Every finding on record at Caring Hearts Hospice Inc

Based on record review and interview, the hospice failed to ensure contact information for an integrated emergency preparedness response with Federal, Tribal and Regional emergency management officials for all patients and employees. --- Findings: A review of emergency preparedness records showed no contact information for an integrated emergency preparedness response with Federal, Tribal and Regional emergency management officials for the agency. On 08/15/25 at 12:30 p.m., Staff A stated the emergency preparedness plan did not include resource contact information for Federal, Tribal and Regional emergency management officials.

Based on record review and interview, the hospice failed to ensure the emergency preparedness communication plan included required staff contact information for the current staff for all patients and staff. --- Findings: A review of emergency preparedness records showed the communication plan included contact information for staff no longer with the hospice and did not include contact information for current staff of the hospice. On 08/15/25 at 12:30 p.m., Staff A stated the communication plan was not updated to reflect contact information of current staff for the hospice.

Based on record review and interview, the hospice failed to ensure the required number of emergency preparedness disaster declarations, table-top exercises, drills, community drills or plan activation events were conducted for calendar year 2024 for all patients and staff. --- Findings: A review of emergency preparedness records showed no emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for calendar year 2024.  On 08/15/24 at 12:30 p.m., Staff A stated the hospice had no emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events in 2024.

Based on record review and interview, the hospice failed to ensure development of a bereavement POC at the time of initial assessment for two (Patients #7 and #8) of 15 patients. --- Findings: Patient #7A review of the clinical record showed an initial bereavement assessment dated 05/15/25 with IDG updates on 05/15/25, 05/28/25, 06/11/25, 06/25/25 and 07/09/25. The clinical record showed a bereavement POC dated 07/08/25. The clinical record showed no patient or caregiver refusal of a bereavement POC on the bereavement assessment dated 05/15/25 or on IDG updates prior to 07/09/25. On 08/15/25 at 1:19 p.m., Staff A stated the patient had no bereavement POC until 07/09/25.Patient #8A review of the clinical record showed an initial bereavement assessment dated 05/15/25 with IDG updates on 05/14/25 and 06/03/25. The clinical record showed a bereavement POC dated 06/02/25. The clinical record showed no patient or caregiver refusal of a bereavement POC on the bereavement assessment dated 05/15/25 or on IDG updates prior to 06/02/25. On 08/15/25 at 1:19 p.m., Staff A stated the patient had no bereavement POC until 06/02/25.

Based on record review and interview, the hospice failed to ensure it maintained a QAPI Program to improve palliative outcomes and services for all patients and staff.  The failed practice had the potential to affect the hospice’s ability to achieve measurable improvement in the care and services it offered for all patients and staff. See tag L561. Based on record review and interview, the hospice failed to ensure its QAPI Program showed utilization of quality indicator data to improved palliative outcomes and hospice services for all patients and staff.  The failed practice had the potential to impact on the hospices ability to evaluate its quality assessment program to identify opportunities for improvement for all patients. See tag L562. Based on record review and interview, the hospice failed to ensure its performance improvement projects included a baseline measurement for all patients and staff. The failed practice had the potential to affect the hospice’s ability to correct problems and monitor actions to improve patient care and organizational outcomes for all patients. See tag L573. Based on record review and interview, the hospice failed to ensure governing body oversite in the conduction of a patient centered QAPI Program for all patients and staff. The failed practice had the potential to affect the hospice’s ability to define, implement and maintain an ongoing quality improvement program and to ensure patient safety for all patients and staff. See tag L574. --- .

Based on record review and interview, the hospice failed to ensure it maintained a QAPI Program to improve palliative outcomes and services for all patients and staff. The failed practice had the potential to affect the hospice’s ability to achieve measurable improvement in the care and services it offered for all patients and staff. --- Findings: A review of QAPI records showed no ongoing patient centered QAPI program in calendar years 2023, 2024 and 01/01/25 to 06/30/25. The records showed:1.    2023 calendar year QAPI records showed:·      1st quarter and 3rd quarter showed no meeting agenda, participation sign in sheets and no meeting minutes.·      2nd quarter and 4th quarter showed no meeting agenda, data reports, participation sign in sheets and no meeting minutes.2.    2024 calendar year QAPI records showed no meeting agenda, data reports, participation sign in sheets and no meeting minutes.3.    01/01/25 to 06/30/25 (1st and 2nd quarter) QAPI records showed no meeting agenda, data reports, participation sign in sheets and no meeting minutes. Additional requests for QAPI records yielded no results. On 08/15/25 at 8:40 a.m., Staff A stated the hospice had no QAPI program records which showed data collection sources, analysis and reporting of collected data, participation sign in sheets or meeting minutes.

Based on record review and interview, the hospice failed to ensure its QAPI Program showed utilization of quality indicator data to improved palliative outcomes and hospice services for all patients and staff.  The failed practice had the potential to impact on the hospices ability to evaluate its quality assessment program to identify opportunities for improvement for all patients. --- Findings: A review of QAPI records showed no ongoing patient centered QAPI program in calendar years 2023, 2024 and 01/01/25 to 06/30/25. 1.    2023 calendar year QAPI records showed:·      1st quarter and 3rd quarter showed no meeting agenda, participation sign in sheets and no meeting minutes.·      2nd quarter and 4th quarter showed no meeting agenda, data reports, participation sign in sheets and no meeting minutes.2.    2024 calendar year QAPI records showed no meeting agenda, data reports, participation sign in sheets and no meeting minutes.3.    01/01/25 to 06/30/25 (1st and 2nd quarter) QAPI records showed no meeting agenda, data reports, participation sign in sheets and no meeting minutes. Additional requests for QAPI records yielded no results. On 08/15/25 at 8:40 a.m., Staff A stated the QAPI program records:1.    Showed patient clinical record audits only.The QAPI records showed no data collection sources, analysis and reporting of collected data, participation sign in sheets or meeting minutes.

Based on record review and interview, the hospice failed to ensure its performance improvement projects included a baseline measurement for all patients and staff. The failed practice had the potential to affect the hospice’s ability to correct problems and monitor actions to improve patient care and organizational outcomes for all patients. --- Findings: A review of QAPI program performance improvement project records for calendar years 2023, 2024 and 01/01/25 to 06/30/25 showed no baseline measurement to determine performance improvement project outcomes. On 08/15/25 at 8:40 a.m., Staff A stated the QAPI program performance improvement project records did not include baseline measurement.

Based on record review and interview, the hospice failed to ensure governing body oversite in the conduction of a patient centered QAPI Program for all patients and staff. The failed practice had the potential to affect the hospice’s ability to define, implement and maintain an ongoing quality improvement program and to ensure patient safety for all patients and staff. --- Findings: A review of governing body meeting minutes and QAPI program records showed no governing body oversite of an ongoing QAPI program for the hospice that included data collection, analysis, reporting activities and oversite determination for calendar years 2023, 2024 and 01/01/25 to 06/03/25. On 08/15/25 at 8:40 a.m., Staff A stated the hospice had no QAPI program activities in 2023, 2024 and for 1st and 2nd quarters of 2025 to report to the governing body for oversite.

Based on record review and interview, the hospice failed to ensure its infection control program surveillance monitoring and reporting was included in QAPI program activities for calendar year 2023, 2024 and 01/01/25 to 06/30/25 for all patients and staff. --- Findings: A review of QAPI program records showed no infection control surveillance data was included in QAPI program activities for calendar year 2023, 2024 and 01/01/25 to 06/30/25. On 08/15/24 at 8:40 a.m., Staff A stated there was no infection control program surveillance data included in the QAPI program.

Based on a record review and interview, the hospice failed to ensure multi-disciplined staff were available to participate and provide input into its QAPI program activities for all patients and staff. --- Findings:A review of QAPI program records showed no multi-disciplined staff participation in QAPI program activities for calendar years 2023, 2024 and 01/01/25 to 06/30/25. On 08/15/25 at 8:40 a.m., Staff A stated the hospice had no QAPI program records which showed multi-disciplined staff participation for the hospice.

Based on a record review and interview, the hospice failed to ensure certification or completion of alternative training requirements to meet the qualifications of a hospice aide for one (Staff G) of five employees reviewed. --- Findings: Staff GA review of personnel records showed certification as a Long-Term Care Aide which expired on 02/28/25. The personnel record showed no current home health aide certification and showed no completion of alternative training requirements to meet the qualifications of a hospice aide. Additional request for information yielded no results. On 08/15/24 at 11:00 a.m., Staff A stated the personnel record (for Staff G) showed no documentation of current home health aide certification or completion of alternative training requirements that met the qualifications of a hospice aide.

Based on record review and interview, the hospice failed to ensure continued review and update of hospice aide care plans for 10 (Patients #1, 2, 3, 4, 6, 7, 9, 10, 11 and #14) of 15 patients. --- Findings: Patient #1A review of the plan of care dated 08/03/25 to 10/01/25 and IDG plan of care updates dated 08/06/25 ordered hospice aide visits three times a week. The POC showed no update to the hospice aide care plan dated 10/11/24. Patient #2A review of the plan of care dated 08/07/25 to 10/05/25 and IDG plan of care updates dated 08/06/25 ordered hospice aide visits three times a week. The POC showed no update to the hospice aide care plan dated 09/06/24.  Patient #3A review of the plan of care dated 07/18/25 to 09/15/25 and IDG plan of care updates dated 07/08/25, 07/23/25 and on 08/06/25 ordered hospice aide visits three times a week. The POC showed no update to the hospice aide care plan dated 03/20/25.  Patient #4A review of the plan of care dated 06/25/25 to 08/23/25 and IDG plan of care updates dated 06/11/25, 06/25/25, 07/09/25, 07/23/25 and 08/06/25 ordered hospice aide visits three times a week. The POC showed no update to the hospice aide care plan dated 08/29/24. Patient #6A review of the plan of care dated 08/03/25 to 10/01/25 and IDG plan of care updates dated 08/06/25 ordered hospice aide visits two times a week. The POC showed no update to the hospice aide care plan dated 10/08/24. Patient #7A review of the plan of care dated 07/14/25 to 09/11/25 and IDG plan of care updates dated 07/09/25, 07/23/25 and on 08/06/25 ordered hospice aide visits two times a week. The POC showed no update to the hospice aide care plan dated 05/15/25. Patient #9A review of the plan of care dated 06/19/25 to 08/17/25 and IDG plan of care updates dated 06/17/25, 07/01/25, 07/15/25, 07/29/25 and on 08/12/25 ordered hospice aide visits two times a week. The POC showed no update to the hospice aide care plan dated 11/25/24. Patient #10A review of the plan of care dated 06/22/25 to 08/20/25 and IDG plan of care updates dated 06/17/25, 07/01/25, 07/15/25, 07/29/25 and on 08/12/25 ordered hospice aide visits two times a week. The POC showed no update to the hospice aide care plan dated 12/26/24. Patient #11A review of the plan of care dated 02/05/25 to 04/05/25 and IDG plan of care updates dated 01/22/25, 02/05/25, 02/19/25 and on 03/05/25 ordered hospice aide visits two times a week. The POC showed no update to the hospice aide care plan dated 06/16/23. Patient #14A review of the plan of care dated 01/28/25 to 03/28/25 and IDG plan of care updates dated 01/22/25, 02/05/25, 02/19/25 and on 03/05/25 ordered hospice aide visits three times a week. The POC showed no update to the hospice aide care plan dated 10/08/24.On 08/15/25 at 1:40 p.m., Staff A stated we do not update the hospice aide care plans every certification period.

Based on record review and interview, the hospice failed to ensure volunteer services were a part of the hospice program for 15 (Patients# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15) of 15 patients, caregivers, and staff. The failed practice affected the hospice’s ability to provide a core service to enhance the patients and caregiver’s hospice experience. See tag L645. Based on record review and interview, the hospice failed to ensure volunteer services were a part of the hospice program for 15 (Patients# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15) of 15 patients, caregivers, and staff. The failed practice prohibited the hospice’s ability to meet the condition of participation target of 5% volunteer personnel utilization of total patient care hours in a year to enhance the patient and caregiver’s hospice care experience. See tag L647.. --- .

Based on record review and interview, the hospice failed to ensure volunteer services were a part of the hospice program for 15 (Patients# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15) of 15 patients, caregivers, and staff. The failed practice affected the hospice’s ability to provide a core service to enhance the patients and caregiver’s hospice experience. --- Findings: A review of administrative records showed the hospice program had no volunteer personnel and showed no volunteer activities from 05/12/23 (end date of the pandemic waiver) to 08/13/25.  On 08/15/25 at 9:00 a.m., Staff A stated:1.    The hospice had no administrative records which showed volunteer service activities from 05/12/23 to 08/13/25.2.    The hospice had no volunteer personnel.

Based on record review and interview, the hospice failed to ensure volunteer services were a part of the hospice program for 15 (Patients# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15) of 15 patients, caregivers, and staff. The failed practice prohibited the hospice’s ability to meet the condition of participation target of 5% volunteer personnel utilization of total patient care hours in a year to enhance the patient and caregiver’s hospice care experience. --- Findings: A review of administrative records showed the hospice program had no volunteer services from 05/12/23 (end date of the pandemic waiver) to 08/13/25.  On 08/15/25 at 9:00 a.m., Staff A stated the hospice had no volunteer personnel and no volunteer activities.

Based on record review and interview, the hospice failed to ensure clinical notes were included in the clinical records for two (Patients # 4 and #6) of 15 patients. --- Findings: Patient #4A review of the plan of care dated 06/25/25 to 08/23/25 showed a skilled nurse frequency of two times a week.  A review of the clinical record showed no skilled nurse notes for SN visit on 08/04/25. The clinical record showed no changes in the frequency ordered, no missed visit notes and no refusal of visits.   On 08/15/25 at 1:15 p.m., Staff A stated the SN note from 08/04/25 was not available because the nurse had not documented it in the clinical record.   Patient #6A review of the plan of care dated 08/03/25 to 10/01/25 showed a skilled nurse frequency of two times a week.  A review of the clinical record showed no skilled nurse notes for SN visit on 08/04/25. The clinical record showed no changes in the frequency ordered, no missed visit notes and no refusal of visits.   On 08/15/25 at 1:18 p.m., Staff A stated the SN note from 08/04/25 was not available because the nurse had not documented it in the clinical record.

Findings: Patient #5A review of the clinical record showed no consent/election of benefit form for a start of care date of 07/06/25. On 08/15/25 at 1:17 p.m., Staff A stated there was no consent/election of benefit form from the start of care date on 07/06/25. Patient #14A review of the clinical record showed no consent/election of benefit form for a start of care date of 10/08/24. On 08/15/25 at 1:17 p.m., Staff A stated there was no consent/election of benefit form from the start of care date on 10/08/24. Patient #15A review of the clinical record showed no consent/election of benefit form for a start of care date of 01/19/25. On 08/15/25 at 1:38 p.m., Staff A stated there was no consent/election of benefit form from the start of care date on 01/19/25.

Based on record review and interview, the hospice failed to ensure effective pain management was provided for one (Patient #14) of 14 patients. --- Patient #14 A review of the plan of care dated 08/18/22 to 10/16/22 showed a primary diagnosis of malignant neoplasm of upper-outer right female breast and documented a skilled nurse frequency of two visits per week. A review of the medical record showed the following: A skilled nurse assessment dated 08/18/22 documented the patient's pain as 8 out of 10 on the classic 0-10 pain scale. Documentation showed no interventions provided and no physician notification of the elevated pain level. A skilled nurse assessment dated 08/20/22 documented the patient's pain as 7 out of 10 on the classic 0-10 pain scale. Documentation showed the physician was notified. Documentation showed medication changes of Fentanyl 25 (patch) micrograms every 72 hours and Oxycodone 30 milligrams one tablet every 6 hours as needed (breakthrough pain). A skilled nurse assessment dated 08/23/22 documented the patient's pain as 7 out of 10 on the classic 0-10 pain scale. Documentation showed no interventions provided. A Chaplain assessment dated 08/26/22 documented the patient pain as 9 out of 10 on the classic 0-10 pain scale. A skilled nurse assessment dated 08/26/22 documented the patient's pain as 8 out of 10 on the classic 0-10 pain scale. Documentation showed the patient reported the Fentanyl 25 microgram patch was causing reactions such as headache, skin rash and was ineffective with managing pain. The physician was contacted with orders to increase the Fentanyl patch to 50 micrograms every 72 hours and decrease the Hydrocodone 30 milligrams to one table once per day as needed for increased pain. Documentation showed the patient and patient care giver were "very unhappy" with this medication change. The patient requested to speak with the physician. A skilled nurse assessment dated 08/30/22 documented the patient's pain as 8 out of 10 on the classic 0-10 pain scale. Documentation showed the patient argued with the physician about the current pain management plan not being effective. The patient stated the Fentanyl patch was not effective. The patient reported "butt rash, face swelling, headache and stomach cramping." The physician "educated the patient" on the benefits of the Fentanyl patch outweighing the risks. Orders were received to increase the Fentanyl patch to 100 micrograms every 72 hours. A skilled nurse assessment dated 09/01/22 documented the patient's pain as 7 out of 10 on the classic 0-10 pain scale. The patient stated the current pain medications were helping but not adequately relieving her pain. The patient reported pain medications that have helped in the past to relieve her pain. Documentation showed no interventions provided and no physician notification of the elevated pain level. A skilled nurse assessment dated 09/05/22 documented the patient's pain as 7 out of 10 on the classic 0-10 pain scale. The patient stated the current pain medications were helping but not adequately relieving her pain. The patient reported pain medications that have helped in the past to relieve her pain. Documentation showed no interventions provided and no physician notification of the elevated pain level. A skilled nurse assessment dated 09/08/22 documented the patient's pain as 8 out of 10 on the classic 0-10 pain scale. Documentation showed the patient's caregiver was argumentative and questioning the current pain management regimen of Fentanyl. Caregiver reported the patch is making the pain worsen. Caregiver stated they didn't want the patient to have the Fentanyl patch because of the side effects and stated, "it took us a while to find the pain medications OXYIR that worked best and why changing it now?" Patient and caregiver were demanding for short acting pain medications to manage her pain. Patient reported the Fentanyl patch was ineffective. Documentation showed no interventions provided and no physician notification of the elevated pain level. A skilled nurse assessment dated 09/12/22 documented the patient's pain as 7 out of 10 on the classic 0-10 pain scale. Documentation showed the patient reported she needed more short acting pain medication to manage her pain. The patient's pain medication was changed to OXYER 120 milligrams twice a day and OXYIR 30 milligrams one daily as needed. A skilled nurse assessment dated 09/18/22 documented the patient's pain as 8 out of 10 on the classic 0-10 pain scale. Documentation showed the patient reported she needed more short acting pain medications to manage her pain. Patient reported her current pain medication was effective but took over an hour to before she felt relief from pain and she did not want to wait that long for pain relief. Patient caregiver believed the nurse was not advocating well enough. Documentation showed no interventions provided and no physician notification of the elevated pain level. On 06/16/23 at 10:25 am, Staff A stated the pain for Patient #14 was not properly managed.

Based on record review and interview, the hospice failed to ensure patient and patient caregiver to participate in development of the plan of care regarding effective pain management for one (Patient #14) of 14 patients. --- Patient #14 A review of the plan of care dated 08/18/22 to 10/16/22 with plan of care updates dated 08/24/22, 09/07/22 and 09/21/22 showed a primary diagnosis of malignant neoplasm of upper-outer right female breast and documented a skilled nurse frequency of two visits per week. A review of the medical record showed the following: A skilled nurse assessment dated 08/26/22 documented the patient's pain as 8 out of 10 on the classic 0-10 pain scale. Documentation showed the patient reported the Fentanyl 25 microgram patch was causing reactions such as headache, skin rash and was ineffective with managing pain. The physician was contacted with orders to increase the Fentanyl patch to 50 micrograms every 72 hours and decrease the Hydrocodone 30 milligrams to one table once per day as needed for increased pain. Documentation showed the patient and patient care giver were "very unhappy" with this medication change. The patient requested to speak with the physician. A skilled nurse assessment dated 08/30/22 documented the patient's pain as 8 out of 10 on the classic 0-10 pain scale. Documentation showed the patient argued with the physician about the current pain management plan not being effective. The patient stated the Fentanyl patch was not effective. The patient reported "butt rash, face swelling, headache and stomach cramping." The physician "educated the patient" on the benefits of the Fentanyl patch outweighing the risks. Orders were received to increase the Fentanyl patch to 100 micrograms every 72 hours. A skilled nurse assessment dated 09/01/22 documented the patient's pain as 7 out of 10 on the classic 0-10 pain scale. The patient stated the current pain medications were helping but not adequately relieving her pain. The patient reported Oxycodone six times a day worked better for pain management. Documentation showed no interventions provided and no physician notification of the elevated pain level. A skilled nurse assessment dated 09/05/22 documented the patient's pain as 7 out of 10 on the classic 0-10 pain scale. The patient stated the current pain medications were helping but not adequately relieving her pain. The patient reported Oxycodone six times a day worked better for pain management. Documentation showed no interventions provided and no physician notification of the elevated pain level. A skilled nurse assessment dated 09/08/22 documented the patient's pain as 8 out of 10 on the classic 0-10 pain scale. Documentation showed the patient's caregiver was argumentative and questioning the current pain management regimen of Fentanyl. Caregiver reported the patch is making the pain worsen. Caregiver stated they didn't want the patient to have the Fentanyl patch because of the side effects and stated, "it took us a while to find the pain medications OXYIR that worked best and why changing it now?" Patient and caregiver were demanding for short acting pain medications to manage her pain. Patient reported the Fentanyl patch was ineffective. Documentation showed no interventions provided and no physician notification of the elevated pain level. A skilled nurse assessment dated 09/12/22 documented the patient's pain as 7 out of 10 on the classic 0-10 pain scale. Documentation showed the patient reported she needed more short acting pain medication to manage her pain. The patient's pain medication was changed to OXYER 120 milligrams twice a day and OXYIR 30 milligrams one daily as needed. A skilled nurse assessment dated 09/18/22 documented the patient's pain as 8 out of 10 on the classic 0-10 pain scale. Documentation showed the patient reported she needed more short acting pain medications to manage her pain. Patient reported her current pain medication was effective but took over an hour to before she felt relief from pain and she did not want to wait that long for pain relief. Patient caregiver believed the nurse was not advocating well enough. On 06/16/23 at 10:25 am, Staff A stated the plan of care was not updated to reflect the patient or caregiver wishes regarding pain management.

Based on record review and interview, the hospice failed to ensure the right to refuse treatment for one (Patient #14) of 14 patients. --- Patient #14 A review of the plan of care dated 08/18/22 to 10/16/22 showed a primary diagnosis of malignant neoplasm of upper-outer right female breast and documented a skilled nurse frequency of two visits per week. A review of the medical record showed the following: A skilled nurse assessment dated 08/26/22 documented the patient's pain as 8 out of 10 on the classic 0-10 pain scale. Documentation showed the patient reported the Fentanyl 25 microgram patch was causing reactions such as headache, skin rash and was ineffective with managing pain. The physician was contacted with orders to increase the Fentanyl patch to 50 micrograms every 72 hours and decrease the Hydrocodone 30 milligrams to one table once per day as needed for increased pain. Documentation showed the patient and patient care giver were "very unhappy" with this medication change. The patient requested to speak with the physician. A skilled nurse assessment dated 08/30/22 documented the patient's pain as 8 out of 10 on the classic 0-10 pain scale. Documentation showed the patient argued with the physician about the current pain management plan not being effective. The patient stated the Fentanyl patch was not effective. The patient reported "butt rash, face swelling, headache and stomach cramping." The physician "educated the patient" on the benefits of the Fentanyl patch outweighing the risks. Orders were received to increase the Fentanyl patch to 100 micrograms every 72 hours. A skilled nurse assessment dated 09/01/22 documented the patient's pain as 7 out of 10 on the classic 0-10 pain scale. The patient stated the current pain medications were helping but not adequately relieving her pain. The patient reported Oxycodone six times a day worked better for pain management. A skilled nurse assessment dated 09/05/22 documented the patient's pain as 7 out of 10 on the classic 0-10 pain scale. The patient stated the current pain medications were helping but not adequately relieving her pain. The patient reported Oxycodone six times a day worked better for pain management. A skilled nurse assessment dated 09/08/22 documented the patient's pain as 8 out of 10 on the classic 0-10 pain scale. Documentation showed the patient's caregiver was argumentative and questioning the current pain management regimen of Fentanyl. Caregiver reported the patch is making the pain worsen. Caregiver stated they didn't want the patient to have the Fentanyl patch because of the side effects and stated, "it took us a while to find the pain medications OXYIR that worked best and why changing it now?" Patient and caregiver were demanding for short acting pain medications to manage her pain. Patient reported the Fentanyl patch was ineffective. A skilled nurse assessment dated 09/18/22 documented the patient's pain as 8 out of 10 on the classic 0-10 pain scale. Documentation showed the patient reported she needed more short acting pain medications to manage her pain. Patient reported her current pain medication was effective but took over an hour to before she felt relief from pain and she did not want to wait that long for pain relief. Patient caregiver believed the nurse was not advocating well enough. On 06/16/23 at 10:25 am, Staff A stated Patient #14 the agency failed to follow the patient's refusal of the use of Fentanyl patches.

Based on record review and interview, the hospice failed to ensure the comprehensive assessment included data elements (with the exception of pain) that allowed for measurement of outcomes for six (Patients #2, 3, 5, 6, 7 and 11) of 14 patients. --- Patient #2 A review of the Initial Assessment dated 05/19/23 showed no data elements (with the exception of pain) included in the comprehensive assessment. Patient #3 A review of the Initial Assessment dated 05/19/23 showed no data elements (with the exception of pain) included in the comprehensive assessment. Patient #5 A review of the Initial Assessment dated 03/24/23 showed no data elements (with the exception of pain) included in the comprehensive assessment. Patient #6 A review of the Initial Assessment dated 04/26/23 showed no data elements (with the exception of pain) included in the comprehensive assessment. Patient #7 A review of the Initial Assessment dated 05/16/23 showed no data elements (with the exception of pain) included in the comprehensive assessment. Patient #11 A review of the Initial Assessment dated 11/02/22 showed no data elements (with the exception of pain) included in the comprehensive assessment. On 06/16/23 at 10:40 am, Staff A stated pain was the only data element which was documented on the initial comprehensive assessments for Patients #2, 3, 5, 6, 7, and 11.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for eleven (Patients #1, 2, 3, 4, 5, 6, 7, 10, 11, 13 and 14) of 14 patients reviewed. --- Patient #1 A review of the plan of care dated 02/16/23 to 05/16/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #2 A review of the plan of care dated 05/19/23 to 07/11/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #3 A review of the plan of care dated 05/30/23 to 08/27/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #4 A review of the plan of care dated 04/22/23 to 07/20/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #5 A plan of care dated 03/24/23 to 06/21/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #6 A plan of care dated 04/26/23 to 06/24/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #7 A review of the plan of care dated 05/16/23 to 08/13/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #10 A review of the plan of care dated 005/17/23 to 07/15/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #11 A plan of care dated 11/02/22 to 01/30/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #13 A plan of care dated 11/23/22 to 02/20/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #14A plan of care dated 08/18/23 to 10/16/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 06/16/22 at 10:20 am, Staff A stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 7, 10, 11, 13 and 14 failed to include services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to ensure quality indicator data was used in it's design of the QAPI program for all 29 current patients and any new patients admitted to the hospice. --- A review of QAPI records showed no use of quality indicator data in the QAPI program documentation for 2021, 2022 and 2023. On 06/16/23 at 10:50 am, Staff A stated the QAPI program did not include the use of quality indicator data.

Based on record review and interview, the agency failed to ensure a coordinated plan of care was developed with long term care facilities for three (Patients #1, 4 and 11) of 14 patients. --- Patient #1 A review of the clinical record and review of long-term care records showed no coordinated plan of care between the agency and the long-term care facility for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #4 A review of the clinical record and review of long-term care records showed no coordinated plan of care between the agency and the long-term care facility for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #11 A review of the clinical record and review of long-term care records showed no coordinated plan of care between the agency and the long-term care facility for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 06/16/23 at 2:15 pm, Staff A stated there was no coordinated plan of care with long term care facilities for Patients #1, 4 and 11.