Every finding on record at Crest Home Health and Hospice, LLC

Based on ALF medical record review, hospice medical record review, and staff interview, it was determined the agency failed to ensure the plan of care contained current and accurate medications the patient was taking for 1 of 3 patients (Patient #4) whose care in the home was observed and whose records were reviewed. Failure to ensure the plan of care contained all current and accurate medications caused potential for duplicate drug therapy and medication side effects. Findings include: --- Patient #4 was an 83 year old female admitted to the agency on 7/03/24 with a terminal diagnosis of senile degeneration of the brain. Additional diagnoses included dementia and anxiety. She received SN, volunteer, social work, chaplain, and aide services. Her record for the certification period 12/30/24 to 2/27/25 was reviewed. A visit to Patient #4 at her residence, an ALF, was conducted with the chaplain on 2/04/25 beginning at 2:15 PM. When the visit was complete, a medication list was obtained from ALF staff. Patient #4s ALF medication list was compared with her hospice medication list and the following discrepancies were identified: - - Ondansetron 4 mg tablet every 4 hours as needed was on the ALF medication list but not the hospice medication list - - Acetaminophen 650 mg suppository and 500 mg tablet every 4 hours as needed was on the hospice medication list but not the ALF medication list - - Euthrox 100 mcg daily and levothyroxine 100 mcg daily were both on the hospice medication list. Euthrox is the brand name for levothyroxine. The medications were duplicates. - - Memantine 10 mg tablet twice daily was listed on the medication list 3 times. All 3 were listed as active medications. The DCS was interviewed on 2/05/25 beginning at 2:10 PM and Patient #4s medication lists were reviewed with her. She confirmed the hospice and ALF medication lists did not match. She confirmed the levothyroxine and memantine were duplicates. The agency failed to ensure the plan of care contained accurate medication lists.

Based on review of Quality Assessment Performance Improvement records and staff interview, it was determined the hospice failed to implement and maintain documentation of performance improvement projects currently being conducted, goals for the selected performance improvement projects, and any measurable progress achieved on these projects. This prevented the agency from examining its patient care processes and had the potential to affect all patients who were currently receiving hospice services. --- The Agencys quality assurance and performance improvement plan was reviewed. It included under the objectives section: ";To collect and analyze data to improve identified processes and outcomes of care." Additionally, under the section titled ";Data Collection," it included. ";Data collection will be ongoing, and frequency will be determined by the process improvement activity and approved by the Governing body. Data collected will be used to monitor the effectiveness and safety of services and the quality of care." Thes processes were not followed, examples included The Agencys quality program and performance improvement projects were reviewed. The listed problem of the agencys performance improvement project was ";5 falls 3rd quarter." In the section titled ";Interventions to correct the problem:" included, ";Root cause Analysis." The performance improvement project included that there were 2 falls in 11/2024 and 3 falls in 12/24. The performance improvement project did not include a goal for the problem identified, an overall analysis of data collected, and did not include the root cause analysis of the falls identified. The Agency Administrator was interviewed on 2/05/24 beginning at 2:15 PM and the performance improvement project was reviewed in his presence. When asked for a documented analysis of the data collected, he was able to verbalize the investigation into the falls but confirmed he did not have documentation of his investigations and analysis. He stated there was no specific documented goal for the performance improvement project. The agency failed to ensure PIP's included data analysis, goals, and measurable improvements were documented. mm

Based on review of organizational charts, review of physician contracts, and staff interview, it was determined the hospice failed to designate a single hospice physician to serve as Medical Director of the agency. This had the potential to result in a lack of clear lines of authority, a lack of accountability, and a lack of sufficient oversight and supervision of patient care. Findings include: --- The Medical Director and additional physician contracts were requested. The agency provided an "Associate Medical Director Agreement" contract. The contract identified 2 physicians (Physician #1 and Physician #2) as the agencys associate medical directors. The Agencys organizational chart included Physician #2 as the agencys medical director. The organizational chart did not list Physician #1. Additionally, a document titled ";Associate Medical Director Agreement," which outlines and defines the qualifications, responsibilities, compensation, billing, termination, etc., listed only Physician #1. The Agencys administrator was interviewed on 2/5/25 at 9:45 AM and the Physician contracts were reviewed in his presence. He confirmed that Physician #1 and Physician #2 were listed as associate medical directors on the contract and amendment. The amendment did not clearly define that there was to be a change in medical directors. It was unclear through contract review which physician was the agencys medical director. The Agency administrator stated that Physician #2 was the medical director and Physician 1 no longer had a role at the agency. Additionally, a document titled ";Associate Medical Director Agreement," which outlines and defines the qualifications, responsibilities, compensation, billing, termination, etc., listed only Physician #1. The agency failed to ensure physician contracts clearly identified Physician #2 as the agencys Medical Director. lkj

Based on Medicare Benefit Policy Manual review, medical record review, and staff interview, it was determined the medical director failed to ensure hospice patients had a terminal illness for 1 of 2 patients (Patient #1) who were live discharges and whose records were reviewed. Failure to ensure hospice patients who did not have a terminal illness were promptly discharged caused improper level of service to be provided to the patient. Additionally, it created the potential for improper billing of hospice level services. Findings include: --- According to the Medicare Benefit Policy Manual chapter 9, "Hospice care is a benefit under the hospital insurance program. To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill." Patient #1 was a 91 year old male admitted to hospice services on 8/30/24 with an initial terminal diagnosis of unspecified protein calorie malnutrition. Additional diagnoses included pneumonitis and hemiplegia. He received SN, volunteer, social work, chaplain, and aide services. His record for the certification period 10/29/24 to 12/27/24 was reviewed. Patient #1 was discharged off hospice services on 12/27/24 because he was no longer terminally ill. Patient #1s medical record included an SN note dated 11/26/24 which stated, ";Discussed that patient will most likely graduate off of hospice at the end of this recertification. Plan for patient to Discharge off of hospice services at end of certification, pending any changes in health, patient will continue on home health services for catheter management after discharge." Patient #1s medical record included an SN note dated 12/07/24 which stated, ";Plan for discharge at end of certification." Patient #1s medical record included an SN note dated 12/13/24 which stated, ";planning for discharge at end of cert [certification] period." Patient #1s IDG meeting notes were reviewed. The IDG meeting on 12/02/24 included the nursing documentation from 11/26/24 which stated Patient #1 would most likely discharge off hospice services. The IDG meeting was signed off by the Medical Director. The IDG meeting on 12/16/24 included the nursing documentation from 11/26/24 which stated Patient #1 would most likely discharge off hospice services. It also included the nursing documentation from 12/07/24 and 12/13/24 which stated the agency planned to discharge Patient #1 at the end of the certification period. The IDG note was signed off by the nurse practitioner. It was unclear why the agency waited until the end of the certification period to discharge Patient #1 who was no longer terminally ill, when it was initially noted by the nurse on 11/26/24, a month prior to being discharged. The administrator was interviewed on 2/05/25 beginning at 12:49 PM and Patient #1s record was reviewed with him. He stated there was confusion regarding Patient #1s face to face assessment, but he should have been discharged within 2 weeks of the nurse noting he was no longer terminally ill. The medical director failed to ensure Patient #1 had a terminal diagnosis.

Based on review of Stanford Health Care guidelines, review of medical records and staff interview, it was determined the hospice failed to ensure the review of patients' medication lists identified duplicate drug therapy for 3 of 11 patients (Patients #1, #3, & #6) whose records were reviewed. This resulted in a lack of clarity of as needed medication orders for nursing staff to implement. Findings include: According to the Stanford Health Care, accessed 12/10/21, "therapeutic duplication is the practice of prescribing multiple medications for the same indication or purpose without a clear distinction of when one agent should be administered over another. For example, prescribing both ibuprofen and acetaminophen for PRN [as needed] mild pain, or prescribing both Zofran and Compazine for PRN nausea and vomiting." 1. Patient #1 was an 86 year old female admitted to the agency 5/20/21 with a primary diagnosis of chronic respiratory failure with hypoxia. Additional diagnoses included pneumonia and COVID-19 infection. She received SN and aide services. Her record for the certification period 8/18/21 to 11/15/21 was reviewed. Patient #1's POC included the following medications: - Senna-S 8.6/50 mg tablet; take 1-4 tablets twice daily as needed for constipation - Miralax 17 gm powder; take once a day as needed for constipation - Acetaminophen 325 mg tablet; take 2 tablets every 6 hours as needed for pain - Hydrocodone/acetaminophen 7.5/325 mg tablet; take 1-2 tablets three times daily as needed for pain - Morphine 5 mg vial; take 1-3 vials every 1 hour as needed for pain or dyspnea - Lorazepam 2 mg/mL; give 0.5 mL every 2 hours as needed for anxiety, agitation, or delirium - Haloperidol 2mg/mL; take 0.25-0.5 mL every 6 hours as needed for anxiety, nausea, or vomiting Patient #1's POC did not include when to give as needed medications when there were multiple medications ordered for the same indication. It did not indicate how the nurse would decide how much medication to give when there was a range of how much medication the patient could take. 2. Patient #3 was a 69 year old male admitted to the agency on 11/07/21 with a primary diagnosis of neoplasm of the intestinal tract. An additional diagnosis included malignant neoplasm of the prostate. He received SN, chaplain, social work, and aide services. His record for the certification period 11//07/21 to 2/02/22 was reviewed. Patient #3's POC included the following medications: - Lorazepam 2 mg/mL; give 0.5 mL every 2 hours as needed for anxiety, agitation, or delirium - Haloperidol 2mg/mL; give 0.5 mL every 2 hours as needed for anxiety, nausea, or vomiting Patient #3's POC did not include when to give as needed medications when there were multiple medications ordered for the same indication. 3. Patient #6 was an 83 year old male admitted to the agency on 4/12/21 with a primary diagnosis of gastrointestinal hemorrhage. Additional diagnoses included heart failure and chronic kidney disease. He received SN, aide, chaplain, and social work services. His record for the certification period 4/12/21 to 7/10/21 was reviewed. Patient #6's POC included the following medications: - Oxycodone 5 mg tablet; take 1 tablet every 4 hours as needed for pain - Morphine 100 mg/5 mL; take 0.25-1 mL every 1 hour as needed for pain or dyspnea Patient #6's POC did not include when to give as needed medications when there were multiple medications ordered for the same indication. It did not indicate how the nurse would decide how much medication to give when there was a range of how much medication the patient could take. The DCS and Administrator were interviewed together on 12/02/21 at 9:44 AM, and Patient #1, #3, & #6's records were reviewed in their presence. They were asked how nursing staff decided which medications to give to patients when there were ranges, or when multiple medications were ordered for the same problem. The DCS stated they used nursing judgement, and started with the smallest dose. She stated certain anxiety medications were used for moderate anxiety, and others were used for severe anxiety. The DCS and Administrator were asked how the nursing staff would know this. They confirmed it was based on common practice. They confirmed there was not a policy that dictated these practices, and the orders did not indicate in what order nursing staff would administer medications. The agency failed to ensure review of the patients' medications identified duplicate drug therapy.

Based on interview and medical record review, it was determined the hospice failed to ensure care and services were provided in accordance with the POC for 1 of 7 patients (Patient #8) who were ordered aide services and whose records were reviewed. This failure had the potential to adversely affect coordination and quality of patient care. Findings include: Patient #8 was an 83 year old female admitted to the agency on 8/23/21, with a terminal diagnosis of malignant neoplasm of right lung. She received SN, social work, chaplain, and aide services. Her record, including the POC, for the certification period of 8/23/21 to 11/20/21, was reviewed. Patient #8's POC included the order for aide services to be provided 2 times a week for 12 weeks beginning on 8/29/21. The order for aide services was to provide 14 total aide visits between the dates of 8/29/21 and 10/16/21. Patient #8 received 4 aide visits where care was provided between those dates. The remainder of the visits were documented as patient refused care or cares provided by another caregiver. Between 8/23/21 and 10/16/21 the 4 IDG meeting notes did not include the status of the hospice aide, and the hospice aides missed visits for Patient #8. The DCS was interviewed on 12/02/21 beginning at 9:00 AM. She stated missed visits were relayed to the physician via their texting communication system. She confirmed coordination of care between team members regarding the aide missed visits was not documented in the IDG meetings. The agency failed to document communication to ensure aide services were provided in accordance with the POC.

Based on record review and staff interview, it was determined the agency failed to ensure an aide supervisory visit was conducted no less than every 14 days for 1 of 7 patients (Patient #8) who were ordered aide services and whose records were reviewed. This resulted in a missed opportunity to evaluate aide services and identify the need to update the POC in a timely manner. Findings include: Patient #8 was a 83 year old female, admitted to the agency on 8/23/21, with a terminal diagnosis of malignant neoplasm of right lung. She received SN, social work, chaplain, and aide services. Her record, including the POC, for the certification period of 8/23/21 to 11/20/21, was reviewed. - Patient #8 received her first aide visit on 9/01/21, completed by Staff #A. The first aide supervisory visit, completed by the RNCM, was documented on 10/15/21, 44 days after aide services were initiated. - Patient #8 received an aide visit on 9/23/21, completed by Staff #B. The first aide supervisory visit completed by the RNCM was documented on 10/15/21, 22 days after the aide visit. - Patient #8 received an aide visit on 9/27/21, completed by Staff #B. The first aide supervisory visit completed by the RNCM was documented on 10/15/21, 18 days after the aide visit. - The aide supervisory visit completed by the RNCM on 10/15/21, did not include which aide was being evaluated. It was unclear which aide was being evaluated. The DCS was interviewed 12/02/21, beginning at 9:00 AM, and Patient #8's record was reviewed in her presence. She confirmed aide supervision should have been performed for each aide at a minimum every 14 days. The agency failed to ensure aide services were supervised every 14 days and assessed to ensure care followed a written aide POC and met the patient's needs.