Every finding on record at Community Hospices of America, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy and procedure #HOS-C_15C "Medication Reconciliation and Management" (revised 01/24/2025) read in part, "For patients residing in their own residence, it is the responsibility of the hospice nurse to perform the following steps at each scheduled nursing visit: 1. Nurse obtains the most current copy of the medication list. 2. Nurse visually reviews the patient's medication list in the home, comparing it to the medication list from the medical record. 4. If the medication lists do NOT match, the nurse ensures the incorrect list is promptly updated to reflect the correct orders and the medication reconciliation process is completed." In 1 of 23 (4%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current prescription and OTC drugs. Clinical Record 4/Home Visit 4: The patient elected hospice care on 08/08/2024 with a diagnosis of Parkinsonism. During the home visit with the Chaplain (CH) [Personnel Record 4] on 02/04/2025, the patient's medication list (updated by the daughter on 01/08/2025) was reviewed. The patient's daughter was not present during the home visit. The patient's medication list and the medications in the home did not match the hospice medication profile or the Hospice IDG Comprehensive Assessment. The hospice medication profile did not document Preservision, one (1) pill two times daily, and donepezil 5 mg tablet daily. A clinical record review revealed the medications were reviewed with the patient's medication regimen. However, Preservision and donepezil were not documented in the hospice medication profile. During a joint phone call on 02/05/2025 with the Director of Clinical Services, the patient's home medication list was reviewed with the patient's daughter, who stated in part, "Mom has been taking both of those medications (Preservision and donepezil) for a while." During a joint record review and interview on 02/05/2025, the Director of Clinical Services confirmed that Preservision and donepezil were not documented on the medication profile for clinical record 4.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met, as evidenced by clinical record review, document review, and interview. In 2 of 23 (9%) clinical records reviewed, the agency did not ensure that a Registered Nurse provided coordination of care to ensure continuous assessment of the patient and family needs and implementation of the interdisciplinary plan of care. Agency policy #HOS-C15 "Nursing Services" (reviewed 12/24/2024) stated in part "Nursing services include the following: g. Collaboration with the interdisciplinary team and coordination of all patient care/support activities." Clinical Record 6: The patient elected hospice on 05/09/2024 with a diagnosis of other sequelae of cerebral infarction. The volunteer assignment completed on 08/27/2024 documented volunteer services four (4) times a month beginning in September for patient companion visits and socialization. Two (2) volunteer visits were documented in September. The coordination note completed by the Volunteer Coordinator on 09/27/2024 documented, "Visits will be paused for a while. Volunteer is out with a surgery. Paused on 09/19/2024." A clinical record revealed no evidence that the Registered Nurse coordinated with the interdisciplinary group to ensure the implementation of the interdisciplinary plan of care to meet the patient's volunteer needs for companionship and socialization needs. Clinical Record 12: The patient elected hospice on 06/14/2024 with a diagnosis of Alzheimer's Disease. The volunteer assignment request dated 06/17/2024 documented, "Patient wants/needs a volunteer. Patient needs socialization, caregiver needs socialization." The volunteer assignment completed on 07/30/2024 documented volunteer services two (2) times per month for patient companion visits and life review video/audio/journal. A clinical record revealed no evidence that the Registered Nurse coordinated with the interdisciplinary group to ensure the implementation of the interdisciplinary plan of care to meet the patient's volunteer needs for companionship and socialization needs. During the joint record review and interview on 02/05/2025, the Director of Clinical Services confirmed that the clinical records lacked evidence that the RN coordinated with the interdisciplinary group regarding volunteer needs identified in the initial and updated comprehensive assessments.

It is required that each patient’s individualized written plan of care: reflects patient, and family goals; [and] 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 #C9 "Written Interdisciplinary Plan of Care" (revised 09/27/2019) stated in part, "The content of the plan of care includes at minimum: a. An assessment of the the patient's and family's needs and goals f. Measurable goals and outcomes for planned interventions." In 5 of 23 (22%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected patient and family goals and identified planned interventions based on problems identified in the comprehensive assessments. Clinical Record 2: The patient elected hospice care on 11/29/2024 with a diagnosis of unspecified sequelae of cerebral infarction. On 12/27/2024, the physician ordered Bactrim DS 800 mg-160 mg, one (1) tab twice daily for urinary tract infection (UTI). A coordination note dated 12/27/2024 documented, "Noted urine in drainage bag to be dark and cloudy. Notified Dr. (name) of patient's (pts) symptoms and received a new order for Bactrim DS BIDx7D." On 12/31/2024 the physician ordered wound care "Coccyx wound-cleanse area to coccyx with wound cleanser, apply barrier cream bid and prn." The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 01/03/2025 and 01/17/2025 did not document patient and family goals and planned interventions for the identified urinary tract infection and coccyx wound. Clinical Record 8: The patient elected hospice care on 08/19/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). On 01/13/2025, the physician ordered, "Amoxicillin 875 mg 1 tablet by mouth 2 times daily for 7 days Reason: UTI." The skilled nursing (SN) visit dated 01/13/2025 documented, "Foley draining blood-tinged urine with sediment, pt complains of burning in the genital area. New order received from Dr. (name) for Amoxicillin 875mg 1 PO BID X7D." The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 01/17/2025 and 01/31/2025 did not document patient and family goals and planned interventions for the identified urinary tract infection. Clinical Record 13: The patient elected hospice care on 05/28/2024 with a diagnosis of COPD. On 01/13/2025, the physician ordered, "Doxycycline 100mg capsule by mouth 2 times daily for 7 days Reason: respiratory infection." The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 01/17/2025 and 01/31/2025 did not document patient and family goals and planned interventions for the identified respiratory infection. Clinical Record 18: The patient elected hospice care on 12/31/2024 with a diagnosis of malignant neoplasm of an unspecified part of the lung. The initial nursing assessment visit dated 12/31/2024 documented a "safety concern related to handling/storage/use of oxygen." The SN visit dated 01/01/2025 documented, "Indicate when dyspnea occurs at rest. PCGR states he is always dyspneic but it is worse tonight... Assisted pt to sitting position and with nebulizer (neb) treatment (tx)." The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 01/03/2025 and 01/17/2025 did not document patient and family goals and planned interventions for the identified dyspnea and oxygen safety. Clinical Record 19: The patient elected hospice care on 03/04/2024 with a diagnosis of senile degeneration of the brain. On 07/10/2024, the physician ordered, "Bactrim DS 800/160mg 1 tablet by mouth every 12 hours x 7 days for UTI." The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 07/19/2024 did not document patient and family goals and planned interventions for the identified urinary tract infection. In a joint record review and an interview on 02/05/2025, the Director of Clinical Services confirmed that clinical record 2 did not include patient and family goals and planned interventions for urinary tract infection and coccyx wound, clinical record 8 did not document patient and family goals and planned interventions for urinary tract infection, clinical record 13 did not document patient and family goals and planned interventions for respiratory infection, clinical record 18 did not document patient and family goals and planned interventions for dyspnea and oxygen safety, and clinical record 19 did not document patient and family goals and planned interventions for urinary tract infection.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 23 (4%) clinical records reviewed and home visits observed, the agency did not ensure that the patient's plan of care included drugs necessary to meet the needs of the patient. Clinical Record 4/Home Visit 4: The patient elected hospice care on 08/08/2024 with a diagnosis of Parkinsonism. During the home visit with the Chaplain (CH) [Personnel Record 4] on 02/04/2025, the patient's medication list (updated by the daughter on 01/08/2025) was reviewed. The patient's daughter was not present during the home visit. The patient's medication list and the medications in the home included Preservision, one (1) pill two times daily, and donepezil 5 mg tablet daily. During a joint phone call on 02/05/2025 with the Director of Clinical Services, the patient's home medication list was reviewed with the patient's daughter, who stated in part, "Mom has been taking both of those medications (Preservision and donepezil) for a while." The patient's Plan of Care Update Reports, effective 01/17/2025 and 01/31/2025, did not document Preservision and donepezil. During a joint record review and interview on 02/05/2025, the Director of Clinical Services confirmed that Preservision and donepezil were not documented on the medication profile and Plan of Care Update Reports.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene; [and] use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, interview, and observation. Agency policy #IPC.11 "Infection Control" (revised 09/30/2024) stated in part, "Infection control measures-Compassus utilizes reference materials from the Centers for Disease Control and Prevention for the development and implementation of infection control measures. Guideline for Hand Hygiene in Health Care Settings, CDC Morbidity and Mortality Weekly Report (MMWR)." The MMWR read in part, "Indications for hand hygiene-After glove removal." In 1 of 6 (17%) home visit observations, the agency did not ensure that hand hygiene was performed when indicated per the agency's policy. Home Visit 3: The patient elected hospice care on 07/08/2022 with a diagnosis of senile degeneration of the brain. The RN provided peri care during the home visit with the Registered Nurse (RN) [Personnel Record 3] on 02/04/2025. After providing peri care, the RN changed their gloves. The RN did not perform hand hygiene after changing/removing gloves per the policy. During an interview on 02/04/2025, the Director of Clinical Services confirmed the finding and the agency policy that hands should be cleansed between and after glove removal.

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C12, "Personnel Qualifications and Licensed Services" (revised 08/18/2022), stated in part, "LP/VNs are supervised by registered nurses not less than every month." In 2 of 20 (10%) clinical records reviewed of patients that received Licensed Practical Nurse (LPN) visits, the agency did not ensure that a Registered Nurse (RN) provided supervision of the LPN nursing services per agency policy. Clinical Record 4: The patient elected hospice care on 08/08/2024 with a diagnosis of Parkinsonism. The plan of care dated 08/08/2024 through 11/05/2025 ordered skilled nursing (SN) services once (1) weekly beginning 08/08/2024. The LPN completed nursing visits on 08/14/2024 and 09/01/2024. A clinical record review revealed no evidence that LPN supervisory visits were completed in August and September per agency policy. Clinical Record 8: The patient elected hospice care on 08/19/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The recertification plans of care dated 08/19/2024 through 11/16/2025 and 11/17/2024 through 02/14/2025 ordered SN services twice (2) weekly beginning 08/19/2024. The LPN completed nursing visits on 12/06/2024, 12/13/2024, 12/20/2024, 12/23/2024, 12/27/2024, and 01/17/2025. An LPN supervisory visit was completed on 11/25/2024. A clinical record review revealed no evidence that LPN supervisory visits were completed in December and January per agency policy. In a joint record review and interview on 02/05/2025, the Director of Clinical Services confirmed that LPN supervisory visits were not completed per agency policy, not less than monthly.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C12, “Personnel Qualifications and Licensed Services” (revised 08/18/2022), stated in part, “Hospice Aides are supervised by registered nurses not less than every 14 days.” In 4 of 16 (25%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that a Registered Nurse (RN) made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the HA. Clinical Record 7: The patient elected hospice care on 06/05/2024 with a diagnosis of chronic diastolic heart failure. The recertification plan of care dated 12/02/2024 through 01/30/2025 ordered HA services twice (2) weekly beginning 12/02/2024. The HA visits were provided beginning 12/02/2024 as ordered. The HA supervisory visits were provided on 12/03/2024 and 12/20/2025, with 17 days outstanding. Clinical Record 8: The patient elected hospice care on 08/19/2024 with a diagnosis of chronic obstructive pulmonary disease. The recertification plan of care dated 11/17/2024 through 02/14/2025 ordered HA services twice (2) weekly beginning 11/17/2024. The HA visits were provided beginning 11/17/2024 as ordered. The HA supervisory visits were provided on 01/03/2025 and 01/20/2025, with 17 days outstanding. Clinical Record 14: The patient elected hospice care on 05/16/2024 with a diagnosis of unspecified sequelae of cerebral infarction. The recertification plans of care dated 08/15/2024 through 11/11/2024 and 11/12/2024 through 01/10/2025 ordered HA services twice (2) weekly beginning 11/11/2024. The HA visits were provided beginning 11/11/2024 as ordered. The HA supervisory visits were provided on 10/29/2024 and 11/29/2024, with 31 days outstanding. Clinical Record 19: The patient elected hospice care on 03/04/2024 with a diagnosis of senile degeneration of the brain. The recertification plan of care dated 06/02/2024 through 07/23/2024 ordered HA services three (3) times weekly beginning 06/02/2024. The HA visits were provided beginning 06/02/2024 as ordered. The HA supervisory visits were provided on 06/10/2024 and 06/28/2024, with 4 days outstanding. In a joint record review and interview on 02/05/2025, the Director of Clinical Services confirmed that, per agency policy, HA supervisory visits were not completed every 14 days.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are: noted in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C20 "Volunteer Services" (reviewed 12/24/2024) stated in part, "Volunteers, under the supervision of the volunteer coordinator, provide both patient support and administrative support in a manner and amount consistent with the program's identified needs." In 2 of 6 (33%) clinical records reviewed of patients with identified volunteer needs, the agency did not ensure volunteers were used in day-to-day direct patient care roles and noted in the plan of care based on needs identified in the initial and updated comprehensive assessments. Clinical Record 6: The patient elected hospice on 05/09/2024 with a diagnosis of other sequelae of cerebral infarction. The volunteer assignment completed on 08/27/2024 documented volunteer services four (4) times a month beginning in September for patient companion visits and socialization. Two (2) volunteer visits were documented in September. The coordination note completed by the Volunteer Coordinator on 09/27/2024 documented, "Visits will be paused for a while. Volunteer is out with a surgery. Paused on 09/19/2024." A clinical record revealed no evidence that the volunteer services were provided, that the patient declined volunteer visits, or that the interdisciplinary group team members increased the frequency of visits to address the patient's companionship and socialization needs. Clinical Record 12: The patient elected hospice on 06/14/2024 with a diagnosis of Alzheimer's Disease. The volunteer assignment request dated 06/17/2024 documented, "Patient wants/needs a volunteer. Patient needs socialization, caregiver needs socialization." The volunteer assignment completed on 07/30/2024 documented volunteer services two (2) times per month for patient companion visits and life review video/audio/journal. A clinical record review revealed no evidence that the volunteer services were provided, the patient declined volunteer visits, or that the interdisciplinary group team members increased the frequency of visits to address the patient and caregiver socialization needs. During the joint record review and interview on 02/05/2025, the Director of Clinical Services (personnel interview 13) confirmed that the clinical record did not include evidence that volunteer services were implemented based on needs identified in the initial and comprehensive assessments.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C31 "Clinical Records" (revised 01/25/2023) stated in part, "Entries into the EMR are to be completed on the date of the visit when at all possible and not later than 10 am the next business day." In 2 of 23 (9%) clinical records reviewed, the agency did not ensure that documentation was completed per the organization's policy. Clinical Record 2: The patient elected hospice care on 11/29/2024 with a diagnosis of unspecified sequelae of cerebral infarction. The Licensed Practical Nurse (LPN) visited the patient on 12/12/2024. The LPN visit note documentation was submitted on 12/15/2024, with one (1) business day outstanding. The Registered Nurse (RN) visited the patient on 12/17/2024. The RN visit note documentation was submitted on 12/22/2024, with three (3) business days outstanding. The RN visited the patient on 12/31/2024. The RN visit note documentation was submitted on 01/06/2025, with three (3) business days outstanding. The RN visited the patient on 01/09/2025. The RN visit note documentation was submitted on 01/12/2025, one (1) business day after the services provided. The LPN visited the patient on 01/14/2025. The LPN visit note documentation was submitted on 01/20/2025, with three (3) business days outstanding. A clinical record review revealed no evidence that the documentation was submitted timely per the agency policy. Clinical Record 8: The patient elected hospice care on 08/19/2024 with a diagnosis of chronic obstructive pulmonary disease. The RN visited the patient on 01/13/2025. The RN visit note documentation was submitted on 01/15/2025, with two (2) business days outstanding. A clinical record review revealed no evidence that the documentation was submitted timely per the agency policy. In a joint record review and interview on 02/05/2025, the Director of Clinical Services confirmed that documentation was not submitted timely per agency policy for clinical records 2 and 8.

Based on policy review, record review, and interviews the hospice provider failed to follow agency policy and ensure the patient received effective pain management in one (Record/Patient #1) of three sampled patients reviewed. The deficient practice has the potential to affect all patients on service with the hospice. Findings included: --- Review of the hospice policy titled "Pain Management", last revised in 2019 showed in part the following: At every nursing visit, fully assess and document the patient's pain, pain interventions, and outcomes; Assess the patients "self-identified threshold (SIT) for pain. This threshold is established at every nursing visit and pain is evaluated against this threshold; If the patient has pain above his/her SIT, or express dissatisfaction with his/her pain management, the nurse will contact the physician, obtain orders, and will implement the intervention. The nurse will ensure the patient is at or below his/her SIT before leaving the patient; The nurse will also follow-up with the patient within 24-hours to assess the effectiveness of the intervention(s) and will document the patient's ongoing pain management; If the patient has pain above his/her SIT, the nurse will visit the patient and perform a full assessment and evaluate utilization of the new intervention. The nurse will notify the physician if the intervention is ineffective and obtain revised orders; and The nurse will follow-up daily until the pain is well managed at or below the patient's SIT/satisfaction. RECORD/PATIENT #1: Review of the hospice plan of care showed that the patient was admitted to hospice service on 03/29/2022 for Lung Cancer. Review of the plan of care and medication profile showed that the patient had the following primary pain management medication orders during his/her hospice admission: On 03/29/2022 Duloxetine 60 mg (milligrams) twice daily (BID) was started. On 03/29/2022 Morphine liquid 5mg every three hours as needed (PRN) was started; On 03/29/2022 Hydromorphone 4 mg every three hours PRN was ordered. This medication was discontinued/changed on 07/05/2022; On 03/29/2022 Fentanyl Patch 50 mcg (micrograms) per hour every three days was ordered. This medication was changed/discontinued on 04/01/2022; On 04/01/2022 Fentanyl Patch (an opioid) 100 mcg (micrograms) per hour every three days was ordered. This medication was changed/discontinued on 07/05/2022; On 04/27/2022 Dilaudid (Hydromorphone-an opioid) 8 mg every four hours PRN was started, this medication was discontinued on 10/12/2022; On 05/17/2022 Fentanyl Patches to equal 150 mcg (micrograms) per hour every three days was ordered. This medication was changed/discontinued on 07/05/2022; On 06/21/2022 Lidoderm 5% patch daily to affected area was started; On 07/05/2022 Morphine (An opioid) liquid 5-20 mg every hour as needed (PRN) was started; On 07/05/2022 Fentanyl Patch 100 mcg (micrograms) two patches, every three days was ordered. This medication was changed/discontinued on 09/08/2022; On 07/05/2022 Hydromorphone 8 mg every three hours PRN was ordered. This medication was discontinued/changed on 09/08/2022; On 09/09/2022 Hydroxyzine 25 mg TID was started; On 09/09/2022 Gabapentin 300 mg twice daily (BID) was ordered. This medication was changed/discontinued on 09/30/2022; On 09/09/2022 Naproxen 500 mg twice daily (BID) was started; On 09/17/2022 Fentanyl Patch 50 mcg (micrograms) per hour every three days was ordered. This medication was changed/discontinued on 09/23/2022; On 09/24/2022 Fentanyl Patch 25 mcg (micrograms) per hour every three days was ordered. This medication was changed/discontinued on 09/30/2022; and On 09/30/2022 Gabapentin 600mg three times a day (TID) was started. Review of the 04/01/2022 nurse visit note showed that the patient had a pain level of 8 (on a scale of 1-10) and his/her acceptable level of pain was 8. The patient expressed importance of pain management and requested medication changes. Fentanyl Patch (an opioid) 100 mcg (micrograms) per hour every three days was ordered. Review of the available nurse and communication notes after the medication changes on 04/01/2022 showed no follow-up within 24 hours to follow-up with the patient regarding medication effectiveness. Review of the 04/12/2022 nurse visit note showed that the patient had a pain level of 7 (on a scale of 1-10) in his/her neck and back, and his/her acceptable level of pain was 7. Review of the 05/05/2022 RN visit note for a face to face visit showed the patient had a pain level of 8 (on a scale of 1-10). The pain is ongoing. The patients acceptable level of pain was not assessed. Review of all available nurse and communication notes showed no follow-up to the reported severe pain. Review of the 05/09/2022 RN visit note showed the patient had a pain level of 8 (on a scale of 1-10). The pain is "severe and stabbing". The patient's acceptable level of pain was 6. The patient was educated on Dilaudid use. The patient's pain decreased during the visit to 5. Review of all available nurse and communication notes showed no follow-up to the patient's ongoing pain and effectiveness of the education provided. Review of the 05/16/2022 RN visit note showed the patient had a pain level of 8 (on a scale of 1-10). The pain is "severe and aching". The patient's acceptable level of pain was 7. Review of all available nurse and communication notes showed no follow-up to the patient's ongoing pain until 05/23/2022. Review of the 05/23/2022 LPN (licensed practical nurse) visit note showed the patient had a pain level of 6 (on a scale of 1-10). The pain is "severe and aching". The patient's acceptable level of pain was not assessed. Review of all available nurse and communication notes showed no follow-up to the patient's ongoing pain until 05/31/2022. Review of the 06/10/2022 RN visit note showed the patient had a pain level of 10 (on a scale of 1-10). The pain is "stabbing/sore". The patient's acceptable level of pain was 6. The nurse contacted the physician without new orders or interventions. The patient was provided pain management education. The patient's pain was 6 by the end of the visit. Review of all available nurse and communication notes showed no follow-up to the patient's ongoing pain or effectiveness pain management education. Review of the 06/20/2022 RN visit note showed the patient had a pain level of 9 (on a scale of 1-10). The pain is "stabbing". The patient's acceptable level of pain/goal was 7. The nurse contacted the physician without new orders or interventions. The patient was provided pain management education. The patient reported pain of 8 by the end of the visit. The nurse obtained orders for an extra PRN dose of Dilaudid (an opioid), and to start Buspirone (An Anxiolytic medication) from the hospice physician. Review of all available nurse and communication notes showed no follow-up to the patient's ongoing pain or effectiveness of the new pain interventions per agency policy. Review of the 07/05/2022 RN visit note showed the patient had a pain level of 7 (on a scale of 1-10). The pain is "aching/dull". The patient's acceptable level of pain was 7. The nurse contacted the physician, the physician explained a narcotic contract with the patients caregiver regarding the extra amount of narcotics the patient is taking. Review of all available nurse and communication notes showed no follow-up to the patient's ongoing pain or effectiveness of education to the caregiver regarding narcotic dosing. Review of the 08/02/2022 RN visit note showed the patient had a pain level of 10 (on a scale of 1-10). The pain is "sore/severe". The patient's acceptable level of pain was 5. The caregiver reported that the patient fell recently. The patient's right foot was swollen and bruised. The nurse contacted the physician, the physician ordered a x-ray of the foot. Review of all available nurse and communication notes showed no follow-up to the patient's ongoing pain or effectiveness of education to the caregiver regarding narcotic dosing. Review of the 08/30/2022 RN visit note showed the patient had a pain level of 9 at 2:46 PM (on a scale of 1-10). The pain is "aching/stabbing". The patient's acceptable level of pain was 6. The nurse "will" call the physician. The nurse documented "no new interventions added". Review of all available nurse and communication notes showed no follow-up after the visit regarding the patient's pain per agency policy. Review of the 09/13/2022 RN visit note showed the patient had a pain level of 8 (on a scale of 1-10). The pain is "severe/shooting". The patient's acceptable level of pain was 6. The nurse documented "no new interventions added". The patient has been getting decreasing doses of narcotics and "recently started on gabapentin" (a nerve pain agent) Review of all available nurse and communication notes showed no follow-up after the visit regarding the patient's pain, or the effectiveness of gabapentin per agency policy. The nurse documented that the patient had a recent fracture of his/her foot. Review of the 09/16/2022 RN visit note showed the patient had a pain level of 8 (on a scale of 1-10). The pain is described generalized "ache". The patient's acceptable level of pain was 6. The nurse documented medication teaching. The section for physician notification was left blank. Review of all available nurse and communication notes showed no follow-up after the visit regarding the patient's severe pain, or the effectiveness of the medication teaching. Review of the clinical record showed that the patient discontinued hospice services on 10/11/2022 with a signed revocation form. It should be noted that 17 different nurses cared for the patient during his/her hospice admission. During an interview with the patient's primary caregiver on 11/09/2022 at 10:20 AM, he/she stated the following: The patient was never satisfied with pain control during admission to the hospice; The nurse never followed-up with him/her after new medication changes to see if the changes worked; and The patient ended hospice services (revocation) for several reasons including that the hospice failed to control the patient's pain. During an interview with the hospice administrator on 11/08/2022 at 9:40 AM, he/she stated that when a patient has pain management intervention changes that he/she expects that the hospice nurse will follow-up with the patient within 24 hours to assess the effectiveness of the intervention. Findings were reviewed with the administrator and any additional documentation was requested regarding follow-up assessments after medication/intervention changes or unmet pain goals. There was no additional information provided by the survey exit. The administrator stated that the hospice has a new software and procedures finalized in October 2022 that better tracks symptom control for follow-up with the patients through daily stand-up meeting assignments.

Based on clinical record review and interviews the hospice provider failed to ensure that the patient's attending physician was forwarded a discharge summary when a patient revoked hospice services in one of one record reviewed for revocation (Record/Patient #1). The deficient practice has the potential to affect all patients on service with the hospice provider. --- Findings included: RECORD/PATIENT #1: Review of the clinical record showed no evidence that a discharge summary was sent or fowarded to physician-A before of after the patient revoked hospice service on 10/12/2022. During an interview with the patient's primary caregiver on 11/09/2022 at 10:20 AM, he/she stated that during "the first of October" he/she notified (the hospice case manager) of the patient's new attending (Physician-A). He/she provided that appointment dates, and all the physician's contact information. During an interview with the patient's registered nurse (RN) case manager on 11/07/2022 at 3PM, he/she stated that the patient's caregiver informed him/her about a new attending physician. The caregiver provider the contact phone number, fax number, and physical address of the new attending physician. During an interview with the hospice director of clinical services on 11/08/2022 at 11:28 AM, he/she stated the following: The hospice did not send over a discharge summery to physician-A before of after the 10/112/2022 revocation; and He/she contacted Physician-A's office on 11/07/2022 and they did not need a discharge summary since the patient had already moved to another physician and another hospice.

Based on clinical record review and interview, the agency failed to ensure the person acting as the representative for the patient was the legal representative designated by the patient, in accordance with state law, to exercise the patient's rights to the extent allowed by state law, in one (Record/Patient #1) of three records reviewed. This deficient practice has the potential to affect the exercise of patient rights for all of the agency's patients. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 03/12/2022, with a terminal diagnosis of aplastic oilgodendroglioma of the frontal lobe (cancer of the brain). The patient resided in his/her own home with his/her spouse. The patient died on 04/06/2022. Review of the document titled, "Hospice RN (registered nurse) Start of Care," dated 03/12/2022 showed that: - The nurse failed to obtain a copy of the patient's advance directive (AD) because, "A copy was not available at the time of admission;" - Failed to obtain verbal identification of the legal representative designated by the AD; - The patient was oriented to person, and the reason the patient's cognitive function was not assessed was, "Not appropriate at time of evaluation;" - Failed to contain documentation that the patient had been declared mentally incompetent; and - The patient's spouse had signed all of the consent forms during the admission visit. Review of subsequent hospice clinical visits performed showed that: - On 03/15/2022, the nurse and chaplain visit documentation failed to contain the efforts of staff to obtain copies of the patient's advance directive, or verbal clarification of the content of the advance directive; - The medical social services visit documentation on 03/15/2022, showed that the patient had an advance directive, and failed to describe the type of advance directive the patient had executed, or the efforts taken to obtain a copy of the patient's advance directive; and - The nursing visits dated 03/18/2022, 03/22/2022, 03/25/2022, and 03/29/2022, failed to contain documentation of efforts to obtain a copy of the patient's advance directive. During an interview on 04/12/2022 at 4:00 PM, the complainant stated that he/she took a copy of the power of attorney (POA) documentation to the agency and that he/she was unsure of the exact date. Review of the document titled, "Advance Directive," dated 07/14/2017, showed that the complainant was assigned as the agent to make health care decision for the patient when he/she became unable to do so or to communicate his/her wishes. During an interview on 04/13/2022 at 12:30 PM, the administrator stated that: - The patient's parent had dropped off a copy of the patient's AD to the hospice office on 04/04/2022; - The Director of Clinical Services (DCS) called the patient's spouse, after the patient's parent had left the agency, and was notified by the spouse that the document assigning POA to the parent had been revoked, and he/she did not have a copy of the revocation, but a copy was at the physician's office; - The administrator called the physician's office and was notified by office staff that the patient had revoked the POA for his/her parent on 12/26/2017; - The administrator had faxed a medical records request to the physician's office on 04/07/2022, requesting a copy of the documentation revoking the POA for the parent; and - The physician's office had not sent the revocation documentation at the time of the interview. Review of the document titled, "General Message," (Page 13), and received via fax at the Department of Health and Senior Services on 04/13/2022, showed that the POA from 07/2017 was no longer valid for the patient's parent effective 12/26/2017. During an interview on 04/14/2022 at 10:50 AM, the administrator stated they expected staff to document their efforts to obtain copies of AD and POA documentation.

Based on review of clinical documentation and interview, the agency failed to assure the patient received information about the services covered under the hospice benefit in one (Record/Patient #1) of one record reviewed. This deficient practice as the potential to affect the services provided to all of the agency's patients. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 03/12/2022, with a terminal diagnosis of aplastic oilgodendroglioma of the frontal lobe (cancer of the brain). The patient resided in his/her own home with his/her spouse. The patient died on 04/06/2022. Review of the start of care nursing visit dated 03/12/2022 showed that: - A self-care deficit and required assistance with eating, bathing, dressing/grooming, toileting, transferring, continence, meal preparation, shopping, and housework; and - The visit note failed to contain documentation that an aide (for bathing and personal care) and/or homemaker services were offered to the patient. During an interview on 04/12/2022 at 4:00 PM, the complainant stated that: - That the patient was bedfast and "basically a vegetable"; - The patient couldn't eat; and - The he/she had requested assistance with bathing and personal care at the end of March. Review of nursing visit dated 04/01/2022 showed that: - The patient continued to have a self-care deficit and required assistance with eating, bathing, dressing/grooming, toileting, transferring, incontinence, male preparation, shopping and housework; - The patient used four to six incontinent briefs each day; and - The visit note failed to contain documentation that an aide (for bathing and personal care) and/or homemaker services were offered to the patient. During an interview on 04/13/2022 at 12:50 AM, registered nurse (RN) 1 stated that: - He/she asked the patient and spouse if assistance was needed with bathing, personal care, or homemakers and they must have declined the service because the services were not listed on the plan of care; and - He/she did not document a specific refusal of the bathing, personal care, or homemaker services in the clinical record. During an interview on 04/13/2022 at 09:30 AM, the RN2 stated that: - He/she performed a follow-up visit on 04/01/2022, as a follow up to a concern made by the patient's parent; - The assessment showed: * The patient was completely bedbound; * The patient would lay on the hospital bed without a top sheet; and * Was incontinent of stool, and the agency provided adult briefs; - Visit frequencies were discussed and the spouse agreed with the current plan of care and visit frequency; and - The visit note failed to contain documentation that an aide (for bathing and personal care) and/or homemaker services were offered to the patient.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interview. 4 of 14 (29%) applicable records of patients who received hospice aide services revealed that care provided were inconsistent with the Interdisciplinary Group orders and the plan of care. The frequency of the aide visits provided did not match the care plan. Record #49455: The plan of care revealed the patient was to receive hospice aide services two times a week starting 01/16/2022. There was only one aide visit documented between 01/30/2022 and 02/06/2022. No documentation was found to support a reason for the missed visits. Record #70248: The plan of care revealed the patient was to receive hospice aide services once a week starting 11/20/2020. There was no evidence of a hospice aide visit weeks of 11/29/2020, 12/06/2020, and 12/31/2020. No documentation was found to support a reason for the missed visits. Record #63801: The plan of care revealed the patient was to receive hospice aide services two times a week starting 03/06/2022. There was only one aide visit documented the week of 03/06/2022, There was no evidence of an aide visit the week of 03/13/2022. No documentation was found to support a reason for the missed visits. Record #58024: The plan of care revealed the patient was to receive hospice aide services once a week starting 10/192021. A review of aide visit notes revealed no documented evidence of aide visits the week of and 10/19/2021. No documentation was found to support a reason for the missed visits. The findings were reviewed by the Hospice Director of Quality Outcomes during an interview on 03/22/2022 who stated, “I don’t know why there are no notes or visits those weeks.” The Hospice Director of Quality Outcomes confirmed these findings and stated, that there should have been visits according to the plan of care.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of: the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records and interview. 2 of 2 (100%) applicable records of patients who revoked their hospice benefit to seek aggressive treatment at a hospital revealed a discharge summary was filled out but there was no evidence that a discharge summary was sent to the receiving hospital, and it did not include what documents should have been sent to the hospital along with the discharge summary thus compliance could not be validated. [Record #10742]. The patient was admitted on 11/10/2021 and revoked his hospice benefit to seek aggressive treatment at a hospital on 01/24/2022. [Record #10467]. The patient was admitted on 12/19/2021 and revoked his hospice benefit to seek aggressive treatment at a hospital on 12/20/2021. These findings were verified during an interview with the Hospice Director of Quality Outcomes on 03/23/2022. She stated that there was no documentation that a discharge summary and other necessary documents were forwarded to the receiving hospital for continuity of care.