continued to have loose stools two to three times a day. On 04/16/2024 the RN documented that "client still complaining of loose stools..." An order was documented on 04/12/2024 (#11581488) to collect a stool sample to test for clostridium difficile due to loose stools for one week and unresponsive to Imodium. The plan of care did not identify planned interventions to address the upper respiratory tract infection or diarrhea. Clinical Record 12: The patient elected hospice care on 02/09/2024 with the primary diagnosis of congestive heart failure. An order was documented on 05/08/2024 (# 11680328) for Trazodone 50mg by mouth every night at bedtime for sleep. On 05/10/2024 another order was documented (#11687997) for Seroquel 25 mg by mouth every night at bedtime for restlessness. The plan of care did not identify planned interventions to address the insomnia and restlessness. Clinical Record 14: The patient elected hospice care on 08/02/2023 with the primary diagnosis of heart disease of the native coronary artery without angina pectoris. The care coordination note completed by the RN on 04/26/2024 documented in part "Notified by HHA … of foul smelling urine with mucous noted in client pure wick collection tub. Contacted Dr... VO received for Bactrim DS 800/160 tab one (1) tab po bid for 7 days for UTI symptoms." An order was documented on the same day (#11637336) for Bactrim DS 80/160 mg, one tablet orally twice daily for seven days for urinary tract infection symptoms. The plan of care was not updated to address the urinary tract infection. During the joint record reviews and interviews on 05/14/2024, 05/16/2024, and 05/17/2024, the Director of Operations confirmed that the patients' care plans had not been updated with the new information obtained from the updated comprehensive assessments. The patients' charts were updated before the end of the site visit, and counseling was conducted with the individual staff members.

It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Interdisciplinary Group (Revised 03/12/2023) stated in part, "The plan of care will reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments... Appropriate communication is implemented... and documented in the point of care system to...Ensure that the care and services provided are based on all assessments of the patient and family needs... Measurable outcomes anticipated from implementing and coordinating the plan of care." In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that the patient's plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 6: The patient elected hospice care on 01/25/2024 with the primary diagnosis of chronic obstructive pulmonary disease (COPD). On 04/09/2024, the Registered Nurse (RN) documented that the patient was having dysuria, flank pain, and discharge. An order was documented on 04/09/2024 (#11572217) for Cipro 250 mg by mouth every other day for three doses to be completed over six days. On 05/07/2024, the RN documented that a call was made to the doctor and an order was documented the same day (#116814406) for a urine culture and for Cipro 500 mg by mouth twice a day for five days for a urinary tract infection. The plan of care was not updated to include goals with measurable outcomes for the treatment of the active urinary tract infection. Clinical Record 7: The patient elected hospice care on 08/24/2023 with the primary diagnosis of breast cancer. On 04/23/2024, the RN documented that the patient complained of a sore throat and had a "raspy voice and cleared her throat frequently" during the visit. Also documented was a dry cough. An order was documented on the same day (#11623864) for Doxycycline Hyclate 100 mg by mouth twice daily for an upper respiratory tract infection. In addition, there was an order documented on 04/30/2024 (#11649533) for Guaifenesin 600 mg by mouth twice daily for seven days for a cough. On 04/11/2024, the RN documented that the patient's daughter reported that her mother had diarrhea for a week. The daughter gave Imodium twice a day for one week without improvement, and the patient reportedly continued to have loose stools two to three times a day. On 04/16/2024 the RN documented that "client still complaining of loose stools..." An order was documented on 04/12/2024 (#11581488) to collect a stool sample to test for clostridium difficile due to loose stools for one week and unresponsive to Imodium. The plan of care was not updated to include goals with measurable outcomes for the upper respiratory tract infection or diarrhea. Clinical Record 12: The patient elected hospice care on 02/09/2024 with the primary diagnosis of congestive heart failure. An order was documented on 05/08/2024 (# 11680328) for Trazodone 50mg by mouth every night at bedtime for sleep. On 05/10/2024 another order was documented (#11687997) for Seroquel 25 mg by mouth every night at bedtime for restlessness. The plan of care was not updated to include goals with measurable outcomes for the treatment of insomnia and restlessness. Clinical Record 14: The patient elected hospice care on 08/02/2023 with the primary diagnosis of heart disease of the native coronary artery without angina pectoris. The care coordination note completed by the RN on 04/26/2024 documented in part "Notified by HHA … of foul smelling urine with mucous noted in client pure wick collection tub. Contacted Dr... VO received for Bactrim DS 800/160 tab 1 tab po bid for 7 days for UTI symptoms." An order was documented on the same day (#11637336) for Bactrim DS 80/160mg: one tablet orally twice daily for seven days for urinary tract infection symptoms. The plan of care was not updated to include goals with measurable outcomes for the treatment of the urinary tract infection. During the joint record reviews and interviews on 05/14/2024, 05/16/2024, and 05/17/2024, the Director of Operations confirmed that the patient's care plans had not been updated with the new information obtained from the updated comprehensive assessments. The patient's charts were updated before the end of the site visit, and counseling was conducted with the individual staff members.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. The code of federal regulation Title 42, Part 418- Hospice Care, § 418.22 stated in part, "Certification of terminal illness. (b) Content of certification (3) The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms." In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the physician provided a narrative on the Certification/recertification of a terminal illness. Clinical Record 14: The patient elected hospice care on 08/02/2023. The physician certification of terminal illness for the third benefit period, effective 01/29/2024 through 03/08/2024, contained no physician narrative describing the patient's terminal condition(s), subjective or objective medical findings, or medication and/or treatments. Clinical Record 15: The patient elected hospice care on 10/26/2023 and transferred to another hospice effective 02/07/2024. The physician certification of terminal illness for the first benefit period effective 10/26/2023 through 01/23/2024 and for the second benefit period effective 01/24/2024 through 04/22/2024, contained no physician narrative describing the patient's terminal condition(s), subjective or objective medical findings, or medication and/or treatments. During a joint record review and interview, the Director of Operations confirmed that the Certifications/Recertifications in the evidence did not contain a written narrative from the hospice Medical Director.