Every finding on record at Crossroads Hospice of Kansas City, Lc

Based on policy review, record review, and interview, the IDG (interdisciplinary group) failed to ensure that all drugs were on the plan of care when a medication was removed from the medication profile without a physicians order and the patient continued to take the medication in one of four records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy titled, "IDG (interdisciplinary Hospice Plan of Care, Coordination and Continuity of Care," dated revised renewed 05/23/2022, showed in part the following: - All drugs when confirmed, suspected, or newly identified should be indicated on the POC (plan of care); and - The medication profile for each patient should be reviewed and initialed or signed by the hospice physician at each IDG, reviewing for contraindications and drug duplications. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted on 05/13/2024 with a primary diagnosis of pulmonary fibrosis (a condition in which the lungs become scarred over time). The patient lived at home alone. Review of the medication list showed on 05/17/2024, Norco (a combination of acetaminophen and hydrocodone that is used to relieve moderate to moderately severe pain) 7.5-325 mg (milligram); one (1) tablet four times a day as needed (PRN) for pain and shortness of air. The medication was discontinued on 05/20/2024. Review of the narcotic count record, showed on 08/14/2024 Norco 7.5 (mg)/325 (mg), current count 23 tablets, amount used 33 tablets (since last narcotic count). Review of the clinical record failed to show an order for Norco tablets. Review of a RN-phone call patient assessment report dated 08/18/2024 at 9:00 AM, showed in part, that the nurse returned a call to the patient in reference to medications needing refilled and ";feeling awful". The patient stated that he/she only had one tablet of Norco 7.5 mg remaining. The pharmacy stated that the medications did not go through, the Norco was too early to fill, and the next refill was not until 08/26/2024. The nurse reviewed the patients physician orders and found that the Norco was discontinued in May. The patient reported he/she was not aware of the medication being discontinued and he/she did not approve it. He/she stated that he/she was taking the tablets (Norco) every four hours. The physician was notified of the issue and did not want to refill until he/she assessed and the narcotic issue was resolved. During an interview on 09/24/2024 at 9:06 AM, the team leader stated that the Norco was discontinued on 05/20/2024 by accident. During an interview on 09/24/2024 at 9:46 AM, the director of nursing stated that the clinical record did not show written or verbal physician orders to discontinue the Norco on 05/20/2024. He/she would expect nurses to reconcile the patient medications with the medication list and notify the physician if the patient was taking medication not ordered. During an interview on 09/24/2024 at 11:59 AM, the patients physician stated that he/she had not discontinued the patients Norco.

Based on record review and interview, the provider failed to conduct an annual full-scale community-based exercise or an annual facility-based functional exercise (if a full-scale community-based exercise was not accessible) that tested the providers emergency plan. This deficient practice has the potential to affect all patients receiving services from the provider. --- Findings included: Review of the providers Emergency Preparedness Manual showed no documentation the facility conducted or participated in an annual full-scale community-based exercise (or an annual facility-based functional exercise) opposite year of the table-top exercise. During interview on 05/13/2024 at 2:40 PM, the Administrator stated no community based exercise had been completed.

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure that: - All alleged violations involving mistreatment, neglect, or verbal and physical abuse were reported immediately by hospice employees to the hospice administrator (508); and - The patient received effective pain management and symptom control (512). The cumulative effect of these deficient practices has the potential to affect all patients served by the provider.

Based on policy review, admission packet review, clinical record review and interviews, the provider failed to ensure all alleged violations involving patients safety were reported immediately by hospice employees to the hospice administrator and a thorough investigation completed in, one of fourteen records reviewed (Record/Patient #5). This deficient practice has the potential to adversely affect the safety of all patients served by the provider with violations reported. --- Findings included: Review of the providers admission packet, section B, "Patient and Family Concern and Grievance Procedure-KC," updated 04/16/2024, showed if any patient/family or patient representative who desire to lodge a concern or grievance about any aspect of care should contact the Hospice Clinical Director in writing. An investigation will be initiated within 24 hours from receipt of the concern/grievance. A report (verbal or written) will be provided to the person lodging a grievance within 15 business days from receipt of the concern. If the concern cannot be resolved to the patient/family's satisfaction, the Hospice et Palliative Care Executive Director will make every effort to resolve the concern. If the Hospice Executive Director cannot resolve the concern, the Clinical and Regulatory Advisor will attempt to resolve the issue and as appropriate, coordinating with the Chief Compliance Officer shall make every effort to resolve the concern to the patient/familys satisfaction. Review of the providers admission packet, section B, policy titled, ";Patient & Family Bill of Rights," updated 05/30/2023, showed a patient/patient representative has the right for staff and volunteers to respect property and person and the right to report violations of these rights to the Hospice and Palliative Care Executive Director or Corporate Compliance as listed above. The Hospice and Palliative Care Executive Director will investigate all alleged violations and complaints and if verified, take swift corrective action. If a complaint is verified, the Executive Director will report violations to the state/local agencies within five days of the incident. Review of the providers policy titled, "Patient and Family Rights Employee Education," Policy Number: 299-36, renewed 05/23/2022, showed upon hire, every employee will receive a copy of the providers Patient – Family Bill of Rights. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 01/17/2024 with a primary diagnoses of heart failure (when the heart muscle doesnt pump blood as well as it should), atherosclerotic heart disease (ASHD: thickening of the arterial wall that results in decreased supply of blood flow) hypertension, cardiomegaly (enlargement of the heart), mitral insufficiency (blood leaking in the wrong direction), and history of breast cancer with metastases (the spread of cancer cells from the place where they first formed to another part of the body). The patient lived at his/her own home with an adult child as primary caregiver. He/she required assistance with activities of daily living. Review of the RN Emergent Assessment Report, dated 04/01/2024, showed end of visit completed for primary caregiver (PCG)s request due to a verbal dispute that night with the patient. Case manager and social worker please follow-up in AM (morning). Please start daily watch visits that day to monitor for patient safety and well-being. Patient tearful at times and stated he/she was worried and concerned about PCG current behavioral state. PCG attempted to explain why he/she was upset with the patient multiple times, unable to express his/her thoughts and feelings about the situation without ruminating and exhibiting manic behavior as speech was fast and explanation for increased agitation was irrational. Hospice Aid (HHA) arrived at patient's home to implement patient safety watch and to allow PCG uninterrupted time to rest. Missouri Adult Abuse and Neglect online form completed and submitted by RN on 04/02/2024. Review of the LPN Phone Call Assessment, dated 04/02/2024, showed the PCG called in stating the patient was getting violent with him/her and he/she was saying he/she had enough of the patient as well. Nurse asked to speak to the patient, PCG threw the phone at patients face. Staff asked patient if he/she felt safe and he/she said no. Primary caregiver grabbed the phone, and as hospice staff was talking, they had 911 called due to the words the PCG was using, such as I'm going to end things, I am done with all of this, things are going to stop sooner or later, things better change now or something is about to happen. Hospice staff stayed on the phone with primary caregiver trying to calm him/her down and the police knocked on the door. PCG ran out the back door and ran for about 20 minutes. Hospice staff was trying to tell him/her to stop running and that the police were not at the house for him/her, that he/she did nothing wrong. After approximately 20 minutes, the phone went blank and hospice staff hung up. A RN and HHA were sent to the home to try to attend to the patient's safety. Patient refused to go anywhere. Police showed up again and so did the PCG, he/she spoke with the police. Nothing could be done since the patient refused to leave the home but if the police were called out to the home again, they would take the patient out of the home. PCG said he/she needed a break and would like help. He/she was crying for help and would like hospice staff to assist. Please follow-up in AM. Patient was on daily's. Staff failed to notify the administrator of the hotline report (04/02/2024) and the situation. During interview on 05/07/2024 starting at 2:46 PM, the administrator stated he/she would have expected to have been notified.

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure that the patient received effective pain management and symptom control from the hospice in, two of fourteen records reviewed (Records/Patients #4 and #12). This deficient practice has the potential to affect all patients on service with the provider. --- Findings included: Review of the provider's policy titled, ";Pain and Symptom Management and Pain Scales," reviewed 05/23/2022, showed in part: - Pain will be managed at a level acceptable to the patient; and - Symptoms, including, but not limited to nausea, dyspnea, anxiety, agitation, restlessness, itching and any others that cause distress, will be controlled using appropriate physician ordered medications, treatments, and interventions to alleviate the symptom(s). Review of the provider's policy titled, ";IDG (Interdisciplinary Group) Hospice Plan of Care-Content, Plan, Goals, Interventions and Outcomes," reviewed 05/23/2022, showed in part: - The goal of effective pain and symptom management is quality of life geared specifically to ensure that pain and symptoms are effectively managed, patients/family are better able to focus on their individualized vision of a positive, pain free dying process and that their goals are effectively met; and - Effective pain and symptom management will include the ongoing assessment of the patient's physical, psychosocial, emotional and spiritual needs and re-evaluating the effectiveness of the current plan and care in order to address those needs. RECORD/PATIENT #4: During home visit observation on 05/01/2024 beginning at 1:00 PM, showed in part: - The patient reported his/her pain at 6/10 (0 being no pain and 10 being the worst); - Pain medication was last taken at 11:30 AM (one hour and 30 minutes prior to the home visit); - The patient reported all over joint pain and chronic back pain; and - The patient wanted the nurse to speak with the hospice team regarding further interventions to alleviate pain. Review of the skilled nurse visit note on 05/01/2024 at 1:00 PM, showed in part: - The patient reported his/her pain at 6/10; - The RN (registered nurse) B discussed pain management interventions to which the patient had replied that he/she had taken his/her pain meds (medications) recently (one hour and 30 minutes prior to the visit); - The patient asked the ";RN if there was anything more that could be done for his/her worsening joint pain. This RN stated that he/she would go over options with the doctor and would get back to them;" and - The clinical record failed to show any follow-up with the doctor regarding the patients options for worsening pain. During an interview on 05/14/2024, at 11:00 AM, the clinical director, stated that: - There was no record that the nurse contacted the doctor and/or followed up regarding pain interventions; and - The nurse should have called the doctor; and - The nurse could have even sent a message to the doctor directly from the tablet if the nurse had the tablet with him/her. RECORD/PATIENT #12: Review of the emergent skilled nurse visit note on 03/20/2023, beginning at 9:45 AM, showed in part: - The patients pain was assessed using FLACC (a behavioral pain assessment scale used for nonverbal or preverbal patients who are unable to self report their level of pain. Pain is assessed through observation ranging from 0 to 10 pain scale) tool; - The patients pain severity was severe pain with a FLACC score of 9; - The PCG (patient caregiver) ";met this nurse on the porch, unhappy that patient has been out of Morphine (narcotic used to treat moderate to severe pain) since 0600-0700 (6:00 AM- 7:00 AM). PCG had been administering Haldol (antipsychotic) and Ativan (sedative that can be used to relieve anxiety) as often as possible to try to manage symptoms (sx). Upon arrival the patient was moaning loudly having involuntary twitching throughout body. Audible secretions and gasping. Patient (Pt) appeared very uncomfortable. Pt was repositioned twice during visit with help from hospice aide (HHA). Large urine output last night, none since. No bowel movement (BM) in weeks. Family concerned that Morphine is not helping. Will follow-up (f/u) with PCG again later today to evaluate sx. Family to call if pt has anymore changes;" and - ";Morphine arrived at 1029 (10:29 AM). Family unhappy that patient ran out of Morphine and now feel like patient is suffering. PCG administered Morphine and Haldol and patient appeared more comfortable at the end of visit". Review of the emergent skilled nurse visit note on 03/20/2023, beginning at 16:30 (4:30 PM- six hours and 45 minutes since last visit), showed in part: - The patients pain was assessed using the FLACC tool and had a score of 8; - The ";family frustrate upon arrival, feeling like the patient is still struggling to breathe and for comfort. Pt continues to gasp, moan, has rigid jerking motions. Pt continues to have low grade fevers that come and go. Family continues to administer comfort meds around the clock without seeing any change. Minimal urine output, family did crush Lasix (diuretic) and administer earlier today for fluid buildup, prior to Morphine arriving, feeling like that would help the patient breathe easier. Pt continues to have tacky pulse, labored irregular breathing and making what sounds like a growling noise. New orders obtained for Morphine 0.5ml (milliliter)-1.5ml QH (every hour) prn (as needed), Haldol 0.25ml-1ml Q2H (every two hours) prn, Ativan 0.25ml-1ml Q4H (every four hours) prn. Rectal foley (a catheter that is inserted into the rectum) placed due to (d/t) aspiration, pt vomited thick dark brown secretions. All meds to be given via rectal foley for choking prevention. Family educated on med admin via rectal foley. All questions answered. Pt repositioned and brief was changed. With assistance from HHA;" and - ";New orders for rectal foley, and new Med orders. Morphine 0.5ml-1.5ml QH prn so(shortness of air)/pain, haldol 0.25ml-1ml Q2H prn agitation, Ativan 0.25ml-1ml Q4H prn anxiety, restlessness." Review of the emergent skilled nurse visit note on 03/21/2023, beginning at 01:00 (1:00 AM- eight and a half hours since previous visit), showed in part: - The patients pain was assessed using the FLACC tool and had a score of seven (7); - EV (evaluation visit) for ";rectal foley replacement, all cares coordinated, new foley placed, comfort meds administered;" and - The ";PCG accidentally pulled out rectal foley, two doses of meds missed while awaiting new cath placement. Prior to that pt was comfortable, had vomited some and was having lengthy periods of apnea. Pt started jerking again and moaning. New rectal foley placed, 14fr (french) 5cc (cubic centimeter) placed without difficulty, all meds administered, pt tolerated well. Pt had small watery BM out. Pt was repositioned to back. PCG to call with any further changes. Cont (continue) EMC" (Even more care; provided by non-nurse staff). Review of the emergent skilled nurse visit note on 03/21/2023, beginning at 16:00 (4:00 PM-15 hours since previous visit), showed in part: - The patient's pain was assessed using the FLACC tool and had a score of 7; and - ";EV for possible rectal foley issues. Appears that all meds are coming right back out in brief or not going through catheter, pt has had no BM in weeks and has had three this evening. Colored meds coming out in bm. Rectal foley replaced, same issue continued, rectal foley removed. At least 16ml Dilaudid (narcotic used to treat moderate to severe pain) wasted after multiple doses came out of rectum seconds after meds were administered multiple times. Meds back to po (by mouth)/sl (sublingual), pt is a significant choking risk but with HOB (head of bed) elevated the pt tolerates well. Lungs negative for aspiration at this time. Vitals stable after two doses of oral comfort meds, involuntary jerking has decreased, pt continues to make the growling noise with episodes of apnea (temporary pause in breathing). Absent pedal pulses, absent bowel sounds (bs)x4. Pt remains unresponsive. Pt will need a CADD (computerized ambulatory drug delivery; used to control the release of medication and can effectively control pain for hospice patients in most cases) pump if sx cannot be managed as this is the third time we have had to play catch up d/t issues keeping meds down the patient." Review of the emergent skilled nurse visit note on 03/22/2023, beginning at 0200 (2:00 AM- 10 hours since previous visit), showed in part: - Patient absent of all vital signs; and - ";Death/TOD (time of death)/0204 (2:04 AM)." During an interview on 05/14/2024 at 10:40 AM, the clinical director, stated that: - He/she did not find any documentation in the clinical record of GIP (general inpatient care, short-term care provided for a patients pain management or acute or chronic symptom control that cannot be managed in other settings) being discussed; - The CADD pump did not require continuous nursing, the nurse sets it up and teaches the family about it and what to report; - When a patient requires IV (intravenous) pain medications to manage symptoms in the hospital, they are usually hard to control with oral pain medications at home; and - He/she would like the nurses to assess the need for continued IV pain medications when the patient is admitted to hospice services in the home to ensure that they are continuing to receive the same level of pain control as they did prior to going home.

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure that: - The patients and the primary caregiver(s) received education and training provided by the hospice as appropriate to their responsibilities for the care and services identified (544); - An individualized plan of care (POC) was developed that reflected the patients interventions (545); - The POC included all medications and treatments necessary to meet the needs of the patient (549); - A system of communication and integration was maintained, in accordance with the hospices own policies and procedures (554); and - Coordination of care when the on-going sharing of information between all disciplines providing care failed to be provided in a discharge summary during a respite stay (557). The cumulative effect of these deficient practices has the potential to affect all patients served by the provider.

Based on policy review, job description review, record review, home visit observation, and interview, the hospice provider failed to ensure that each patient and the primary caregiver(s) received education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in three of four home visit observations (Records/Patients #1, #3, and #4). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy titled, ";IDG (Interdisciplinary Group) Plan of Care, Coordination and Continuity of Care- (Patients with Declining Financial Resources)" reviewed 05/23/2022, showed, in part: - Consulting with and educating the patient/family/facility staff regarding: * The disease processes * Self-care techniques * End of life care * The processes for dealing with issues of ethical concerns * Initiating appropriate preventative nursing procedures - The Hospice will ensure that each patient and the primary caregiver(s) receive education and training, provided by the Hospice, as appropriate to their responsibilities for care as stated in the plan of care; and - Documentation of teaching and the patients or representatives level of understanding, involvement, and agreements with the plan of care should appear in the clinical record. Review of the provider's policy titled, ";Pain and Symptom Management and Pain Scales," reviewed 05/23/2022, showed, in part: - The Hospice and palliative care nurse will perform teaching with patient/patient representative regarding pain management, drug usage, dosage, and side effects as appropriate and document such teachings; and - The Hospice and palliative care team will educate and/or coordinate the education of patient/patient representative to plan activities and treatments around peak time of pain control as indicated. Review of the Registered Nurse (RN) Job Description, showed, in part: - Teach and demonstrate care to the patient/significant other, utilizing established available patient education principals, guidelines, and resources; - Document patient teaching and response in patient record; - Reinforced with patient and/or significant other information and skills taught by physician, nurse, and other disciplines; and - Educate the patient, family and referral sources; regarding the philosophy, criteria, benefit of Hospice services. RECORD/PATIENT #3: During home visit observation on 04/30/2024, beginning at 12:30 PM, showed, in part: - The patient was admitted to hospice on 09/25/2023 with a primary diagnosis of Atherosclerotic heart disease (a buildup of fat, cholesterol and other substances in the blood vessels that obstruct the blood flow); - The patient was 102 years old and resided in the home with the PCG (patient caregiver); - The PCG was the patients only child, is the primary caregiver, and assists with translating for the patient, as the patient is Spanish speaking only; - Social Worker (SW) A asked the PCG about Funeral Home choice; - The PCG reported that the patient will be cremated; - The social worker educated the PCG on the need for a funeral home to perform the cremation; - The social worker explained to the PCG that hospice will need to know who to call when the patient passes away; - The PCG asked the social worker if hospice takes care of all the arrangements after the patient passes away; - The Social Worker explained hospices role at end of life; - The PCG asked who to call if the patient passes away ";in the middle of the night" and asked if he/she needed to ";call 911 or hospice." The social worker explained to call hospice and if he/she would like hospice staff to be with him/her at the time of passing then they will provide ";whatever supportive needs" that the PCG wanted; - The social worker explained bereavement services that are available, and the PCG requested to have any and all services offered due to being an only child and needing support; - The PCG expressed wanting a bath aide to assist 3 (three) times a week instead of just 2 (two); - The social worker informed the PCG that he/she will speak to the hospice team but that he/she did not know if the patient would qualify for a bath aide 3 times a week; and - The PCG was educated almost seven months after the patient was admitted to hospice, regarding hospice services at the end of life, hospices role at the end of life, who to contact when the patient passes away, and bereavement services available to family/caregivers. Review of the SW visit note on 04/30/2024 at 12:30 PM, showed, in part: - SW A coordinated care with the PCG about the patients funeral choice and the SW provided a funeral home list to the PCG for choosing a provider; - ";Much discussion was had Funeral Home choice as well as EOL [end of life] event and what that may look like, who PCG can call if she believes the Pt has passed, EMC [even more care- provided by non-nurse staff to sit with the patient/family], etc;" and - The ";PCG wishes that HHA could come to see the Pt 3x per week rather than twice per week" and ";SW would mention this but felt the answer may be we are not able to do so due to restrictions" (The SW did not discuss any restrictions during the observation visit and the clinical record failed to clarify what the restrictions were). During an interview on 05/14/2024, at 11:15 AM, the clinical director, stated that: - There were no restrictions or qualifications for patients to be able to have a bath aide 3 times per week; - The nurses always start patients at 2 times per week until they get to know the patients and what the patient/family needs are; and - If patients or families request a bath aide 3 times a week, they can have a bath aide 3 times a week. RECORD/PATIENT #4: During home visit observation on 05/01/2024 beginning at 1:00 PM, showed, in part: - The patient reported all over joint pain and chronic back pain; - The patients spouse asked if any of the medications that the patient was taking may have possible side effects that included joint pain; - The spouse reported that he/she used to get education pamphlets with the medications when they were being filled at the pharmacy but he/she no longer receives any; - The spouse reported that the joint pain was new and he/she just wanted to make sure that it was not caused by one of the medications; - RN B informed the spouse that the patients steroid injections on the 27th (May 27th, 2024) should help alleviate the joint pain (The patient receives steroid injections every 3 months and the patients appointment wasnt for 26 more days); and - RN B failed to provide the patient and/or spouse medication education on any possible side effects from the patients current medications. Review of the skilled nurse visit note on 05/01/2024 at 1:00 PM, showed, in part: - The patient reported his/her pain at 6/10; - The RN discussed pain management interventions to which the patient had replied that he/she had taken his/her pain meds (medications) recently (1 hour and 30 minutes prior to the visit); - The patient asked the ";RN if there was anything (more) could be done for [his/her] (worsening) joint pain. This RN stated that [he/she] would go over options with the doctor and would get back to them;" and - The clinical record failed to show any follow-up with the doctor regarding the patients options for worsening pain. During an interview on 05/14/2024, at 11:00 AM, the clinical director, stated that: - The nurse should have taken (his/her) tablet into the visit and the medications would have been able to be reviewed from the tablet with education provided; and - The nurse could have even sent a message to the doctor directly from the tablet if the nurse had the tablet with (him/her). RECORD/PATIENT #1: Review of the Registered Nurse (RN) comprehensive assessment patient assessment report, completed by RN D, dated 02/21/2024, showed, in part: - The patient is 79 years old with a primary diagnosis of senile degeneration of the brain (a decrease in cognitive abilities or mental decline) and secondary diagnoses of dementia (decline in mental capacity) and repeated falls; - The patient is a frequent faller, with the last fall 02/19/2024; - The RN and primary caregiver (PCG) discussed what he/she does when the patient falls and the PCG stated that he/she calls a friend to help get him/her off the floor; - The RN discussed a Hoyer lift (a mechanical lift used for transferring patients) and hospital bed to facilitate transfers; and - The PCG agreed to the Hoyer lift but declined the hospital bed. Review of the hospice aide (HA) visit, completed by HA A on 02/22/2024, showed in part: The PCG declined need for shower today, but requested need for education with Hoyer lift that had just been delivered. The aide provided education with Hoyer to PCG. Review of the interdisciplinary group (IDG) Meeting Notes dated 02/28/2024 by LPN C at 4:17 AM on 02/23/2024, showed patient declined assessment: phone call. Review of the IDG Meeting Notes dated 02/28/2024 by LPN C at 4:20 AM by LPN C on 02/23/2024 showed: General: Received a phone call from PCG stating that the patient slid out of bed onto the floor, and unsure on how to use the Hoyer lift. PCG would like the nurse to come out to assist. The nurse is out with another patient so advised them to call 911 for a non-emergency assist to lift, to place patient back into bed. Patient denies any pain or discomfort, No medication list on file. Educated to call with any further questions or concerns. During the home visit on 04/29/2024 at 3:33 PM, the PCG stated he/she called 911 for assist to get the patient up off the floor as directed per phone call to the provider due to it would be an hour before anyone could get there to help get the patient up off the floor and now has a $252.00 bill from the ambulance service and he/she was told to call 911 for assist to lift. The PCG received no education on the Hoyer lift when it was delivered but the HA A did show the PCG a little training what he/she wasnt to do. RN D offered instructions on the Hoyer lift after it had already been used. The clinical record failed to show documentation that the nurse coordinated with the durable medical equipment (DME) company when DME would be delivered for education on using the Hoyer lift. During an interview, on 05/14/2024 at 10:15 AM, the clinical director stated that the DME company provides education when delivering the equipment and the nurse educate with reinforcement hopefully within 24 hours of delivery of the DME. The aide can educate and reinforce what has been taught. Educate it is safer to use Hoyer lift with 2 people.

Based on policy review, record review, home visit observations, and interview, the hospice provider failed to develop an individualized plan of care (POC) that reflected the patients interventions in, four of fourteen records reviewed (Records/Patients #1, #2, #3, and #8). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy titled, ";IDG (Interdisciplinary Group) Hospice Plan of Care-Content, Plan, Goals, Interventions and Outcomes," reviewed 05/23/2022, showed, in part: - The plan of care will identify all the services needed to address problems identified in the initial, comprehensive and updated assessments; - Name, dosage, route, frequency and indication of medication/treatments ordered; - Plans of care will be individualized and patient-specific; and - The plan of care will be documented, will support that the development of the plan of care was a collaborative effort involving all members of the IDG, the patient/family and as appropriate, the attending physician. Review of the provider's policy titled, ";Pain and Symptom Management and Pain Scales," reviewed 05/23/2022, showed, in part: - An initial assessment will be performed upon admission to determine the patient's immediate needs, including pain and symptoms; and - All medications/treatments will be documented on the patients medication/treatment plan of care. RECORD/PATIENT #3: During home visit observation on 04/30/2024, beginning at 12:30 PM, showed, in part: - The patient was admitted to hospice on 09/25/2023 with a primary diagnosis of Atherosclerotic heart disease (a buildup of fat, cholesterol and other substances in the blood vessels that obstruct the blood flow); - The patient was 102 years old and resided in the home with the PCG (patient caregiver); - The PCG assisted with translating for the patient, as the patient is Spanish speaking only; - The PCG requested that visitors and hospice staff remove their shoes at the door and walk into the restroom and wash their hands immediately upon arrival; - The PCG that the patients nurse coordinates visits with the pcg to ensure that the pcg is available to translate for the patient; - The PCG reported that the patients hospice bath aide speaks Spanish as well so the PCG does not have to be present to translate; - There was one occasion that the bath aide was unable to conduct the visit and a different bath aide made the visit; - The PCG was unaware that the bath aide was going to be making a visit and therefore the PCG was not present to translate for the patient; and - The bath aide was unaware of coordinating the bath visits with the PCG prior to conducting the visit. The plan of care failed to include patient-specific interventions regarding the need to coordinate visits with the PCG to assist with translating for the patient. RECORD/PATIENT #8: Review of the clinical record showed, in part: - The patient was admitted to hospice services on 04/28/2023 with a primary diagnosis of Zenkers Diverticulum (a pouch that develops in the back of the throat and causes difficulty with swallowing) with a secondary diagnosis of dysphagia (difficulty swallowing) and aspiration pneumonia (a long infection that occurs when food, liquid, or other material is inhaled into the lungs instead of being swallowed); and - The patient resided at home alone and had a private caregiver during the day. Review of the Spiritual Care routine patient assessment report, dated 07/18/2023, showed, in part: - The Pt is processing ";wanting to end it all" by ";taking the medication in the ekit;" - The chaplain ";helps pt process lots of issues-wanting to end it all, evil thoughts presenting themselves as the devil through the ekit;" - ";Processing ideas on how to make the bad feelings go away;" - Pt was ";thankful a lockbox would be delivered this evening;" and - The chaplain coordinated with the clinical director ";who would send an RN to deliver a lockbox and hide the key in home and let team know where key is located but pt will not know." Review of the Suicide Assessment and Risk Inquiry document, completed by Social Worker A, on 07/19/2023, showed, in part: - Yes, was answered for the suicidal thoughts question; -The frequency of suicidal thoughts showed, ";1 or 2 brief thoughts;" - The patient had a brief thought about taking meds (medications) to end his/her life; - The patient thought about how he/she would end his/her life with ";overdose of meds;" - Have you received mental healthcare in the past was answered with ";yes" and ";Pt routinely in long-term therapy" with ";PAD;" and - Do you have access to a rope, gun, knife, drugs, to your method of choice, was answered with ";No-meds in lockbox." The Plan of Care failed to include interventions and/or orders related to the increased suicide risk after having suicidal thoughts, the implementation of a safety plan, the lockbox for Morphine (used to treat moderate to severe pain), plan for other controlled substance medications that were not in the lockbox, and plan for medication administration if the medications were needed for the patient. During an interview, on 05/14/2024 at 10:50 AM, the Clinical Director stated that: - The Morphine was locked up in a lockbox because that is the medication that the patient mentioned taking; - The patient was on other controlled substance medications for symptom management; - There was discussion about locking all of the controlled medications up, but the patient was actively taking the other medications to control pain and anxiety; - It would have been hard to lock all of the medications up because the patient lived alone; and - The patient had a caregiver, but the caregiver was not always there. RECORD/PATIENT #1: Review of the Registered Nurse (RN) comprehensive assessment patient assessment report, completed by RN D, dated 02/21/2024, showed, in part: - The patient is 79 years old with a primary diagnosis of senile degeneration of the brain (a decrease in cognitive abilities or mental decline) and secondary diagnoses of dementia (decline in mental capacity) and repeated falls; - The patient is a frequent faller; and - The RN discussed a Hoyer lift (a mechanical lift used for transferring patients) to help facilitate transfers. Review of the hospice aide (HA) visit, completed by HA A on 02/22/2024, showed in part: the PCG requested need for education with Hoyer lift that had just been delivered. The aide provided education with Hoyer to PCG. Review of the IDG Meeting Notes dated 02/28/2024 by LPN C at 4:20 AM by LPN C on 02/23/2024 showed in part, received a phone call from PCG stating that the patient slid out of bed onto the floor, and unsure on how to use the Hoyer lift. PCG would like the nurse to come out to assist. During the home visit on 04/29/2024 at 3:33 PM, the PCG stated he/she called 911 for assist to get the patient up off the floor as directed per phone call to the provider due to it would be an hour before anyone could get there to help get the patient up off the floor. The PCG hadnt received any education on the Hoyer lift when it was delivered but HA A did show the PCG a little training of what he/she wasnt to do. The plan of care failed to include patient-specific interventions regarding the need for a Hoyer lift for the PCG to use in transferring the patient. RECORD/PATIENT #2: Review of the Registered Nurse (RN) comprehensive assessment patient assessment report, completed by RN B, dated 04/16/2024, showed, in part: - The patient is 89 years old with a primary diagnosis of congestive heart failure (CHF) and hypertension and wears oxygen at two liters per a minute nasal cannula continuously. The plan of care failed to include patient-specific interventions regarding the need for oxygen setting of two liters nasal cannula continuously.

Based on the policy review, record review, home visit observation, and interview, the hospice provider failed to ensure that the plan of care (POC) included all medications and treatments necessary to meet the needs of the patient in, two of fourteen records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy titled, ";IDG (Interdisciplinary Group) Hospice Plan of Care-Content, Plan, Goals, Interventions and Outcomes," reviewed 05/23/2022, showed, in part: - The plan of care will identify all the services needed to address problems identified in the initial, comprehensive and updated assessments; - Name, dosage, route, frequency and indication of medication/treatments ordered; - Plans of care will be individualized and patient-specific; and - The plan of care will be documented, will support that the development of the plan of care was a collaborative effort involving all members of the IDG, the patient/family and as appropriate, the attending physician. Review of the provider's policy titled, ";Pain and Symptom Management and Pain Scales," reviewed 05/23/2022, showed, in part: - An initial assessment will be performed upon admission to determine the patient's immediate needs, including pain and symptoms; and - All medications/treatments will be documented on the patients medication/treatment plan of care. RECORD/PATIENT #4: During home visit observation on 05/01/2024 beginning at 1:00 PM, showed, in part: - The patient reported that he/she has an appointment for steroid injections in his/her back on May 27th, 2024; and - The patient reports that he/she receives steroid injections every three (3) months for an old back injury that was over twenty (20) years ago. The plan of care failed to show documentation that the patient received steroid injections every 3 months for a back injury. During an interview on 05/14/2024, at 11:00 AM, the clinical director, stated that: - The clinical record failed to include the patient receives steroid injections; - The nurses should be conducted medication reconciliations during routine visits; and - The plan of care medication profile should include all medications the patients take in order to monitor for drug interactions. RECORD/PATIENT #1: - Review of the clinical record showed the patient was admitted to hospice services on 02/20/2024 with a primary diagnosis of senile degeneration of the brain and comorbidities of repeated falls. The patient resided in his/her own home with the assistance of his/her adult child (primary caregiver – (PCG). Review of the document titled, "Hospice Aide Visit," dated 4/15/2024 showed, in part, skin issues noted and PCG. made aware of issues. Patient had a red raw area on left side of belly fold, patient did not feel pain at this time in that area. The PCG agreed to provide SELAN AF (antifungal moisture barrier cream) to the red raw area and to keep it clean and dry. Review of the document titled, "Hospice Aide Visit," dated 4/17/2024 showed, in part, patient allowed aide to assist with partial bath cares after transfers to her bed, with moisture barrier cream applied under breast and under belly fold. It appears to be healing more today than past bath visit on Monday. Review of the document titled, "IDG Meeting Notes," dated 05/08/2024 showed that the documents failed to contain orders for the use of the SEAN AF for the patient. During an interview on 04/15/2024 at 10:20 AM, the area clinical director stated that they would have expected the plan of care to contain orders for the use of SELAN AF.

Based on policy review, record review, and interview, the hospice provider failed to maintain a system of communication and integration, in accordance with the hospices own policies and procedures in, two of fourteen records reviewed (Records/Patients #5 and #8). This deficient practice has the potential to affect the care provided to all patients served by the hospice provider. --- Findings included: Review of the agency's policy titled, ";IDG Hospice Plan of Care-Content, Plan, Goals, Interventions and Outcomes," reviewed 05/23/2022, showed, in part: - Communication with the attending physician may be through phone calls, electronic methods, orders received, or other means according to Hospice policy and patient needs; - The Hospice will develop and maintain a system of communication and integration, in accordance with policies and procedures to ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided; - The Hospice will ensure systems are in place to facilitate the exchange of information and coordination of services among staff and with other non-hospice healthcare providers; -The Hospice will ensure that coordination and care occurs between services provided directly and those under arrangement; and - The Hospice will ensure that documentation within the clinical record is geared and reflects the sharing of information between all disciplines providing care and with other healthcare providers furnishing services to the patient family. Review of the providers policy titled, ";Suicide Watch Procedures for Hospice and Palliative Care Patients and Family/Caregiver," revised 08/03/2023 showed the following duties: - All patients including palliative care patients as well as family/caregivers will be monitored for the risk of suicide on ongoing basis. (Document if threat is present); - Any patient family caregiver that exhibits risk factors for suicide, such as: * Verbalizing a desire to die or harm oneself * Unusual calm after a period of agitated depression * Prior suicide attempts * Direct statements of suicide or inviting death * The patient family will be placed on immediate suicide watch - Question patient family and ask them directly if they are having ideas of suicide harming self; - If patient family verbalizes desire to harm kill themselves and the patient has access or plans contact 911; - If the patient family member does not have a plan and is willing to talk, contact support services team members for immediate visit. Social worker and or bereavement coordinator will complete a suicide assessment and risk inquiry form; and - Document statements, findings, and assessments within the EMR/patient record. RECORD/PATIENT #8: Review of the Registered Nurse (RN) phone call patient assessment report, completed by RN B, dated 07/17/2023, showed, in part: - After setting up a visit with the patient tomorrow, he/she became upset and stated ";I just dont know if I can do this anymore;" - The patient stated that he/she told a friend that he/she ";wondered what would happen if [he/she] took the morphine;" - His/her ";friend became upset" and the patient stated that he/she was just kidding; - This nurse asked the patient why they would tell his/her friend that and the patient stated ";I don't know I wouldn't do it. Besides my caregiver [named] is here with me." This nurse suggested a visit, but the patient refused. The nurse asked if the patient would like to speak to the Chaplain and the patient stated that was who he/she needed to speak with; and - The message was sent to the chaplain who stated he/she was planning on seeing the patient tomorrow anyway. The clinical record failed to show documentation that the nurse coordinated with IDG and the social worker regarding the patients suicidal thoughts. During an interview, on 05/09/2024 at 12:45 PM, the administrator stated that: - A social worker should have gone out right after the nurse was told that about the morphine; - There is a social worker on-call 24/7 (24 hours a day, seven (7) days a week) for emergent visits; - The policy is for a social worker to conduct an immediate suicide risk assessment; and - The social worker did not make a visit and conduct a suicide risk assessment until two (2) days after the comment was made about taking the Morphine. RECORD/PATIENT #5: Review of the Spiritual Care – Initial/Comprehensive Assessment Patient Assessment Report completed by Chaplain B, dated 01/18/2024, showed primary caregiver (PCG) was present and lives with the patient. PCG is on probation due to an altercation - pushing mom and resulting in a broken wrist. All is being worked out. The clinical record failed to show documentation that the chaplain coordinated with IDG and the social worker regarding the patients PCG on probation for pushing the patient resulting and resulting in a broken wrist. During an interview on 05/07/2024 at 1:27 PM, social worker A stated that he/she was not aware of the PCG breaking the patients wrist or that the PCG was not to be in the patients home. The PCG told him/her that he/she was on probation due to drugs. During an interview, on 05/07/2024 at 2:35 PM, the administrator stated that the chaplain should have shared the information in the IDG meeting.

Based on policy review, record review, and interview, the hospice provider failed to ensure coordination of care when the on-going sharing of information between all disciplines providing care failed to be provided in a discharge summary during a respite stay in, one of one record reviewed for respite care (Record/Patient #6). This deficient practice has the potential to adversely affect communication and care to all the provider's patients in respite care. --- Findings included: Review of the policy titled, ";Discharge From Services, Transfers and Discharge Planning" renewed on 05/23/2022, showed in part: - The following will be provided to the patient/patient representative, the receiving organization, facility and/or physician as applicable, included in part; * Discharge summary which will include the patient's name, date of discharge, reasons for discharge, type of care slash treatment during the Hospice stay * Other requirements per state law and regulation; and - The primary care physician must be sent (via fax, scanned via secured e-mail, or standard mail) a copy of the discharge summary within 72 hours of discharge. RECORD/PATIENT #6: Review of the clinical record, showed in part: - The patient was admitted to hospice on 03/30/2023 with a primary diagnosis of non-traumatic intracerebral hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery) and secondary diagnosis of chronic atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat); - The patient lived at home with his/her adult child as primary caregiver; - The patient was admitted to a long-term care facility (LTCF) for a respite stay 01/16/2024 to 01/22/2024; and - The clinical record failed to include record that the discharge summary was provided to the hospice provider after discharge from his/her respite stay at the LTCF. During an interview on 05/13/2024 at 11:50 AM, the administrator stated that there was no discharge summary provided from the LTCF.

Based on policy review, review of the providers job descriptions, record review, and interview, the hospice provider failed to: - Ensure that the nursing needs of the patients were met as identified in the initial assessment, comprehensive assessment, and updated assessments (L591); and - Ensure that medical social services were provided based on the patients psychosocial assessment and the patients and familys needs and acceptance of these services (L594). The cumulative effect of these deficient practices has the potential to affect all patients served by the provider.

Based on policy review, review of the providers job description, record review, and interview, the hospice provider failed to ensure that the nursing needs of the patient were met, in two of fourteen records reviewed (Records/Patients #5 and #9). This deficient practice has the potential to adversely affect the provision of care to all patients served by the provider. --- Findings included: Review of the provider's policy titled, ";Pain and Symptom Management and Pain Scales," reviewed 05/23/2022, showed, in part: - Pain will be managed at a level acceptable to the patient; and - Symptoms, including, but not limited to nausea, dyspnea, anxiety, agitation, restlessness, itching and any others that cause distress, will be controlled using appropriate physician ordered medications, treatments, and interventions to alleviate the symptom(s). Review of the Registered Nurse Job Description, showed, in part: - Assess existing and potential problem areas, needs and resources of individuals, families and significant others; set priorities in collecting data, developing and updating the comprehensive assessment and Plan of Care; - Initiate nursing care plan in response to identified nursing diagnosis immediately after development of the initial plan of care; - Immediately update the plan of care as changes occur; - Make clinical decisions regarding patient care based on objective and subjective data, nursing assessment, and quality assurance criteria; - Monitor to effectiveness of treatments and medications for Hospice and palliative care patients, (as appropriate) including the assessment of and the monitoring of usage (such as narcotic counts) of controlled substances; - Continue to meet the needs of the Hospice and palliative care patients and their families by ensuring all pain and symptoms are effectively managed; - Provide service in accordance with the established plan of care and in compliance with third-party regulations, certified Hospice care requirements, and standards of practice; - Communicate patient condition/information to the clinical team/clinical managers (team leader, ACD, Clinical Director, LPN's on call staff and Hospice aides) to ensure coordination of care; - Provide ongoing symptom control, as ordered and based on the patient's immediate needs; and - Make necessary changes in assignment to compensate for emergency situations, eminent death, pain/symptoms out of control and/or acutely ill patients. RECORD/PATIENT #9: Review of the skilled nurse visit note on 02/20/2024 at 13:00 (1:00 PM), showed in part: - The patient is a 96-year-old with the primary dx (diagnosis) of atherosclerotic heart disease (a build-up of fat, cholesterol and other substances in the blood vessels that causes obstructed blood flow); - The patient is alert and oriented times four (person, place, time, situation); - ";Patient with c/o [complaint of] catheter leaking today. Could not detect leakage, but noted fresh bout of purple bag syndrome" (is a rare medical syndrome where purple discoloration of urine occurs in people with urinary catheters and co-existent urinary tract infection); - ";Enquired if pt went to urologist appointment. CG [caregiver] states pt refused, patient stated CG did not wish to take [him/her];" - Instructed on use of the ER (emergency room) should the patient experience signs of confusion; and - ";Telephoned urologist office" and ";spoke with triage nurse." Review of the skilled nurse visit note on 03/07/2024 at 12:30 (PM), showed in part: - ";Bloody" and ";red" urine noted; - ";UA [urinalysis] report received, physician reviewing will wait for culture;" - ";UA returned with UTI [urinary tract infection] indicated;" - ";PCP [primary care provider] wants to wait for culture for ABX [antibiotics];" and - The patient and family member voiced understanding. Review of the emergent skilled nurse visit note on 03/08/2024 at 09:15 (9:15 AM), showed in part: - The nurse was called to the patients home for leaking of the leg bag; - The catheter was flushed ";with 10ml [milliliter] sterile NS [normal saline], return noted;" - The nurse spoke to the patients son and ";updated that catheter should be draining;" and - ";Will plan on calling son in afternoon to check on output." Review of the routine skilled nurse visit note on 03/08/2024 at 17:45 (5:45 PM), showed in part: - The ";family reports pt had catheter flushed earlier today for clogged foley;" - The ";family reports no urine output has been noted in Foley bag this afternoon;" - ";Foley flushed without urine return;" - ";Foley clogged;" - The skilled nurse changed the foley catheter and applied a new leg bag; and - The ";family reports patient with positive UTI awaiting sensitivity report." The clinical record failed to show any follow-up with the physician to inquire about the patients need for antibiotics. Review of the emergent skilled nurse visit note on 03/17/2024 at 02:45 (2:45 AM), showed in part: - The patients son called to report the patient had wandered out of the home and was now in the ER with suspected UTI and increased confusion; - The son ";reports increased confusion over several days" and history of ";recurrent UTI's;" - ";Spoke with NP [named] who confirms UTI with pending cultures;" - ";To start oral or IV [intravenous] levaquin [antibiotic] with efficacy being discussed with son;" - ";NP checked with hospitalist [named] who agreed to admit patient with dx of UTI and treat with IV Rocephin [antibiotic];" - The patients son signed revocation papers; and - ";Son and NP aware to call [hospice] when patient ready to discharge for readmit to [hospice]." During an interview on 05/14/2024, at 11:30 AM, the clinical director, stated that: - The UA obtained on 03/04/2024 was negative; - If an oral antibiotic was an option, then the patient should have been treated with an oral antibiotic; and - The nurse that instructed the patient go to the ER (on 02/20/2024) if the patient experiences signs of confusion, (RN C) was notorious about telling patients and families to go to the ER. During an interview on 05/14/2024, at 11:40 AM, the Medical Director, stated that: - He/she would not jump to recommending a patient go to the ER; - He/she did not know the reason behind the nurse recommending that; and - He/she would want a UA and to try to treat the patient at home first. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 01/17/2024 with a primary diagnoses of heart failure (when the heart muscle doesnt pump blood as well as it should), atherosclerotic heart disease (ASHD: thickening of the arterial wall that results in decreased supply of blood flow) hypertension, cardiomegaly (enlargement of the heart), mitral insufficiency (blood leaking in the wrong direction), and history of breast cancer with metastases (the spread of cancer cells from the place where they first formed to another part of the body). The patient lived at his/her own home with an adult child as primary caregiver. He/she required assistance with activities of daily living. Review of the initial plan of care (IPOC), dated 01/17/2024, showed, in part, the frequency by discipline: Skilled Nurse two times a week and one as needed (PRN). Review of the record showed the following skilled nurse visits: - 03/03/2024 to 03/09/2024: one skilled nurse (SN) visit and one phone call; - 03/10/2024 to 03/16/2024: one SN visit; one emergent visit and two phone calls; - 03/17/2024 to 03/23/2024: one SN visit, one emergent visit and five phone calls with one resulting in a visit; - 03/24/2024 to 03/30/2024: one SN visit and one phone call; - 03/31/2024 to 04/06/2024: one SN visit, two emergent visits, three watch visits and five phone calls; - 04/07/2024 to 04/13/2024: one SN visit and one phone call; - 04/14/2024 to 04/20/2024: one SN visit one emergent visit and one phone call; - 04/21/2024 to 04/27/2024: one SN visit and one phone call; - 04/28/2024 to 05/04/2024: one SN visit; - 05/05/2024 to 05/11/2024: one SN visit, one watch and one phone call. Review of the record showed skilled nursing only made one scheduled visit once a week 03/03/2024 through 05/11/2024. During an interview on 05/13/2024, at 02:50 PM, the clinical director, stated staff are to follow the POC and update as needed.

Based on policy review, job description review, record review, and interview, the hospice provider failed to ensure that the medical social services needs of the patient were met, in two of fourteen records reviewed (Records/Patients #5 and #8). This deficient practice has the potential to adversely affect the provision of care to all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Suicide Watch Procedures for Hospice and Palliative Care Patients and Family/Caregiver," revised 08/03/2023 showed the following duties: - All patients including palliative care patients as well as family/caregivers will be monitored for the risk of suicide on ongoing basis. (Document if threat is present); - Any patient family caregiver that exhibits risk factors for suicide, such as: * Verbalizing a desire to die or harm oneself * Unusual calm after a period of agitated depression * Prior suicide attempts * Direct statements of suicide or inviting death * The patient family will be placed on immediate suicide watch - Question patient family and ask them directly if they are having ideas of suicide harming self; - If patient family verbalizes desire to harm kill themselves and the patient has access or plans contact 911; - If the patient family member does not have a plan and is willing to talk, contact support services team members for immediate visit. Social worker and or bereavement coordinator will complete a suicide assessment and risk inquiry form; and - Document statements, findings, and assessments within the EMR/patient record. Review of the Social Worker Job Description, showed, in part: - Assist with the SSD (support services director) department with the coordination and manage the daily workload by providing direct patient care, with direct reporting to and supervision by the SSD and the clinical director; - Provide direct patient care for work hours assignments, on call time, and employee vacation time off by assisting the SSD as deemed necessary; - Responsible for ensuring patient care visits are made, are compassionate, timely and are within compliance; - Provide patient/family with requested or required community and legal resources, (such as Meals on Wheels etc) as required and/or requested; - Assess existing and potential problem areas, needs and resources of individuals, families and significant others; - Assist the family and discuss alternative methods of alleviating problems situations; - Make necessary changes in assignments to compensate for changing situations; - Assure that patient care is provided in compliance with federal/state/accrediting body regulations and current standards of practice; and - Perform or supervise support staff to ensure that urgent/emergent patient care visits are performed as deemed necessary. RECORD/PATIENT #8: Review of the Social Worker (SW) Initial/Comprehensive Assessment report, on 05/01/2023, showed, in part: - The patient needs, ";interpersonal support" and a description of ";lack of support;" - The patients suicide risk showed low; - The patient requested ";no contact be made with [his/her] son" until he/she ";can inform him of hospice admission;" and - The visit note failed to include any documentation of the patients history of mental health issues requiring long-term therapy. Review of the Registered Nurse (RN) phone call patient assessment report, completed by RN B, dated, 07/17/2023, showed, in part: - After setting up a visit with pt tomorrow he/she became upset and stated ";I just dont know if I can do this anymore;" - The patient stated that he/she told a friend that he/she ";wondered what would happen if [he/she] took the morphine;" - The ";friend became upset" and the patient stated he/she was just kidding; - This nurse suggested a visit, but pt refused; - This nurse asked if the pt would like to speak to the Chaplain and the patient stated that he/she would like to speak with the chaplain; and - The message was sent to chaplain who stated that he/she was planning on seeing the patient tomorrow anyway. Review of the Spiritual Care routine patient assessment report, dated, 07/18/2023, showed, in part: - The RN reached out to the chaplain to call the patient at patients request to process that the patient was ";struggling;" - The Pt is processing ";wanting to end it all" by ";taking the medication in the ekit;" - The chaplain ";helps pt process lots of issues-wanting to end it all, evil thoughts presenting themselves as the devil through the ekit;" - ";Processing ideas on how to make the bad feelings go away;" - Pt was ";thankful a lockbox would be delivered this evening;" and - The chaplain ";coordinated with SW" about ";f/u tomorrow." Review of the Social Worker routine patient assessment report, completed by SW A on 07/19/2023, showed, in part: - ";Pt states [he/she] has been in psychiatric care and therapy for 16 years and still working with a therapist for [his/her] childhood trauma and self-compassion;" - Suicidal thoughts frequency showed, ";1 or 2 brief thoughts;" - The patient stated his/her ";mental health dx include depression and anxiety;" - The patient ";describes poor self-esteem and shame related to [his/her] childhood trauma;" - The patient ";described thinking the devil was in the med box;" and - ";SW provided much supportive listening and validation of Pts worth, and value in that [he/she] deserved love, kindness, compassion and care." Review of the Suicide Assessment and Risk Inquiry document, completed by the Social Worker A, on 07/19/2023, showed, in part: - Yes was answered for the suicidal thoughts question; - Frequency of suicidal thoughts showed, ";1 or 2 brief thoughts;" - The patient had a brief thought about taking meds (medications) to end his/her life; - The patient thought about how he/she would end his/her life with ";overdose of meds;" - Have you received mental healthcare in the past was answered with ";yes" and ";Pt routinely in long-term therapy" with ";PAD;" and - Do you have access to a rope, gun, knife, drugs, to your method of choice, was answered with ";No-meds in lockbox." (The patient lived at home alone and had access to other controlled substance medications that he/she was taking for pain and anxiety). During an interview, on 05/09/2024, at 12:45 PM, the administrator stated that: - A social worker should have gone out right after the nurse was told that bout the morphine; - There is a social worker on-call 24/7 for emergent visits; - The policy was for a social worker to conduct an immediate suicide risk assessment; and - The social worker did not make a visit and conduct a suicide risk assessment until two (2) days after the comment was made about taking the Morphine. RECORD/PATIENT #5: Review of the Spiritual Care/Initial/Comprehensive Assessment report, on 01/18/2024, showed, in part: - The patients requested needs, ";spiritual support;" - Summary – Coordination of Care- Primary caregiver (PCG) present and lives with the patient. PCG is on probation due to an altercation of pushing the patient and resulting in a broken wrist. All is being worked out; and - Narrative- Chaplain made initial visit to patient for emotional and spiritual support with social worker and registered nurse also present. Review of the Social Worker (SW) Initial/Comprehensive Assessment report, on 01/18/2024, showed, in part: - The patient needs, ";interpersonal support" and a description of ";lacking support;" - The patients ";anticipatory grief" showed ";grieving;" - The patients suicide risk showed low; - The patients ";precautions, safety, and teachings" showed ";moderate risk;" - Social worker made joint initial visit with the chaplain to complete initial assessment and establish a plan of care (POC); and - The visit note failed to include any documentation of the PCG on probation from pushing the patient and resulting in a broken wrist. Review of the Social Worker Assessment Report, dated 1/19/2024, showed, in part: - The patients emotional status is stressed and concerned about her financial state sharing extensive financial concerns with the social worker. The social worker educated the patient that the social worker is not educated in financial items and will try to find resources for assistance in case patient has been taken advantage of. The social worker coordinated care with the primary caregiver in person who contributed to patient sharing of her financial concerns. Review of the Registered Nurse (RN) Patient Assessment Report, dated, 01/27/2024, showed on arrival the patient and PCG both talked over each other offering past medical and medication history. Review of the RN Phone Call Assessment, dated, 02/05/2024, showed the PCG was anxious and stated it was because he/she was missing an appointment today because he/she couldn't leave the patient alone. Reassured PCG that a conversation about this might help to come up with ideas and a plan for situations like this. Visit planned for today. Also message social worker. Regarding this. Review of the Social Worker Emergent Assessment Report, dated 02/05/2024, showed, in part: - The social worker provided engagement primarily with the PCG while the registered nurse provided care to the patient. The PCG needs multiple letters sent to providers stating that he/ she is the primary carer for the patient who is on Hospice. The social worker engaged with the patient about her physical status and her financial concerns. The patient's concerns are such that the social worker recommended the patient would likely need to contact an attorney for assistance with her concerns. Review of the Licensed Practical Nurse (LPN) Phone Call Assessment, dated, 03/21/2024, showed visit made related to PCG called and reported police on the way related to neighbors invaded home. Arrived at home and two police officers present trying to calm PCG, PCG very repetitive in conversation and pupils extremely dilated. After the police left, nurse was asked to enter home and check on patient. Patient resting peacefully in bed, very soft spoken. PCG reports neighbors were shining flashlights in windows, and patient was afraid they were going to kill him/her, support provided. Review of the LPN Phone Call Assessment, dated, 03/22/2024, showed PCG called has called twice in the past six hours due to saying there are people in his/her yard that are neighbors peeking in his/her windows and shining flashlights. Police were called the first time and LPN A went to the home and checked on the patient and he/she was resting comfortably. Neighbors were not invading or causing any problems. Nothing was done at that time due to PCG was just being paranoid. Second time, PCG wanted a nurse to come out due to same reason and staff stated that this has nothing to do with the patient being on hospice. If you are concerned, call the police again, but there is nothing that hospice can do for you. He/she stated that neighbors were invading his/her home and inside his/her home. Staff stated again to call the police. Review of the LPN Phone Call Assessment, dated, 03/23/2024, showed PCG complaining of neighbors shining lights in the house and yelling. He/she stated that he/she sprayed the neighbor with the hose. He/she asked the LPN to stay on the phone. He/she then stated they must have left. The PCG has called three nights in a row now with these concerns, this LPN staff thinks he/she needs to be evaluated for behaviors him/herself and the patient needs to be placed temporary for safety concerns. Review of the LPN Phone Call Assessment, dated, 03/26/2024, showed Return call made to the patient and he/she stated he/she was fine, just fine. The patient just wanted hospice staff to come out and see him/her because he/she misses them. There is no emergency, he/she just wanted to see them again. The PCG was then heard in the background telling the patient what to say next. He/she stated go ahead and tell them what you did today. The patient told a story about a visitor today and what he/she did during the day. Review of the RN Emergent Assessment Report, dated 04/01/2024, showed end of visit complete for PCGs request due to verbal dispute tonight with patient. Case manager and social worker please follow up in AM. Please start daily watch visits today to monitor for patient safety and well-being. Patient tearful at times and states he/she is worried and concerned about PCG current behavioral state. PCG attempts to explain why he is upset with patient multiple times,. unable to express his/her thoughts and feelings about situation without ruminating and exhibiting manic behavior as speech is fast and explanation for increased agitation is irrational. Home Health Aid (HHA) arrived at patients home to implement patient safety watch and to allow PCG uninterrupted time to rest. Missouri Adult Abuse and Neglect online form completed and submitted RN on 4/2/2024. Review of the RN Watch Care Visit Assessment, dated 04/02/2024, showed, in part, there has been some recent anxiety related to decline and risk for caregiver burnout. Patient reports anxiety has been managed well with rest, meditation and medications. Continued respite discussion and patient is considering respite for caregiver role strain patients. PCG verbalized personal coping mechanisms. Review of the RN Phone Call Assessment, dated, 04/02/2024, showed a phone call to 911 dispatch for patient and PCG domestic disturbance completed and a call to RN to report to patients home to ensure patient safety. Review of the LPN Phone Call Assessment, dated, 04/02/2024, showed the PCG called in stating the patient is getting violent with him/her and he/she is saying he/she has had enough of the patient as well. Nurse asked to speak to patient, PCG threw the phone at patients face. Staff asked patient if he/she felt safe and he/she said no. Primary caregiver grab the phone, and as hospice staff was talking, they had 911 called due to the words the PCG was using, such as I'm going to end things. I am done with all of this, things are going to stop sooner or later, things better change now or something is about to happen. Hospital staff stayed on the phone with primary caregiver trying to calm him/her down, and the police knocked on the door. PCG ran out the back door and ran for about 20 minutes. Hospital staff was trying to tell him to stop running and that the police were not at the house for him, that he did nothing wrong. After approximately 20 minutes, the phone went blank and hospice staff hung up. A RN and HHA were sent to the home to try to attend to patient safety. Patient refused to go anywhere. Police showed up again and so did the PCG, he/she spoke with the police. Nothing can be done since patient refused to leave the home but if police are called out to the home again, they will take patient out of the home. PCG says he needs a break and would like help. He is crying for help and would like Hospice staff to assist. Please follow up in AM. Patient is on dailies. Social worker and RN up with caregiver. Review of the Spiritual Care Patient Assessment Report, dated, 04/02/2024, showed, in part, routine visit made to patient for emotional and spiritual support. Chaplain and social worker made joint visit due to last night activity and safety sit provided. Patient appears uncomfortable and has shortness of air throughout visit even when wearing oxygen. Patient appears to have moments of disassociation with conversation and PCG circles his/her conversation, stating same concerns and questions multiple times. PCG is frustrated with situation showing signs of caregiver burnout, trying to get patient to consider respite for each of their mental and physical well-being. Both patient and PCG are at ropes end but cannot come to conclusion as to next steps for safety of patient and PCG. Active listening provided. Review of the RN Watch Care Visit Assessment, dated 04/03/2024, showed, in part, PCG talking rapidly, slurring words about incident between patient and him last night through this morning. Unable to understand most of what PCG was saying but did listen intently. When offering a response, PCG did stop this nurse from speaking by saying he wasn't finished. This happened three more times. During this time, listeners did monitor and assess patient who continued to have her eyes closed, respirations even and had a content look on his/her face. Did alert team leader and team regarding PCG erratic behavior and restlessness as he demonstrated with fast, jerky moves and crying while he/she talked. After approximately 45 minutes, the PCG had called him/herself and was able to speak clearer. Suggested to PCG that maybe respite for the patient would help the struggles they were having or maybe PCG was going through burnout. PCG stated he/she would be able to take care of the patient if he/she wouldn't be horrible to him/her and his/her aunt would just stay out of their lives. This nurse encouraged PCG to let patient sleep as he/she didn't get much sleep last night. Instead, he/she didnt get much sleep last night. Instead, he/she walked over to the patient, taking the straw n his/her cup and attempting to give her some of her drink while he/she slept. Nurse educated PCG not to give a drink when the patient was sleeping. Review of the Social Worker Routine Assessment Report, dated 04/03/2024, showed this social worker requested PCG to sign a release of information allowing the social worker to communicate with his community caseworker to advise the caseworker with an overview of the situation that patient has been in and to request additional support for the PCG. The PCG agreed and provided the name, phone numbers and signed release of information. Review of the RN Emergent Assessment Report, dated 04/04/2024, showed, in part, the patient was crying and visibly upset, his/her legs were giving out, took two persons assist to get the patient back into bed. Received report from primary on call nurse of a domestic disturbance and the patients son/daughter threw a cell phone at the patient. Patient denies this and states they were just verbally arguing. Patient states she feels safe with him/her in the home. Called 911 to transport patient to the hospital due to patients PCG had taken off and is not in the home and patient is not safe in home alone. 911 dispatcher advised they will not send ambulance. Sent the police and they called for an ambulance, emergency medical system (EMS) checked patient out, but he/she refused to go to the hospital. PCG arrived back home. Police cleared the scene and advised they had no reason to believe patient was not safe with PCG at this time. PCG agreed to stay at home. Review of the RN Routine Assessment Report, dated 04/16/2024, showed, in part the patient was having some pain and the PCG gave the patient his/her pain medication. The patient became upset when PCG frequently interrupted him/her when he/she was trying to talk. The PCG was reminded that the patient was talking about his/her pain and what was going on with him/herself and if he/she could give him/her the time to talk about it, then he/she could talk afterwards. Patient was having a hard time concentrating on what he/she was saying when he/she was interrupted. Review of the RN Emergent Assessment Report, dated 04/19/2024, showed, in part, reports she would like a visit for shortness of air. Upon arrival, knocked and rung doorbell three times before the PCG answered the front door. Patients, PCG appears anxious and agitated, expressing concerns with the patients recent behavior, the PCG explained that the patient was on the phone with his/her sister discussing his/her care. The PCG reports that the patient had some concerns with his/her care, and this has caused stress to the PCG. The PCG reports that a neighbor has been notified of concerns and has seemed to be watching his/her house causing anxiety. The PCG reports that police have been notified for concerns in the past as well. This nurse explains to the PCG that the patient has the rights and can express his/her concerns to whom he/she wishes freely. This nurse reached out to the team leader and requested social worker involvement for PCG support/offer resources. PCG reports that he/she is very aware of needs, and he is tending to them. Explained to the PCG that patients covering health have top priority at this time. Throughout the patient's assessment, PCG continues to argue with the patient and this nurse about patients involving her family from outside the home into care. Again, discussed with the primary caregiver this is the patient's information and he/she is allowed to share with who he/she she wants. This nurse offered discuss caregiver concerns with the PCG outside as the PCG agitation is creating anxiety for the patient. The PCG refused and said, ";just go home." Patient reports that he/she feels safe in the home currently. Education given on respite stay, permanent placement or new placement with other family. Patient reports she will think about these options. The patient has a phone and can call Hospice herself. Review of the RN Routine Assessment Report, dated 04/22/2024, showed, in part the patient stated his/her skin was itchy again and the PCG and patient were asked if the PCG had picked up the prescribed cream that patient had an order for. It had been ordered approximately seven days prior to this visit. The PCG stated he/she hadn't had time to pick it up, but he/she would go soon. While assessment was continuing, the PCG received a phone call and answered it with the speaker on, the person on the other end of the phone stated he/she was the Parole Supervisor and he/she needed to give the PCG a message. At this point the PCG become upset, raising his/her voice to the caller on the phone. The patient became worried and tried to ask PCG what was going on, but the PCG didn't hear him/her. The hospice RN tried to reassure patient when PCG was off the phone, he/she would be able to tell him/her what was going on. The patient refused to have any further assessment done as he/she was getting more upset. Notification was sent to the Clinical Director, Social Worker and chaplain in regard to the PCG stating the judge said he/she wasn't supposed to live with the patient. The patient began to yell that his/her son wasn't going anywhere. The patient was asked if he/she would go on respite or long-term care until this was straightened out but the patient refused, stating, ";I'm staying right here." Patient is alert and oriented. PCG had walked down the hallway and disappeared into a room. The patient was asked if he/she felt safe and he/she stated, ";of course I'm safe." Reminded patient he/she could always call if he/she needed something. During an interview on 05/07/2024 at 1:27 PM, social worker A stated that: - The PCG told him/her that he/she was on probation due to drugs and asked if he/she would send letters to probation and mandated therapy and he/she agreed but was unable to get anyone to call him/her back so he/she could send the letters, they were still on his/her desk, he/she was not saying the patient was safe just that the PCG was the PCG for the patient; and - He/she was not aware of the PCG breaking the patients wrist or that the PCG was not to be in the patients home. During a telephone interview on 05/07/2024 at 5:10 PM, the clinical director stated that: - On 04/03/2024, the day they went out to make a visit, the patient slept and would not talk, they talked about respite so the son could get ";quality time", they talked to the son and educated that they could not always call about family drama, they reviewed the reasons to call hospice in the hospice book and if he/she called again they would call the police for a wellness check along with the state; - The social worker is to report to state any abuse or neglect and that if someone notifies state, they are to let upper management know what is going on, what was reported, and what was going on with state; - The PCG kept saying over and over he/she was overwhelmed, and he/she signed a consent for the social worker to contact his/her mental health worker (04/03/2024); - The social worker had worked with the patient and PCG, the patient had no other family to care for him/her while the PCG was in the home; - He/she was not aware of any of the PCG issues in January and had no idea; - If it was brought up it would be in interdisciplinary group (IDG) and he/she did not always attend IDG; - There should have been on-going communication documented; - Instructed overnight staff to call police to do well check and if it was a medical issue to take the police in with them; and - The hospice uses on-call chat and will review for safety practices and may have verbally spoke about March 26th. The record failed to show documentation and notification to the probation officer and the clinical director of all the PCG problems including mental issues, PCG burnout issues and verbal issues from the start of care to current. Findings included: Review of the providers policy titled, ";Suicide Watch Procedures for Hospice and Palliative Care Patients and Family/Caregiver," revised 08/03/2023, showed the following duties: - All patients including palliative care patients as well as family/caregivers will be monitored for the risk of suicide on ongoing basis. (Document if threat is present); - Any patient family caregiver that exhibits risk factors for suicide, such as: * Verbalizing a desire to die or harm oneself * Unusual calm after a period of agitated depression * Prior suicide attempts * Direct statements of suicide or inviting death * The patient family will be placed on immediate suicide watch - Question patient family and ask them directly if they are having ideas of suicide harming self; - If patient family verbalizes desire to harm kill themselves and the patient has access or plans contact 911; - If the patient family member does not have a plan and is willing to talk, contact support services team members for immediate visit. Social worker and or bereavement coordinator will complete a suicide assessment and risk inquiry form; and - Document statements, findings, and assessments within the EMR/patient record. Review of the Social Worker Job Description, showed in part: - Assist with the SSD (support services director) department with the coordination and manage the daily workload by providing direct patient care, with direct reporting to and supervision by the SSD and the clinical director; - Provide direct patient care for work hours assignments, on call time, and employee vacation time off by assisting the SSD as deemed necessary; - Responsible for ensuring patient care visits are made, are compassionate, timely and are within compliance; - Provide patient/family with requested or required community and legal resources, (such as Meals on Wheels etc) as required and/or requested; - Assess existing and potential problem areas, needs and resources of individuals, families and significant others; - Assist the family and discuss alternative methods of alleviating problems situations; - Make necessary changes in assignments to compensate for changing situations; - Assure that patient care is provided in compliance with federal/state/accrediting body regulations and current standards of practice; and - Perform or supervise support staff to ensure that urgent/emergent patient care visits are performed as deemed necessary. RECORD/PATIENT #5: Review of the Spiritual Care/Initial/Comprehensive Assessment report, dated 01/18/2024, showed in part: - The patients requested needs, ";spiritual support;" - Summary – Coordination of Care- Primary caregiver (PCG) present and lived with the patient. PCG was on probation due to an altercation of pushing the patient and resulted in a broken wrist. All was being worked out; and - Narrative- Chaplain made initial visit to patient for emotional and spiritual support with social worker and registered nurse also present. Review of the Social Worker (SW) Initial/Comprehensive Assessment report, dated 01/18/2024, showed in part: - The patient needs, ";interpersonal support" and a description of ";lacking support;" - The patients ";anticipatory grief" showed ";grieving;" - The patient's suicide risk showed low; - The patient's ";precautions, safety, and teachings" showed ";moderate risk;" - Social worker made joint initial visit with the chaplain to complete initial assessment and establish a plan of care (POC); and - The visit note failed to include any documentation of the PCG on probation from pushing the patient and resulting in a broken wrist. Review of the Social Worker Assessment Report, dated 01/19/2024, showed in part: - The patients emotional status was stressed and concerned about his/her financial state sharing extensive financial concerns with the social worker. The social worker educated the patient that the social worker was not educated in financial items and would try to find resources for assistance in case patient had been taken advantage of. The social worker coordinated care with the primary caregiver in person who contributed to patient sharing of his/her financial concerns. Review of the Registered Nurse (RN) Patient Assessment Report, dated 01/27/2024, showed on arrival the patient and PCG both talked over each other offering past medical and medication history. Review of the RN Phone Call Assessment, dated 02/05/2024, showed the PCG was anxious and stated it was because he/she was missing an appointment that day because he/she couldn't leave the patient alone. Reassured the PCG that a conversation about this might help to come up with ideas and a plan for situations like that. Visit planned for that day. Also messaged social worker, regarding this. Review of the Social Worker Emergent Assessment Report, dated 02/05/2024, showed in part: - The social worker provided engagement primarily with the PCG while the registered nurse provided care to the patient. The PCG needed multiple letters sent to providers stating that he/ she was the primary caregiver for the patient who was on hospice. The social worker engaged with the patient about his/her physical status and his/her financial concerns. The patient's concerns were such that the social worker recommended the patient would likely need to contact an attorney for assistance with his/her concerns. Review of the Licensed Practical Nurse (LPN) Phone Call Assessment, dated 03/21/2024, showed visit made related to PCG called and reported police on the way related to neighbors invaded home. Arrived at the home and two police officers were present trying to calm the PCG. The PCG was very repetitive in conversation and pupils extremely dilated. After the police left, nurse was asked to enter the home and check on the patient. The patient was resting peacefully in bed, very soft spoken. PCG reported neighbors were shining flashlights in the windows and the patient was afraid they were going to kill him/her, support provided. Review of the LPN Phone Call Assessment, dated 03/22/2024, showed the PCG had called twice in the past six hours due to saying there were people in his/her yard that were neighbors peeking in his/her windows and shining flashlights. Police were called the first time and LPN A went to the home and checked on the patient and he/she was resting comfortably. Neighbors were not invading or causing any problems. Nothing was done at that time due to PCG was just being paranoid. Second time, PCG wanted a nurse to come out due to same reason and staff stated that this had nothing to do with the patient being on hospice. If he/she was concerned, to call the police again, but there was nothing that hospice could do for him/her. He/she stated that neighbors were invading his/her home and inside his/her home. Staff stated again to call the police. Review of the LPN Phone Call Assessment, dated 03/23/2024, showed PCG complaining of the neighbors shining lights in the house and yelling. He/she stated that he/she sprayed the neighbor with the hose. He/she asked the LPN to stay on the phone. He/she then stated they must have left. The PCG had called three nights in a row with those concerns. This LPN staff thought he/she needed to be evaluated for behaviors him/herself and the patient needed to be placed temporary for safety concerns. Review of the LPN Phone Call Assessment, dated 03/26/2024, showed return call made to the patient and he/she stated he/she was fine, just fine. The patient just wanted hospice staff to come out and see him/her because he/she missed them. There was no emergency, he/she just wanted to see them again. The PCG was then heard in the background telling the patient what to say next. He/she stated go ahead and tell them what he/she did that day. The patient told a story about a visitor that day and what he/she did during the day. Review of the RN Emergent Assessment Report, dated 04/01/2024, showed emergent visit completed for PCGs request due to a verbal dispute that night with the patient. Case manager and social worker please follow-up in AM (morning). Please start daily watch visits that day to monitor for patient safety and well-being. Patient tearful at times and stated he/she was worried and concerned about PCG current behavioral state. PCG attempted to explain why he/she was upset with the patient multiple times, unable to express his/her thoughts and feelings about the situation without ruminating and exhibiting manic behavior as speech was fast and explanation for increased agitation was irrational. Home Health Aid (HHA) arrived at patient's home to implement patient safety watch and to allow PCG uninterrupted time to rest. Missouri Adult Abuse and Neglect online form completed and submitted by RN on 04/02/2024. Review of the RN Watch Care Visit Assessment, dated 04/02/2024, showed in part, there had been some recent anxiety related to decline and risk for caregiver burnout. Patient reported anxiety had been managed well with rest, meditation, and medications. Continued respite discussion and patient was considering respite for caregiver role. PCG verbalized personal coping mechanisms. Review of the RN Phone Call Assessment, dated 04/02/2024, showed a phone call to 911 dispatch for patient and PCG domestic disturbance completed and a call to RN to report to patients home to ensure patient safety. Review of the LPN Phone Call Assessment, dated 04/02/2024, showed the PCG called in stating the patient was getting violent with him/her and he/she was saying he/she had enough of the patient as well. Nurse asked to speak to the patient, PCG threw the phone at patients face. Staff asked patient if he/she felt safe and he/she said no. Primary caregiver grabbed the phone, and as hospice staff was talking, they had 911 called due to the words the PCG was using, such as I'm going to end things, I am done with all of this, things are going to stop sooner or later, things better change now or something is about to happen. Hospice staff stayed on the phone with primary caregiver trying to calm him/her down and the police knocked on the door. PCG ran out the back door and ran for about 20 minutes. Hospice staff was trying to tell him/her to stop running and that the police were not at the house for him/her, that he/she did nothing wrong. After approximately 20 minutes, the phone went blank and hospice staff hung up. A RN and HHA were sent to the home to try to attend to the patient's safety. Patient refused to go anywhere. Police showed up again and so did the PCG, he/she spoke with the police. Nothing could be done since the patient refused to leave the home but if the police were called out to the home again, they would take the patient out of the home. PCG said he/she needed a break and would like help. He/she was crying for help and would like hospice staff to assist. Please follow-up in AM. Patient was on daily's. Social worker and RN with caregiver. Review of the Spiritual Care Patient Assessment Report, dated 04/02/2024, showed in part, routine visit made to patient for emotional and spiritual support. Chaplain and social worker made joint visit due to night before activity and safety sit provided. Patient appeared uncomfortable and had shortness of air throughout visit even while wearing oxygen. Patient appeared to have moments of disassociation with conversation and PCG circled his/her conversation, stating same concerns and questions multiple times. PCG was frustrated with situation showing signs of caregiver burnout, trying to get patient to consider respite for each of their mental and physical well-being. Both patient and PCG were at ropes end but could not come to a conclusion as to next steps for safety of patient and PCG. Active listening provided. Review of the RN Watch Care Visit Assessment, dated 04/03/2024, showed in part, PCG talking rapidly, slurring words about incident between patient and him/her the night before through that morning. Unable to understand most of what PCG was saying but did listen intently. When offered a response, PCG stopped nurse from speaking by saying he/she wasn't finished. That happened three more times. During that time, listeners did monitor and assess the patient who continued to have his/her eyes closed, respirations even and had a content look on his/her face. Did alert team leader and team regarding PCG erratic behavior and restlessness as he/she demonstrated with fast, jerky moves and crying while he/she talked. After approximately 45 minutes, the PCG had calmed him/herself and was able to speak clearer. Suggested to PCG that maybe respite for the patient would help the struggles they were having or maybe PCG was going through burnout. PCG stated he/she would be able to take care of the patient if he/she wouldn't be horrible to him/her and his/her aunt would just stay out of their lives. This nurse encouraged PCG to let patient sleep as he/she didn't get much sleep the night before. Instead, he/she walked over to the patient, taking the straw in his/her cup and attempting to give him/her some of his/her drink while he/she slept. Nurse educated PCG not to give a drink when the patient was sleeping. Review of the Social Worker Routine Assessment Report, dated 04/03/2024, showed this social worker requested PCG to sign a release of information allowing the social worker to communicate with his/her community caseworker to advise the caseworker with an overview of the situation that patient had been in and to request additional support for the PCG. The PCG agreed and provided the name, phone numbers and signed release of information. Review of the RN Emergent Assessment Report, dated 04/04/2024, showed in part, the patient was crying and visibly upset, his/her legs were giving out, took two people to assist to get the patient back into bed. Received report from primary on call nurse of a domestic disturbance and the patients son/daughter threw a cell phone at the patient. Patient denied this and stated they were just verbally arguing. Patient stated he/she felt safe with him/her in the home. Called 911 to transport patient to the hospital due to patients PCG had taken off and was not in the home and the patient was not safe in the home alone. 911 dispatcher advised they would not send an ambulance. Sent the police and they called for an ambulance, emergency medical system (EMS) checked patient out, but he/she refused to go to the hospital. PCG arrived back home. Police cleared the scene and advised they had no reason to believe patient was not safe with PCG at that time. PCG agreed to stay at home. Review of the RN Routine Assessment Report, dated 04/16/2024, showed in part the patient was having some pain and the PCG gave the patient his/her pain medication. The patient became upset when PCG frequently interrupted him/her when he/she was trying to talk. The PCG was reminded that the patient was talking about his/her pain and what was going on with him/herself and if he/she could give him/her the time to talk about it, then he/she could talk afterwards. Patient was having a hard time concentrating on what he/she was saying when he/she was interrupted. Review of the RN Emergent Assessment Report, dated 04/19/2024, showed in part, the patient reported he/she would like a visit for shortness of air. Upon arrival, knocked and rung doorbell three times before the PCG answered the front door. PCG appeared anxious and agitated, expressing concerns with the patient's recent behavior, the PCG explained that the patient was on the phone with his/her sister discussing his/her care. The PCG reported that the patient had some concerns with his/her care, and that had caused stress to the PCG. The PCG reported that a neighbor had been notified of concerns and had seemed to be watching his/her house, causing anxiety. The PCG reported that the police had been notified for concerns in the past as well. This nurse explained to the PCG that the patient had the right and could express his/her concerns to whom he/she wished freely. This nurse reached out to the team leader and requested social worker involvement for PCG support/offer resources. PCG reported that he/she was very aware of needs, and he/she was tending to them. Explained to the PCG that patient's health had top priority at that time. Throughout the patient's assessment, PCG continued to argue with the patient and this nurse about the patient involving his/her family from outside the home into care. Again, discussed with the primary caregiver that was the patient's information and he/she was allowed to share with whomever he/she wanted. This nurse offered to discuss caregiver concerns with the PCG outside as the PCG's agitation was creating anxiety for the patient. The PCG refused and said, ";just go home." Patient reported that he/she felt safe in the home currently. Education given on respite stay, permanent placement or new placement with other family. Patient reported he/she would think about those options. The patient had a phone and could call hospice him/herself. Review of the RN Routine Assessment Report, dated 04/22/2024, showed in part the patient stated his/her skin was itchy again and the PCG and patient were asked if the PCG had picked up the prescribed cream that patient had an order for. It had been ordered approximately seven days prior to that visit. The PCG stated he/she hadn't had time to pick it up, but he/she would go soon. While assessment was continuing, the PCG received a phone call and answered it with the speaker on, the person on the other end of the phone stated he/she was the Parole Supervisor and he/she needed to give the PCG a message. At that point the PCG became upset, raising his/her voice to the caller on the phone. The patient became worried and tried to ask PCG what was going on, but the PCG didn't hear him/her. The hospice RN tried to reassure the patient when the PCG was off the phone, he/she would be able to tell him/her what was going on. The patient refused to have any further assessment done as he/she was getting more upset. Notification was sent to the clinical director, social worker and chaplain in regards to the PCG stating the judge said he/she wasn't supposed to live with the patient. The patient began to yell that his/her adult child wasn't going anywhere. The patient was asked if he/she would go on respite or long-term care until things were straightened out, but the patient refused, stating, ";I'm staying right here." Patient was alert and oriented. PCG had walked down the hallway and disappeared into a room. The patient was asked if he/she felt safe and he/she stated, ";of course I'm safe." Reminded patient he/she could always call if he/she needed something. During an interview on 05/07/2024 at 1:27 PM, social worker A stated that: - The PCG told him/her that he/she was on probation due to drugs and asked if he/she would send letters to probation and mandated therapy and he/she agreed but was unable to get anyone to call him/her back so he/she could send the letters, they were still on his/her desk, he/she was not saying the patient was safe just that the PCG was the PCG for the patient; and - He/she was not aware of the PCG breaking the patients wrist or that the PCG was not to be in the patients home. During a telephone interview on 05/07/2024 at 5:10 PM, the clinical director stated that: - On 04/03/2024, the day they went out to make a visit, the patient slept and would not talk, they talked about respite so the adult child could get ";quality time", they talked to the adult child and educated that they could not always call about family drama, they reviewed the reasons to call hospice in the hospice book and if he/she called again they would call the police for a wellness check along with the state; - The social worker is to report to state any abuse or neglect and that if someone notifies state, they are to let upper management know what is going on, what was reported, and what was going on with state; - The PCG kept saying over and over he/she was overwhelmed, and he/she signed a consent for the social worker to contact his/her mental health worker (04/03/2024); - The social worker had worked with the patient and PCG, the patient had no other family to care for him/her while the PCG was in the home; - He/she was not aware of any of the PCG issues in January and had no idea; - If it was brought up it would be in interdisciplinary group (IDG) and he/she did not always attend IDG; - There should have been on-going communication documented; - Instructed overnight staff to call police to do well check and if it was a medical issue to take the police in with them; and - The hospice uses on-call chat and will review for safety practices and may have verbally spoke about March 26th. The record failed to show documentation of notification by the social worker to the probation officer, clinical director and administrator of all the PCG problems including mental issues, PCG burnout issues and verbal issues from the start of care to current. The documentation failed to show if the the social worker provided adequate resources and support for the patient. RECORD/PATIENT #8: Review of the Social Worker (SW) Initial/Comprehensive Assessment report, dated 05/01/2023, showed in part: - The patient needs, ";interpersonal support" and a description of ";lack of support;" - The patient's suicide risk showed low; - The patient requested ";no contact be made with his/her son" until he/she ";can inform him of hospice admission;" and - The visit note failed to include any documentation of the patients history of mental health issues requiring long-term therapy. Review of the Registered Nurse (RN) phone call patient assessment report, completed by RN B, dated 07/17/2023, showed in part: - After setting up a visit with patient for the next day, he/she became upset and stated ";I just dont know if I can do this anymore;" - The patient stated that he/she told a friend that he/she ";wondered what would happen if [he/she] took the Morphine;" - The ";friend became upset" and the patient stated he/she was just kidding; - This nurse suggested a visit, but the patient refused; - This nurse asked if the patient would like to speak to the chaplain and the patient stated that he/she would like to speak with the chaplain; and - The message was sent to the chaplain, who stated that he/she was planning on seeing the patient the next day anyway. Review of the Spiritual Care routine patient assessment report, dated 07/18/2023, showed in part: - The RN reached out to the chaplain to call the patient at the patient's request to process that the patient was ";struggling;" - The patient was processing ";wanting to end it all" by ";taking the medication in the ekit (emergency kit);" - The chaplain ";helps patient process lots of issues-wanting to end it all, evil thoughts presenting themselves as the devil through the ekit;" - ";Processing ideas on how to make the bad feelings go away;" - Patient was ";thankful a lockbox would be delivered this evening;" and - The chaplain ";coordinated with SW" about ";f/u (follow-up) tomorrow." Review of the Social Worker routine patient assessment report, completed by SW A, dated 07/19/2023, showed in part: - ";Pt states he/she has been in psychiatric care and therapy for 16 years and still working with a therapist for his/her childhood trauma and self-compassion;" - Suicidal thoughts frequency showed, ";1 or 2 brief thoughts;" - The patient stated his/her ";mental health dx (diagnoses) included depression and anxiety;" - The patient ";describes poor self-esteem and shame related to his/her childhood trauma;" - The patient ";described thinking the devil was in the med box;" and - ";SW provided much supportive listening and validation of the patient's worth, and value in that he/she deserved love, kindness, compassion, and care." Review of the Suicide Assessment and Risk Inquiry document, completed by the Social Worker A, dated 07/19/2023, showed in part: - Yes was answered for the suicidal thoughts question; - Frequency of suicidal thoughts showed, ";1 or 2 brief thoughts;" - The patient had a brief thought about taking meds (medications) to end his/her life; - The patient thought about how he/she would end his/her life with ";overdose of meds;" - Have you received mental healthcare in the past was answered with ";yes" and ";Pt routinely in long-term therapy" with ";PAD;" and - Do you have access to a rope, gun, knife, drugs, to your method of choice, was answered with ";No-meds in lockbox." (The patient lived at home alone and had access to other controlled substance medications that he/she was taking for pain and anxiety). During an interview, on 05/09/2024 at 12:45 PM, the administrator stated that: - A social worker should have gone out right after the nurse was told that bout the morphine; - There is a social worker on-call 24/7 for emergent visits; - The policy was for a social worker to conduct an immediate suicide risk assessment; and - The social worker did not make a visit and conduct a suicide risk assessment until two (2) days after the comment was made about taking the Morphine.

Based on policy review, review of employee files, record review, and interview, the hospice provider failed to ensure that: - Nursing services and drugs were available on a 24-hour basis to meet the needs of the patient and family when the patients waited extended periods of time for nurse visits and pain medications (653); - Orientation about the hospice philosophy was completed by all employees and contracted staff who had patient and family contact (661); - Employee files contained documentation of an initial hospice orientation (662); and - Competence was assessed on all staff furnishing care/services to hospice patients (663). The cumulative effect of these deficient practices has the potential to affect all patients served by the provider.

Based on policy review, record review, and interview, the provider failed to ensure that nursing services and drugs were available on a 24-hour basis to meet the needs of the patient and family when the patients waited extended periods of time for nurse visits and pain medications in, five of fourteen records reviewed (Records/Patients #1, #2, #8, #12, and #13). This deficient practice has the potential to affect all patients on service with the provider. --- Findings included: Review of the providers policy titled, ";Pain and Symptom Management and Pain Scales," reviewed 05/23/2022, showed, in part: - Pain will be managed at a level acceptable to the patient; and - Symptoms, including, but not limited to nausea, dyspnea, anxiety, agitation, restlessness, itching and any others that cause distress, will be controlled using appropriate physician ordered medications, treatments, and interventions to alleviate the symptom(s). Review of the policy titled, ";Response and care Time Protocol/After Hours/On Call Protocols and Timely Delivery of Medications, Supplies and DME for Hospice Patients" renewed on 05/08/2024, showed, in part: - If an emergent or urgent situation, the visit should be made within one-hour of receipt of initial call/contact and determination of issues; - After regular business hours, a skilled after-hours nurse is available to address the needs of the patient/family; - If the primary skilled after-hours nurse is unable to respond to the call in an appropriate time, a secondary/back-up skilled on-call nurse is available to respond to the needs of the patient/family; - Staff must be proactive and ensure medical supplies are not depleted and are refilled or delivered in an appropriate time frame; and - If it is determined that there may be a delay in delivery of medications, the nurse should contact clinical leadership for other alternatives for delivery of medications (if possible). RECORD/PATIENT #8: Review of the on-call log, showed, in part, on 06/13/2023 at 20:23 (8:23 PM) the patient contacted the agency after hours and the action taken showed, ";nausea, uncontrolled, requesting nurse, SN sent," and licensed practical nurse (LPN) A was listed as the responding staff. Review of the emergent skilled nurse visit note, dated 06/13/2023 at 22:00 (10:00 PM), showed, in part: - The visit was made by LPN B (LPN A was listed as the responding staff for the first call made regarding uncontrolled nausea but the clinical record failed to show if it was made by LPN A); - The vital signs show respiratory assessment on 06/14/2023 at 9:03 AM, blood pressure assessment on 06/14/2023 at 9:02 AM, and pulse assessment on 06/14/2023 at 9:03 AM (The clinical record failed to show if the assessment was late entry documentation or if the assessment was after the final call made by the patient on 06/14/2023 at 6:37 AM); - The pain assessment was dated 6/14/2023 at 9:16 AM with a description of ";client rates pain 8/10. This nurse recommends client try and take some pain meds and she declined. Due to increased vomiting this nurse recommended client eat a bland diet and take sips of Sprite and or ginger ale. Client voiced understanding. This nurse ordered comfort meds per client request due to Zofran (can prevent nausea and vomiting) not helping with nausea;" - The narrative note section dated 06/14/2023 at 08:36 AM showed, in part, ";reported to this nurse that two nurses have come out on the night shift and that she feels like nobody is helping (him/her)" (The documentation failed to show any other visits made on 06/13/2023 and/or who the two nurses were that made a visit to the patient for nausea and/or vomiting); and - The emergent skilled nurse visit start time was 1 hour and 24 minutes after the initial call, the hospice providers policy states that the visit should be made within one-hour. Review of the on-call log, showed, in part: - On 06/14/2023 at 5:23 (5:23 AM), the patient contacted the agency after hours and the action taken showed, ";continues education client awaiting for medication to be delivered" and LPN B was listed as the responding staff; and - On 06/14/2023 at 6:37 (6:37 AM), the patient contacted the agency after hours and the action taken showed, ";caller requested this nurse to contact son to give updates on new medications and current status" and LPN B was listed as the responding staff. The clinical record failed to show a skilled nurse visit was made after the calls on 06/14/2023 at 5:23 AM and 6:37 AM. During an interview on 05/14/2024 at 10:45 AM, the administrator stated that: - The patient called three times between 06/13/23 at 8:23 PM and 06/14/23 at 6:37 AM and the clinical record only showed one visit was made on 06/13/23 at 10:00 PM; - The assessment date and times on 06/14/23 may have been when the nurse documented the visit from the night before; and - The clinical record did not show a visit made after the patient called two more times. RECORD/PATIENT #12: Review of the emergent skilled nurse visit note on 03/20/2023, beginning at 9:45 AM, showed, in part: - The patients pain was assessed using FLACC (a behavioral pain assessment scale used for nonverbal or preverbal patients who are unable to self-report their level of pain. Pain is assessed through observation ranging from 0 to 10 pain scale) tool; - The patients pain severity was severe pain with a FLACC score of nine (9); - The Pcg (patient caregiver) ";met this nurse on the porch, unhappy that patient has been out of morphine since 0600-0700. Pcg had been administering Haldol (antipsychotic) and Ativan (sedative) as often as possible to try to manage sx [symptoms]. Upon arrival the patient was moaning loudly having involuntary twitching throughout body. Audible secretions and gasping. Pt [patient] appeared very uncomfortable. Pt was repositioned twice during visit with help from HHA [hospice aide]. Large urine output last night, none since. No BM (bowel movement) in weeks. Family concerned that morphine is not helping. Will f/u [follow up] with pcg again later today to evaluate sx (symptoms). Family to call if patient has anymore changes;" and - ";Morphine arrived at 1029 [10:29 AM]. Family unhappy that patient ran out of morphine and now feel like patient is suffering. Pcg administered morphine and haldol and patient appeared more comfortable at the end of visit. Review of the emergent skilled nurse visit note on 03/20/2023, beginning at 16:30 (4:30 PM), showed, in part: - The patients pain was assessed using the FLACC tool and had a score of 8; - The ";family frustrate upon arrival, feeling like the patient is still struggling to breathe and for comfort. Pt continues to gasp, moan, has rigid jerking motions. Pt continues to have low grade fevers that come and go. Family continues to administer comfort meds around the clock without seeing any change. Minimal urine output, family did crush Lasix (used to treat fluid retention) and administer earlier today for fluid buildup, prior to morphine arriving, feeling like that would help the patient breathe easier. Pt continues to have tacky pulse, labored irregular breathing and making what sounds like a growling noise. New orders obtained for Morphine (it can treat moderate to severe pain) 0.5ml (milliliter)-1.5ml QH prn, Haldol 0.25ml-1ml Q2H (every two hours) prn (as needed), Ativan 0.25ml-1ml Q4H (every four hours) prn. Rectal foley (device used to administer fluids and medications rectally and used in hospice care to help control severe symptoms) placed d/t (due to) aspiration (breathing in a foreign object), pt vomited thick dark brown secretions. All meds to be given via rectal foley for choking prevention. Family educated on med admin via rectal foley. All questions answered. Pt repositioned and brief was changed. With assistance from HHA;" and - ";New orders for rectal foley, and new Med orders. Morphine 0.5ml-1.5ml QH (every hour) prn soa (shortness of air)/pain, Haldol 0.25ml-1ml Q2H prn agitation, Ativan 0.25ml-1ml Q4H prn anxiety, restlessness." Review of the emergent skilled nurse visit note on 03/21/2023, beginning at 01:00 (1:00 AM), showed, in part: - The patients pain was assessed using the FLACC tool and had a score of seven (7); - EV (evaluation visit) for ";rectal foley replacement, all cares coordinated, new foley placed, comfort meds administered;" and - The ";pcg accidentally pulled out rectal foley, 2 (two) doses of meds missed while awaiting new cath placement. Prior to that pt was comfortable, had vomited some and was having lengthy periods of apnea (temporary cessation of breathing). Pt started jerking again and moaning. New rectal foley placed, 14fr (French) 5cc (cubic centimeter) placed without difficulty, all meds administered, pt tolerated well. Pt had small watery bm (bowel movement) out. Pt was repositioned to back. Pcg to call with any further changes. Cont (continue) EMC (even more care- provided by non-nurse staff to sit with the patient/family)." Review of the emergent skilled nurse visit note on 03/21/2023, beginning at 16:00 (4:00 PM), showed, in part: - The patients pain was assessed using the FLACC tool and had a score of seven (7); and - ";EV for possible rectal foley issues. Appears that all meds are coming right back out in brief or not going through catheter, pt has had no BM in weeks and has had 3 (three) this evening. Colored meds coming out in bm. Rectal foley replaced, same issue continued, rectal foley removed. At least 16ml dilaudid (can treat moderate to severe pain) wasted after multiple doses came out of rectum seconds after meds were administered multiple times. Meds back to po (by mouth)/sl (sublingual, under tongue), pt is a significant choking risk but with HOB (head of bed) elevated pt tolerates well. Lungs negative for aspiration at this time. Vitals stable after 2 (two) dose of oral comfort meds, involuntary jerking has decreased, pt continues to make the growling noise with episodes of apnea. Absent pedal pulses, absent bsx4 (bowel sounds times four). Pt remains unresponsive. Pt will need a CADD pump (computerized ambulatory drug delivery, used to control the release of medication and can effectively control pain for hospice patients in most cases) if sx (symptoms) cannot be managed as this is the third time we have had to play catch up d/t (due to) issues keeping meds down the patient." Review of the emergent skilled nurse visit note on 03/22/2023, beginning at 02:00 (2:00 AM), showed, in part: - The patient was absent of all vital signs; and - ";Death/TOD (time of death)/0204(A) (2:04 AM)." Review of the complaint log showed, in part: - Date of incident was 03/20/2023; and - Description of incident or complaint showed ";Daughter states that yesterday she asked nurse (dw) to order more medication for patient. Patient on EMC watch status. Nurse told her patient had 18 hours of meds left and did not feel needed to order. He also stated he did not want to pay the $100 fee for after-hours delivery. Daughter said she did not care about the fee she felt that even if he thought it, he should not have said it to the family;" and - ";They ran out of morphine and it caused unneeded stress for [the patient] and them." During an interview on 05/14/2024 at 10:40 AM, the clinical director stated that: - He/she did not find any documentation in the clinical record of GIP (general inpatient care, a short-term care provided for a patients pain management or acute or chronic symptom control that cannot be managed in other settings) being discussed; - The CADD pump does not require continuous nursing, the nurse sets it up and teaches the family about it and what to report; - When a patient requires IV (intravenous) pain medications to manage symptoms in the hospital they are usually hard to control with oral pain medications; and - He/she would like the nurses to assess the need for continued IV pain medications when the patient is admitted to hospice services in the home to ensure that they are continuing to receive the same level of pain control as they did prior to going home. RECORD/PATIENT #13: Review of the complaint log showed, in part: - Date of incident was 04/02/2024; and - Description of incident showed ";Pcg reports on call nurse told her she was in Liberty and it would be awhile before she for there. Also told pcg there probably wasnt anything she could do about it. Pcg felt nurse was trying to get out of making visit. Call was at 830pm. Nurse didnt arrive until 0130 (1:30 AM)." Review of the skilled nurse visit note, dated 04/03/2024 that started at 00:30 (12:30 AM) and was completed on 01:45 (1:45 AM) showed, in part: - ";NEV complete for c/o foley catheter leaking urine around urethra one time this evening while ambulating with walker to BR;" and - Urine is dark red with scant amount blood clots observed in drainage bag. During an interview on 05/14/2024, at 10:15 AM, the clinical director, stated that: - The patient should not have had to wait that long for a nurse visit; - The nurse that made the visit was seeing another patient in Liberty at the time of the call (over an hour and a half away from the city the patient resided in); and - The nurse that took the initial call was the primary nurse; - The nurse that made the visit was the secondary nurse; - The primary nurse should have made the visit; and - He/she had a conversation with the primary nurse to let them know that they should have made the visit. RECORD/PATIENT #1: Review of the Registered Nurse (RN) comprehensive assessment patient assessment report, completed by RN D, dated 02/21/2024, showed, in part: - The patient is 79 years old with a primary diagnosis of senile degeneration of the brain (a decrease in cognitive abilities or mental decline) and secondary diagnoses of dementia (decline in mental capacity) and repeated falls; - The patient is a frequent faller; - The RN discussed a Hoyer lift (a mechanical lift used for transferring patients) and hospital bed to facilitate transfers; and - The PCG agreed to the Hoyer lift but declined the hospital bed. Review of the hospice aide (HA) visit, completed by HA A on 02/22/2024, showed in part: The PCG requested need for education with Hoyer lift that had just been delivered. The aide provided education with Hoyer to PCG. Review of the interdisciplinary group (IDG) Meeting Notes dated 02/28/2024 by LPN C at 4:17 AM on 02/23/2024, showed patient declined assessment: phone call. Review of the IDG Meeting Notes dated 02/28/2024 by LPN C at 4:20 AM by LPN C on 02/23/2024 showed: General: Received a phone call from PCG stating that the patient slid out of bed onto the floor, and unsure on how to use the Hoyer lift. PCG would like the nurse to come out to assist. The nurse is out with another patient so advised them to call 911 for a non-emergency assist to lift, to place patient back into bed. Patient denies any pain or discomfort, No medication list on file. Educated to call with any further questions or concerns. During the home visit on 04/29/2024 at 3:33 PM, the PCG stated he/she called 911 for assist to get the patient up off the floor as directed per phone call to the provider due to it would be an hour before anyone could get there to help get the patient up off the floor. The PCG received no education on the Hoyer lift when it was delivered but the HA did show the PCG a little training what he/she wasnt to do. RN D offered instructions on the Hoyer lift after it had already been used. During an interview on 05/14/2024 at 10:11 AM, the clinical manager stated that: education should have been provided when the Hoyer lift was delivered. RECORD/PATIENT #2: Review of the on-call log, showed, in part, on 11/21/2023 at 20:25 (8:25 PM). The caller stated that the patient needs a refill on medications. Caller is waiting for a call back. Spoke with (named staff), reports needing valium reordered before holiday weekend, ordered via RXNT for Wednesday delivery. call log, showed, in part, on 3/11/2024 at 5:49 AM. The caller stated that they need a refill on the patients Ativan and only have a four-day supply of the patients diazepam. Sent to the case manager. Review of the on-call log, showed, in part, on 1/27/2024 at 12:40 PM. The caller stated the patient is out of a medication. Out of medications, prescription sent and on call doctor notified. Review of the on-call log, showed, in part, on 1/29/2024 at 18:38 (6:38 PM). Caller stated he/she has been waiting on the patients medications and havent heard back for days. DC (direct call) to nurse on call (named staff.) Facility staff and patients adult child called related to (rt) patient being out of medication valium, call placed to Sterling (pharmacy) to verify delivery tonight. Case manager please start checking with facility related to medication count. Review of the LPN routine visit report dated 01/29/2024, by LPN D showed the facility nurse was upset that she called the hospice provider Friday, Saturday and this morning without receiving the patients diazepam. RNXT showed it was scheduled for delivery 1/28. Sterling reports they don't have the order and needs it submitted again. The facility nurse will call the hospice provider 24/7 with questions, concerns, and changes. Review of the spiritual care routine patient assessment report dated 01/30/2024, by Chaplain A showed the primary caregiver (PCG) was very upset and said that the patient had gone for three days without medication. PCG was also upset as he/she had not been informed of change in the nurse aide. PCG wanted to speak to someone higher up in the hospice provider than the Chaplin. Chaplain called the chaplain manager who spoke to PCG and will contact the clinical manager to investigate concerns. Chaplain offered reflective listening to PCG and assured him/her it is the goal of the provider to provide excellent care and was certain the clinical director would be in touch after investigation of medical patient issue. Review of the on-call log, showed, in part, on 2/26/2024 at 5:44 AM. The caller stated they wanted to notify that the patient needs a medication refill. Medication reordered for today. Review of the on-call log, showed, in part, on 03/11/2024 at 5:49 AM. The caller stated that the patient needed a refill on his/her Ativan and only has a four-day supply of diazepam. Case manager is to follow up. During an interview on 05/14/2024 at 10:11 AM, the clinical manager stated the medications are to be monitored during the patients visits and re-ordered accordingly. Medications can be ordered ahead of time in the program with a set delivery date or they can provide a verbal delivery date. He/she knows the medications called about on 03/11/2024 were ordered on 03/14/2024.

Based on review of employee files and interview, the hospice provider failed to ensure orientation about the hospice philosophy was completed by all employees and contracted staff who had patient and family contact in one of four employee files reviewed (Employee #4). This deficient practice has the potential to affect all patients on service with the provider. --- Findings included: Employee #4: Review of the employee file showed the following: -The employee was a registered nurse (RN) B; - The employee was a current direct clinical staff of the hospice provider; and - The employee file failed to show evidence that the employee had orientation about the hospice philosophy. During an interview on 05/09/2024 at 11:20 AM, the hospice administrator stated RN B employee file was missing the required components.

Based on review of employee files and interview, the hospice provider failed to ensure documentation of an initial hospice orientation for three of four hospice employees reviewed (Employee registered nurse (RN) B, Chaplain A, social worker (SW) A). This deficient practice has the potential to affect all patients on service with the hospice provider. --- Finding included: RN B: The hospice hired RN B on 01/08/2024. RN B had first patient contact on 01/17/2024. The employee file reviewed on 05/09/2024 failed to include proof of any initial hospice orientation. Chaplain A: The hospice hired chaplain A on 11/08/2023. Chaplain A had first patient contact on 11/13/2023. The employee file reviewed on 05/09/2024 failed to include proof of any initial hospice orientation. SW A: The hospice hired SW A on 01/30/2023. SW A had first patient contact on 02/06/2023. The employee file reviewed on 05/09/2024 failed to include proof of any initial hospice orientation. During an interview on 05/09/2024 at 11:20 AM, the hospice administrator stated the documentation was missing on orientation.

Based on review of employee files and interview, the hospice provider failed to ensure that the skills and competence were assessed on all staff furnishing care/services to hospice patients in three of four employee files reviewed (Employee registered nurse (RN) B, Chaplain A, social worker (SW) A). This deficient practice has the potential to affect all patients on service with the hospice provider. --- Findings included: Employee RN B: Review of the employee file showed the following: - Date of hire: 01/08/2024; - The employee was a current direct clinical staff of the hospice provider; and - No evidence that the employee had skills and competence assessed at orientation. Skills competence completed 05/6/2024 (four months after date of hire (DOH). Chaplain A: Review of the employee file showed the following: - Date of hire: 11/08/2023; - The employee was a current direct clinical staff of the hospice provider; and - No evidence that the employee had skills and competence assessed at orientation. Skills competence completed 12/13/2021 (two years prior to his/her DOH and re-employment with the provider). Employee SW A: Review of the employee file showed the following: - Date of hire: 01/30/2023; - The employee was a current direct clinical staff of the hospice provider; and - No evidence that the employee had skills and competence assessed at orientation. Skills competence completed 02/06/2024 (one year and seven days after DOH). During an interview on 05/09/2024at 11:20 AM, the hospice administrator stated the following: - The RN B employee file was missing the original document, so he/she completed the requested missing form; - The Chaplain A had worked for the provider previously and upon his/her return to the provider a skills competency document was not completed at orientation; and - The SW A did not complete a skills competency document due to the staff were not aware it needed to be completed on hire. Findings included: Employee RN B: Review of the employee file showed the following: - Date of hire: 01/08/2024; - The employee was a current direct clinical staff of the hospice provider; and - No evidence that the employee had skills and competence assessed at orientation. Skills competence completed 05/6/2024 (four months after date of hire (DOH). Chaplain A: Review of the employee file showed the following: - Date of hire: 11/08/2023; - The employee was a current direct clinical staff of the hospice provider; and - No evidence that the employee had skills and competence assessed at orientation. Skills competence completed 12/13/2021 (two years prior to his/her DOH and re-employment with the provider). Employee SW A: Review of the employee file showed the following: - Date of hire: 01/30/2023; - The employee was a current direct clinical staff of the hospice provider; and - No evidence that the employee had skills and competence assessed at orientation. Skills competence completed 02/06/2024 (one year and seven days after DOH). During an interview on 05/09/2024at 11:20 AM, the hospice administrator stated the following: - The RN B employee file was missing the original document, so he/she completed the requested missing form; - The Chaplain A had worked for the provider previously and upon his/her return to the provider a skills competency document was not completed at orientation; and - The SW A did not complete a skills competency document due to the staff were not aware it needed to be completed on hire.

Based on policy review, record review, and interview, the hospice provider failed to ensure all record entries were complete and appropriately authenticated and dated in accordance with the providers policy, in two of fourteen records reviewed (Records/Patients #8 and #12). This deficient practice has the potential to adversely affect the quality of care provided to all patients served by the provider. --- Findings included: Review of the provider's policy titled, ";Discharge From Services, Transfers and Discharge Planning" renewed on 05/23/2022, showed in part: - The following will be provided to the patient/patient representative, the receiving organization, facility and/or physician as applicable, included in part; * Discharge summary which will include the patient's name, date of discharge, reasons for discharge, type of care slash treatment during the Hospice stay * Other requirements per state law and regulation; - The primary care physician must be sent (via fax, scanned via secured e-mail, or standard mail) a copy of the discharge summary within 72 hours of discharge; and - All assessments, Clinical Eligibility Audit Tool (CMS LCD) sheets and documentation must be filed within the patients Hospice medical record. Review of the provider's policy titled, ";Response and care Time Protocol/After Hours/On Call Protocols and Timely Delivery of Medications, Supplies and DME for Hospice Patients" renewed on 05/08/2024, showed in part: - The following will be accurately and concisely recorded; * Name of caller reporting party * Date and time of receipt of initial call * Name of patient * Problem reported * If call was triaged to another staff member * Name of Hospice staff receiving call information * Time of Hospice staff member receiving call information * If the visit was recommended or made * Intervention and if visits are made the visiting staff member will complete the appropriate clinical documentation within the ER visit note - because the on call logs are not part of the medical record, for legal purposes, the documentation within the ER must include all of the above, as well as details of the reason for the call, communication, intervention, findings, discussions, teaching, interventions and follow up plans; and - If a visit has been determined not to be needed/necessary, all communication, directives (as listed above) will be documented. RECORD/PATIENT #8: Review of the on-call log, showed in part: - On 06/13/2023 at 20:23 (8:23 PM), the patient contacted the provider after hours and the action taken showed, ";nausea, uncontrolled, requesting nurse, SN (skilled nurse) sent," and licensed practical nurse (LPN) A was listed as the responding staff; - On 06/14/2023 at 5:23 (5:23 AM), the patient contacted the provider after hours and the action taken showed, ";continues education client awaiting for medication to be delivered" and LPN B was listed as the responding staff; - On 06/14/2023 at 6:37 (6:37 AM), the patient contacted the provider after hours and the action taken showed, ";caller requested this nurse to contact son to give updates on new medications and current status" and LPN B was listed as the responding staff. Review of the skilled nurse visit note, dated 06/13/2023 at 22:00 (10:00 PM), showed in part: - The visit was made by LPN B (LPN A was listed as the responding staff for the first call made regarding uncontrolled nausea but the clinical record failed to show if the visit was made by LPN A); - The vital signs show a respiratory assessment on 06/14/2023 at 9:03 AM, blood pressure assessment on 06/14/2023 at 9:02 AM, and pulse assessment on 06/14/2023 at 9:03 AM (The clinical record failed to show if the assessment was late entry documentation or if the assessment was after the final call made by the patient on 06/14/2023 at 6:37 AM); - The pain assessment was dated 6/14/2023 at 9:16 AM with a description of ";client rates pain 8/10 (0 was no pain and 10 was worst). This nurse recommends client try and take some pain meds and she declined. Due to increased vomiting this nurse recommended client eat a bland diet and take sips of Sprite and or ginger ale. Client voiced understanding. This nurse ordered comfort meds per client request due to Zofran (prevents nausea and vomiting) not helping with nausea;" and - The narrative note section was dated 06/14/2023 at 08:36 AM, showed in part, ";reported to this nurse that two nurses have come out on the night shift and that she feels like nobody is helping (him/her)" (The documentation failed to show any other visits made on 06/13/2023 and/or who the two nurses were that made a visit to the patient for nausea and/or vomiting). During an interview on 05/14/2024 at 10:45 AM, the administrator stated that: - The patient called three times between 06/13/2023 at 8:23 PM and 06/14/2023 at 6:37 AM, and the clinical record only showed one visit made on 06/13/2023 at 10:00 PM; - The assessment date and times on 06/14/2023 may have been when the nurse documented the visit from the night before; and - The clinical record did not show a visit made after the patient called two more times. RECORD/PATIENT #12: Review of a discharge summary, dated 03/22/2023, showed in part: - The type of discharge was listed as death; - The location was at home; - The time of death was 0204 (2:04 AM); - The pain management was listed as ";Roxanol (antisychotic);" - The summary of care showed, in part, the Pt (patient) was admitted on ";03/14/2023 to (hospice) with stomach CA (cancer), liver and bile duct CA. (He/she) passed away on EMC (even more care) at (his/her) son's home with family at bedside. TOD (time of death) was pronounced @ 0204 (at 2:04 AM). Physician, (pharmacy), MWR and (named) funeral home were notified. Coroner (named) was notified. Coroner report completed and faxed. Medications were destroyed in coffee. Family declined (provider) to wait for FH (funeral home) and very thankful for our services;" - The summary was completed on a paper form; and - The signature of the nurse that completed the summary was not legible and had a date of 03/22/2023. Review of a second discharge summary, dated 03/22/2023, showed in part: - The type of discharge was listed as death; - The location was at home; - The time of death was 0204 (2:04 AM); - The pain management was listed as ";comfort meds"; - The summary of care showed, in part, the Pt (patient) was admitted on ";03/14/2023 to (hospice) with stomach cancer. Pt was placed on EMC d/t (due to) decline and symptom management. Pt passed with family and hospice at bedside 03/22/2023;" - The summary was completed on a paper form; and - The signature of the nurse that completed the summary was not legible and had a date of 03/24/2023 (Two days after the first discharge summary was completed and the signatures did not match). During an interview on 05/14/2024, at 10:30 AM, the clinical director, stated that: - The original was the one completed on 03/22/2023 and was uploaded into the EMR on 03/31/2023 (nine days later); - The second discharge summary was not scanned into the EMR (electronic medical record); - He/she was unsure who signed the discharge summaries; - The signatures were not legible; and - He/she would guess that the case manager did not see that the first discharge summary was completed and redid it.

Based on policy review, record review, and interview, the hospice provider failed to ensure a discharge summary was provided to the patients attending physician upon discharge from the hospice when a patient revoked hospice services in, one of two applicable records reviewed (Record/Patient #9). This deficient practice has the potential to adversely affect the post discharge continuity of care for all the live patients discharged by the provider. --- Findings included: Review of the provider's policy titled, ";Discharge From Services, Transfers and Discharge Planning" renewed on 05/23/2022, showed in part: - The following will be provided to the patient/patient representative, the receiving organization, facility and/or physician as applicable, included in part; * Discharge summary which will include the patient's name, date of discharge, reasons for discharge, type of care slash treatment during the Hospice stay * Other requirements per state law and regulation; and - The primary care physician must be sent (via fax, scanned via secured e-mail, or standard mail) a copy of the discharge summary within 72 hours of discharge. RECORD/PATIENT #9: Review of the clinical record, showed in part: - The patient was admitted to hospice services on 01/12/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of fats, cholesterols and other substances collected on the inner walls of the heart arteries and causes narrowing or blockage); - The patient resided at home with spouse; - The patient was found wandering in the street on 03/17/2024 at 1:00 AM by the son and was taken to the ER (emergency room) for concerns of a UTI (urinary tract infection) with increased confusion; - The patient revoked hospice services on 03/17/2024 to receive antibiotic treatment for a UTI; and - The clinical record failed to include record that the discharge summary was provided to the patients attending physician after discharge from hospice services. During an interview, on 05/13/2024, beginning at 11:50 AM, the administrator stated that: - The discharge summary had a fax stamp but no date to show when it was faxed; and - They looked for a fax confirmation but do not usually keep them.

Based on policy review, record review, and interview, the hospice provider failed to develop an individualized plan of care (POC) in one of three full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the hospice providers policy titled, "IDG (interdisciplinary group) Hospice Plan of Care, Coordination and Continuity of Care," renewed 05/23/2022, showed: - The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions; - The agency will designate a registered nurse who is a member if the IDG to provide program coordination, ensure continuous assessment of each patients and family needs, and ensure the implementation and revision of the plan of care; - The plan of care (POC) is one of the most important documents in hospice care; - The plan of care will include the initial assessment, comprehensive assessment, and initial plan of care, comprehensive plan of care, medication/treatment records, and comprehensive assessment updates; and - Each patients individualized written POC: * Reflects patient and family goals; and * Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 03/31/2023 with a diagnosis of fistula of intestines (an abnormal opening in the stomach or intestines that allows the contents to leak to another part of the body). Review of the registered nurse (RN) comprehensive assessment, dated 04/03/2023 at 1:39 PM, showed the patient had a ";nephrostomy (tube inserted into the kidney for urine drainage) left" (the left side of the back), the nephrostomy tube had not drained for four days and the primary caregiver (PCG) had been flushing three times a day and no longer able to get the tube to flush. The patient has an appointment to change the tube tomorrow (04/04/2023) and discontinue the inguinal drain (there was no assessment of the left groin-location of the inguinal drain). Patient also had drain from abscess in right back with small amount of brown liquid in bulb. The PCG was educated in barrier cream. The POC failed to include problems, interventions and goals of skin integrity, nephrostomy tube, abscess drain in right side of back, and inguinal drain. Review of the RN comprehensive assessment, dated 04/11/2023 at 2:30 PM, showed the patient had a small red area near middle of lower back where tube has rubbed, applied Calmoseptine to area. The assessment failed to contain measurements of the red area on the middle lower back, or documentation of coordination of care with the physician. The POC failed to include problems, interventions and goals of skin issues. Review of a physician order, dated 04/11/2023, showed to cleanse areas with normal saline and gauze, pat dry, skin prep around tube sites, apply Opsite to nephrostomy site with 2 inch x 2 inch below tube under Opsite and apply Zetuvit dressing (superabsorbent dressing) to abscess site with small gauze under tube under Zetuvit. Change both daily and apply Calmoseptine to buttock daily and as needed to buttock. The hospice provider failed to add the orders to the plan of care and medication list. The POC failed to include problems, interventions, and goals for nephrostomy tube and site and buttocks. Review of the RN-routine patient assessment report, dated 04/13/2023 at 2:15 PM, showed both dressings to both drain sites on back were changed (physician orders in patient record for dressing changes). The PCG was educated on changing dressing daily so the dressing does not leak all over (did not assess what drain site was leaking or assessment of site). The PCG was educated on barrier cream. Patient continues with drainage tube and nephrostomy tube and new redness to tube sight related to pressure, education on repositioning and side lying to help alleviate pressure to tubes in back. The assessment report failed to contain documentation to show if the nurse treated the buttock, nephrostomy tube, or provided education to the PCG on the new orders, dated 04/11/2023, for Calmoseptine to buttock daily and the change in orders for the nephrostomy dressing. There was no documentation of coordination with the physician. The POC failed to include problems, interventions and goals, for both drain sites on back, skin integrity, and nephrostomy tube. Review of the LPN-routine visit report, dated 04/19/2023 at 2:00 PM, showed patient with new redness to tube sights (did not assess tube sites or specify which tube sight) related to pressure, education on repositioning and side lying to help alleviate pressure to tubes in back. The visit report failed to include documentation of an assessment of the buttocks that Calmoseptine was ordered for on 04/11/2023. Review of the LPN-routine visit report, dated 04/22/2023 at 5:45 PM, showed the patient had slight elevated temperature, abdomen with edema to left lower quadrant (left inguinal abscess) where tube has been removed a few weeks ago and the area around was slightly red (no measurements). PCG will continue to monitor the area and advice (advise) hospice of any changes. The visit report failed to include if there was coordination of care with the RN and physician. The POC failed to include problems, interventions, and goals for the inguinal abscess. Review of the RN-routine patient assessment report, dated 04/27/2023 at 2:30 PM, showed reddened indurated area surrounding drain surgical site following removal of inguinal tube (drain) two weeks ago (no further assessment of the area). New order received for Augmentin 875 milligram (mg) twice a day for ten days. The POC failed to include problems, interventions and goals for the inguinal abscess. Review of the RN comprehensive assessment, dated 05/09/2023 at 3:15 PM, showed the patients buttock was red but nothing opened. Dressing to left groin area due to abscess reopening. The patient and PCG was educated that this area would not close and the dressing needed changed on a daily basis at that site (no orders). The assessment report failed to include if there was coordination with the physician. The POC failed to include problems, interventions and goals for skin integrity and inguinal abscess. The POC failed to include orders for the dressing applied to the left groin during the visit, or orders for ongoing wound care. Review of the RN-routine patient assessment, dated 05/16/2023 at 10:00 AM, showed surgical site left side from nephrostomy tube removal draining scant amounts of serous to red exudate, the patient verbalized tenderness to area but no pain, requested that site be left open to air for now so new dressing not applied. The POC failed to show a change in the dressing order for the nephrostomy tube since 04/11/2023. The POC and medication list failed to include the physician orders from 04/11/2023. The documentation failed to include an assessment of the patients buttocks. The documentation failed to include if there was coordination of care with the physician. The POC failed to include problems, interventions, and goals for surgical site, nephrostomy tube and buttocks. Review of three photographs from 05/23/2023, provided by the director of nursing on 06/27/2023, showed the left inguinal wound was approximately 7 centimeters (cm) length by 5 cm with three small open areas in the middle. The buttocks (coccyx (tailbone)) area measured approximately 7 centimeters (cm) length x 7 cm width reddened area with a 4 cm length by 0.5 cm width slit in the middle. The photo of the nephrostomy tube showed the skin surrounding the tube was intact and no redness. There was no measurements in the medical record. The POC failed to include information regarding the left inguinal wound, coccyx area, and nephrostomy tube. During a telephone interview on 06/27/2023 at 9:44 AM, the PCG state that the patient had an inguinal tube removed, the patient stated that it hurt at one time, the nurse gave him/her a pain pill, and the staff were providing dressing changes. The patients buttocks was reddened and he/she was applying cream. He/she did not know if the area on the buttocks was open, he/she did recall the RN took a picture of the buttocks. During an interview on 06/27/2023 at 11:54 AM, LPN A stated that the left groin drainage tube was removed on 04/11/2023 and there was a little scab over the area. On 04/22/2023, the left groin area was reddened, and an antibiotic was ordered on 04/27/2023. Sometime in May (2023) the patient developed a stage 2 (pressure ulcer), the superficial layer of skin was opened, and he/she did not measure the area but it was a little smaller than a dime. The surrounding skin was reddish/light purplish and worsened. He/she did a visit on 05/23/2023 with the RN, and the area was getting redder and had more drainage. The RN took a picture. The physician was notified. There was a few times the patient wanted a pill before the dressing change. One time, the patient complained of pain during the treatment and said it hurt; he/she needed a pain pill. Generally, documentation included assessments, the areas treated and the treatment provided. If a new order is uploaded he/she goes by the order or looks in documents for previous orders, he/she will review previous nursing notes before going to the home to see what is going on with the patient. The plan of care tells you everything. During an interview on 06/27/2023 at10:30 AM, the director of nursing stated the photos taken on 05/23/2023 of the skin issues showed no description or measurements of the areas. The POC showed to document wound care (the POC provided by the agency did not show any individualized problems of buttocks, inguinal abscess, nephrostomy tube) and there was no mention of how often to measure the wound and education to be provided to the patient and PCG. During an interview on 06/27/2023 at 10:54 AM and 11:35 AM, the administrator stated that IDG (interdisciplinary group) discusses new treatments. He/she had stated the treatment to the nephrostomy tube was discontinued on 04/11/2023, new treatment orders were obtained and the new treatment was not added to the medication profile until May (no specific date provided). The order should have been updated. There was no coordination of care with the physician on 04/22/2023 regarding the left inguinal abscess infection. He/she expects the POC to be individualized and not every treatment would be included. There was no documentation of the wounds.

Based on policy review, record review, grievance file review, and interview, the agency failed to promote and protect the following patient's rights: -To voice grievances regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the hospice (L505); -To receive effective pain management and symptom control from the hospice for conditions related to the terminal illness (L512); and -Be involved in developing his/her plan of care (L513). The cumulative effect of this deficient practice has the potential to affect all patients served by the agency.

Based on policy review, record review, grievance/complaint log, and interview the agency failed to conduct/document timely investigation and resolution in one (Record/Patient #2) of two applicable records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the patient rights information included in the admission packet, updated 05/11/2021, and titled ""Patient & Family Bill of Rights," showed that the patient/patient representative has the right to exercise their rights, to be treated with respect, voice grievances, and be protected from discrimination or reprisal for exercising these rights. Review of the agency's policy titled, "Patient and Family Concern Grievance Procedures," dated revised 05/06/2022, showed in part the following: -Any patient or family who desires to lodge a concern or grievance about any aspect of care should contact the Clinical Director or Executive Director of the hospice verbally or in writing or may also reach any individual or agency listed on the Patient/Family Grievance Procedure included in the registration packet. This includes information on state specific hotline reporting information; -The agency Clinical Director and/or Executive Director are responsible for immediately beginning to investigate concerns or grievances and shall make every effort to resolve the concern/grievance to the patient and/or familys satisfaction; -The leadership will notify the complainant of the receipt of the complaint as soon as possible, but no later than 24 hours. The leadership will investigate the concerns and follow-up with complainant with a resolution as soon as possible but no later than 72 hours; and -All patient/family, facility complaints/grievances will be documented, with the appropriate investigation, intervention and/or resolution included. Additionally, the complaints/grievances will be recorded/logged in the ";complaints" reports and retained. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 06/14/2022 with a terminal diagnosis of senile degeneration of brain (decrease cognitive abilities or mental decline). The patient resided in a long-term care facility (LTCF). Review of the complaint form, provided by the agency to the surveyor, showed the following: -The patient's caregiver returned a bereavement call on 09/16/2022; -Caregiver had a complaint regarding patient care, communication, and dissatisfied with services; -Caregiver was dissatisfied with services for his/her loved one; -Caregiver's first issues was that he/she specifically asked for calls after every nursing visit, but that mostly did not happen; -Caregiver's prominent complaint was not being educated on terminal illness signs and symptoms. Caregiver stated, "I was shocked when I walked in the room and my loved one was crying out to God and asking to die and writhing in the bed." Caregiver reported that Registered Nurse (RN) A was there, had prescriptions administered to patient, and told the caregiver that he/she would have the LTCF administer hourly for symptom management. The caregiver stated, "No one ever came back to give my loved one medication. I sat with my loved one for nine hours to keep him/her from falling from the bed because they cannot use side rails at the LTCF. I was not able to go to the bathroom or get anything to eat. Finally, someone passing medications came by and I called out for help. Then after my loved one died, I stayed to wait for the funeral home because the LTCF locks the doors at 7:00 PM and I knew they would not answer the doors. I have nightmares about that day since my loved one died. I never heard from RN A again"; -Follow-up/Findings: Blank; -Resolution: Blank; -Is additional follow-up required? Not applicable; and -Form completed by: Bereavement staff on 09/16/2022. Review of the agency's grievance/complaint log failed to show documentation of the report made on 09/16/2022. During an interview on 09/27/2022 at 3:50 PM, the interim clinical director stated that he/she just found the patient's complaint form today (09/27/2022) on the desk of the former clinical director and the agency had not investigated the complaint.

Based on policy review, clinical record review, and interview, the agency failed to ensure that patients received effective pain management and symptom control for conditions related to the terminal illness and related conditions in one (Record/Patient #2) of three records reviewed. This deficient practice has the potential to affect the pain and symptom management of all patients served by the agency. --- Findings included: Review of the patient rights information, included in the admission packet, updated 05/11/2021, and titled "Patient & Family Bill of Rights," showed the patient has the right to receive competent, compassionate, effective pain management and symptom control interventions to alleviate distress and discomfort for conditions related to, when receiving hospice services, the terminal illness to the fullest extent safely possible. Review of the agency's policy titled, "Pain and Symptom Management and Measurements," dated renewed 07/01/2022, showed in part the following: -Standard statement: This agency ensures that patient's symptoms are managed and controlled to promote comfort and dignity throughout the hospice admission and dying process and will use stringent guidelines, follow regulations, consistent assessment reviews and obtain as appropriate, physician orders for all pain and symptom management issues and ensure that the patient/family needs are met; -An initial assessment will be performed upon admission to determine the patient's immediate needs, including pain and symptoms and the severity of such symptoms as appropriate; -A numeric scoring key can be used to assess the severity of end of life symptoms to increase the ability to determine an increase or decrease in symptoms and to assess the effectiveness of the intervention(s). By using numeric measurements, even if within the same 'range' such as mild, a patient with a score of 3 that previously was a "1" indicates that the symptom, is increasing. This will assist the interdisciplinary group (IDG) team member(s) in determining if an intervention is effective slightly, moderately or even not effective. This measurement key can be used for symptoms such as nausea, dyspnea (shortness of breath), anxiety, agitation, restlessness. Pain scales will be used as appropriate; -The agency will ensure an adequate supply of pain/symptom medications are available to the patient at all times; -The agency will evaluate effectiveness and/or educate patient/family/facility to evaluate effectiveness of pain medications within two hours of administration and to report any ineffective treatments and/or increase in symptoms; and -Symptoms, including, but not limited to nausea, dyspnea, anxiety, agitation, restlessness, itching and any others that cause distress, will be controlled using appropriate physician ordered medications, treatments, and interventions to alleviate the symptom(s). RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 06/14/2022 with a terminal diagnosis of senile degeneration of brain (decrease cognitive abilities or mental decline). The patient resided in a long-term care facility (LTCF). Review of the initial comprehensive assessment, dated 06/14/2022 showed the following: -The patient had no signs or symptoms of imminent death; -Oriented to person and place; -No pain noted; -No behaviors documented; -Comfort medications ordered and handed to facility nurse. Review of admission orders, dated 06/14/2022, showed the following: -Lorazepam (sedative) 0.5 milligram (mg) one tablet every four hours as needed for anxiety/restlessness; and -Roxanol (narcotic) 20 mg per milliliter (ml) 0.25 ml by mouth or subliguinal (SL) every four hours as needed for pain or shortness of air. Review of the hospice aide visit, dated 07/26/2022, showed the patient was saying "help me Lord," over and over during visit. Report was given to facility nurse and agency nurse. Review of a note sent to RN A on 07/27/2022 at 7:44 AM, showed the nursing facility was requesting a visit as soon as possible for the patient due to decline in condition, cool limbs, and restlessness. The facility did not have any comfort medication orders. RN A responded "thanks" on 07/27/2022 at 7:50 AM. Review of an emergent visit by RN A, dated 07/27/2022 at 8:00 AM, showed upon arrival the patient was restless, yelling for "help," and grabbing at things. FLACC was 4 (moderate pain). Spoke with the facility nurse to obtain medication for restlessness and according to the facility nurse they needed to obtain a script in order to get it out of the facility system. The primary care physician was on his/her way to the facility to sign scripts. The agency nurse sat with the patient until the patient's caregiver arrived. Caregiver educated on terminal restlessness, decline, and symptom management. After a prolonged time, the hospice medical doctor sent signed scripts. At 10:15 AM Roxanol was available and the patient was given 0.25 ml. Was still waiting on lorazepam. At 10:25 AM sent stat order for lorazepam to local pharmacy due to the facility not having any available. The patient appeared to be settling down some, spoke with attending physician who gave order to increase Roxanol to 0.25 ml every hour as needed. Nursing facility nurse aware of new order and updated facility record. Upon departure, the caregiver and chaplain were at bedside, the patient was still yelling "help," and reaching for the caregiver, yet that would only last for a few seconds and then the patient would be peaceful again. Overall the patient was less restless and education was provided to the nursing facility on symptom management. The caregiver also agreed that the patient was less restless. Will continue to monitor and will do a follow-up one time tonight. Review of complaint form, provided by the agency, showed the following: -The patient's caregiver returned a bereavement call on 09/16/2022; -Had a complaint regarding patient care, communication, and dissatisfied with services; -Caregiver was dissatisfied with services for his/her loved one; -Caregiver's first issues was that he/she specifically asked for calls after every nursing visit, but that mostly did not happen; -Caregiver's prominent complaint was not being educated on terminal illness signs and symptoms. Caregiver stated, "I was shocked when I walked in the room and my loved one was crying out to God and asking to die and writhing in the bed." Caregiver reported that Registered Nurse (RN) A was there, had prescriptions administered to patient, and told the caregiver that he/she would have the LTCF administer hourly for symptom management. The caregiver stated, "No one ever came back to give my loved one medication. I sat with my loved one for nine hours to keep him/her from falling from the bed because they cannot use side rails at the LTCF. I was not able to go to the bathroom or get anything to eat. Finally, someone passing medications came by and I called out for help. Then after my loved one died, I stayed to wait for the funeral home because the LTCF locks the doors at 7:00 PM and I knew they would not answer the doors. I have nightmares about that day since my loved one died. I never heard from RN A again"; -Follow-up/Findings: Blank; -Resolution: Blank; -Is additional follow-up required? Not applicable; and -Form completed by: Bereavement staff on 09/16/2022. During an interview on 09/27/2022 at 3:25 PM, the interim clinical director stated that: -The facility should have had the Roxanol and lorazepam as they were ordered on admission; -Two hours was too long to wait for symptom control; -The nurse's should have been checking with the facility on each visit to see if the patient was utilizing the Roxanol and lorazepam and what the count was, so the patient didn't have to wait for two hours while getting scripts and medication; and -RN A should have followed-up with the facility or caregiver within two hours to see how the patient was doing.

Based on admission packet bill of rights, record review, and interview the agency failed to ensure that the patient/family was involved in developing his or her hospice plan of care in two (Records/Patients #1 & #2) of three records reviewed. This deficient practice has the potential to affect the rights of all patients served by the agency. --- Findings included: Review of the patient rights information, included in the admission packet, updated 05/11/2021, and titled, "Patient & Family Bill of Rights," showed that the patient/patient representative has the right: -To participate in the planning of their own care; -To be involved with the development of the plan of care and planning changes in the care; and -To be fully informed of their medical condition, including diagnosis, prognosis, treatment plan, frequency of visits, treatment alternatives and to receive care coordinated with family and/or facilities. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 07/08/2022 with a terminal diagnosis of congestive heart failure (CHF; occurs when the heart muscle doesn't pump blood as well as it should). The patient had a DPOA (durable power of attorney) that was active. The DPOA was the primary caregiver (PCG). The patient resided in a long-term care facility (LTCF). Review of the plan of care (POC) dated 07/08/2022, showed to call the PCG after each visit with update. Review of a phone visit, dated 07/10/2022 at 7:15 AM, failed to show any documentation that the PCG was contacted after the visit. Review of the routine skilled nurse (SN) visit dated 07/11/2022 at 1:15 PM, failed to show documentation that the PCG was contacted after the visit. Review of a phone visit dated 07/19/2022 at 4:30 PM, showed the following: -Facility nurse reported a 10 pound weight gain for that day and had notified the attending physician and received orders for Lasix (diuretic) 40 milligram (mg) daily for five days for edema and to check labs on 07/25/2022; and -Failed to show any documentation that the PCG was contacted after the visit. Review of comprehensive assessment, dated 07/27/2022 at 4:45 PM showed the following: -Patient's blood pressure low 82/44 (normal- 120/80), reported to facility nurse and aide, informed them to observe and report continued low blood pressure readings; and -Failed to show any documentation that the PCG was contacted after the visit. Review of phone visit, dated 07/30/2022 at 10:00 AM showed the following: -The facility nurse had called and stated that the patient's urine culture and sensitivity (test to check for bacteria in the urine and what antibiotics will cover the bacteria) report had come back and that the patient had E. coli (bacteria) in his/her urine and the facility had contacted the patient's attending physician and received an order for Macrobid (antibiotic) 100 mg twice a day for seven days and probiotic (live microorganisms promoted with claims that they provide health benefits when consumed, generally by improving or restoring the gut microbiota) one daily for ten days; and -Failed to show any documentation that the PCG was contacted after the visit. During an interview on 09/27/2022 at 3:03 PM, the interim clinical director stated that the PCG should have been contacted after each visit as per the POC and documentation should reflect that contact. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 06/14/2022 with a terminal diagnosis of senile degeneration of brain (decrease cognitive abilities or mental decline). The patient had a DPOA that was active. The DPOA was the PCG. The patient resided in a long-term care facility (LTCF). Review of a routine SN visit dated 06/22/2022 at 2:00 PM, showed the following: -The facility nurse reported that the patient had not eaten much in the previous two days. The nurse also noted the patient had constipation(fewer than three bowel movements a week) and had received milk of magnesia (laxative) with no results. After the visit the facility nurse was going to administer a suppository (a dosage form used to deliver medications by insertion into a body orifice where it dissolves or melts to exert local or systemic effects); and -Failed to show any documentation that the PCG was contacted after the visit. Review of the comprehensive assessment dated 06/27/2022 at 2:00 PM, showed the following: -Patient disoriented times two to three. The patient had difficulty making needs known. Eating approximately 25 to 50% of his/her meals; and -Failed to show any documentation that the PCG was contacted after the visit. Review of routine SN visit, dated 07/18/2022 at 12:45 PM showed the following: -Attempted to assist the patient with his/her lunch, the patient took sips of juice only, then waved the nurse's hand away. Patient only eating 0 to 25% of most meals. Patient potential for dehydration due to refusal to drink. The patient at risk for skin breakdown due to decreased nutrition, hydration, immobility, incontinence, and decreased cognition; and -Failed to show any documentation that the PCG was contacted after the visit. Review of comprehensive assessment, dated 07/25/2022 at 3:15 PM showed the following: -Patient disoriented times three, unable to make needs known. Eating less than 10 to 20% of meals. Required total care for all activities of daily living (ADLs). Bed to chair required maximum assist; and -Failed to show any documentation that the PCG was contacted after the visit. During an interview on 09/27/2022 at 3:25 PM, the interim clinical director stated that the PCG should have been contacted after visits and he/she would expect that documentation to be in the clinical record.

Based on job description review, record review, and interview, the agency failed to provide nursing care and oversight in a manner consistent with acceptable standards of practice (L591). The cumulative effect of this deficient practice has the potential to affect all patients served by the agency.

Based on job description review, record review, and interview the agency failed to ensure the patient received needed nursing services in one (Record/Patient #1) of three records reviewed. This deficiency has the potential to affect all the agencys patients who receive nursing services. --- Findings included: Review of the agencys job description titled, ";Registered Nurse/Case Manager," dated renewed 05/16/2022, showed in part, the Registered Nurse (RN) should: -Communicate with the referring, attending and the hospice physician regarding the patient's condition, documenting findings, working with families, and all other duties to ensure that patients deemed appropriate for services receive the level of care/services deemed appropriate for that specific patient; -Assess existing and potential problem areas, needs, and resources of individuals, families, and significant others and set priorities in collecting data, developing and updating the comprehensive assessment and plan of care (POC); -Continue to meet the needs of the hospice patients and their families by ensuring all pain and symptoms are effectively managed; -Provide service in accordance with standards of practice; and -Evaluate the effectiveness of the established POC, and modify the POC as appropriate. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 07/08/2022 with a terminal diagnosis of congestive heart failure (CHF; occurs when the heart muscle doesn't pump blood as well as it should). The patient resided in a long-term care facility (LTCF). Review of the routine skilled nurse (SN) visit, dated 07/18/2022, showed the nurse returned a call to the patient's caregiver, who expressed concerns regarding the patient. One of the caregiver's concerns was that the patient was stand-by assist and the caregiver felt the patient needed more assist than that. He/she was also concerned with the patient's edema symptoms. The nurse informed the caregiver that he/she was currently at the facility and would follow-up with facility staff regarding the concerns. The nurse began coordinating with the facility nurse regarding the caregiver's concerns, when a facility aide informed them that the patient was found on the floor. When the nurse arrived to the patient's room, the patient was sitting on the floor by his/her wheelchair on his/her bottom. The patient was alert, denied hitting his/her head and denied pain. The patient informed the nurse that he/she was trying to transfer self from his/her recliner into his/her wheelchair, when he/she fell. Assessment revealed wheelchair to be unlocked, which may have contributed to the fall. The patient had a trace of edema to his/her bilateral lower extremities (BLE). The hospice nurse and facility nurse transferred the patient from the floor to the wheelchair. Within five minutes of the patient sitting up in his/her wheelchair the patient had two plus dependent edema noted to BLE. The facility nurse informed the hospice nurse that the facility received an order the previous Friday for Lasix (diuretic medication) 20 milligrams daily to assist in decreasing edema symptoms. The nurse then called the caregiver back and updated him/her on the patient's status and plan of care. The documentation failed to show the attending physician and/or the hospice medical director were notified regarding the fall. The plan of care was not updated to include the fall. Review of the comprehensive assessment, dated 07/27/2022 showed the patient's blood pressure low 82/44 (normal- 120/80), reported to facility nurse and aide, informed them to observe and report continued low blood pressure readings. The documentation failed to show the attending physician and/or the hospice medical director were notified of the low blood pressure reading. The plan of care was not updated with any changes regarding the low blood pressure. Review of the SN visit, dated 07/29/2022, showed the visit was requested for a foot injury from a fall. The facility nurse reported the patient had multiple falls due to spontaneously getting up without assistance. The facility staff was unsure when the patient sustained the injury to his/her foot. The patient's caregiver was at bedside and wanted an x-ray of the patient's foot. The patient's foot was severely bruised from the ankle to the toes. The patient had loose skin on the top of his/her foot with fluid pocketed underneath. The patient denied verbally to having pain, but was restless. The facility nurse reported the patient had been given morphine (narcotic medication for severe pain) as ordered that day. The caregiver verbalized to the nurse the desire to have a conference with the hospice case manager to discuss the plan of care going forward, and wanted x-ray report as soon as possible. The documentation failed to show the attending physician and/or the hospice medical director were notified of bruising and edema. The plan of care was not updated with any changes regarding the bruising and edema. Review of an emergent visit, dated 07/30/2022 at 5:00 PM, showed facility nurse requested visit. The facility nurse verbalized the patient's caregiver was requesting a steroid injection for the patient's right hip pain. The hospice nurse discussed with the facility nurse, that hospice did not cover the steroid injection. The hospice nurse offered to "peek in" on the patient. Upon entering the patient's room, the patient was sitting in chair next to his/her bed with his/her feet elevated and a blanket over his/her legs. The caregiver was present and was informed that hospice did not cover steroid injection. The caregiver stated that he/she felt hospice was not trying to help, but rather hinder the patient from getting better. The agency nurse educated the caregiver on the hospice philosophy that hospice was for comfort not cure. The caregiver still upset and wanted the patient to receive steroid injection. The agency nurse informed the caregiver that the steroid injection could be given was it would be private pay and hospice would not cover. The caregiver was informed that the agency management would be informed regarding all the concerns the caregiver had. The agency nurse failed to document any pain or symptom assessment for this visit. Review of a phone visit, dated 08/05/2022 at 1:30 PM, showed the caregiver requested a visit regarding a concern of edema to the patient's bilateral upper extremities (BUE), more so in the hands and the left worse than the right. The caregiver had not spoken to the facility staff regarding the edema, but felt the patient may have needed his/her Lasix increased. The hospice nurse spoke to the facility nurse who stated he/she would assess the patient and contact hospice if an in-person visit was needed. Review of a phone visit, dated 08/05/2022 at 5:45 PM, showed the facility nurse called and stated the patient did have some increased edema of his/her hands and feet non-pitting. The patient was taking Lasix 20 mg daily and the facility nurse had called the primary physician to request an increase of the Lasix, however the patient's caregiver and sibling was at bedside and requested an in-person visit. Review of the clinical record failed to show any documentation of an in-person visit for 08/05/2022. During an interview on 09/27/2022 at 3:03 PM, the interim clinical director stated that the physician should have been notified regarding the fall, the low blood pressure, the bruising, and the edema. He/she expected the plan of care to be updated when the patient had changes. He/she would have expected the nurse to have completed and documented a pain assessment on the visit 07/30/2022. He/she would have expected a visit to have been completed on 08/05/2022.

Based on agency policy, clinical record review, home visit observation, and interview, the agency failed to ensure that the hospice plan of care identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care in three (Records/Patients #1, #2, & #3) of three records reviewed. This deficient practice has the potential to affect the coordination of care for all of the agency's patients who reside in nursing facilities. --- Findings included: Review of the agency's policy titled, "Providing and Coordination of Hospice Care to Residents of a SNF (skilled nursing facility)/NF (nursing facility), LTC (long term care, or ICF (intermediate care facility)/MR (mental retardation)/DD (developmental disability) and Contractual Agreements," dated renewed 05/09/2022, showed in part the following: -All hospice care provided is in accordance with the hospice plan of care; -The written plan of care will identify services and providers of those services; and -The hospice provides the SNF/NF or ICF/MR/DD the most recent hospice plan of care specific to each resident. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 07/08/2022 with a terminal diagnosis of congestive heart failure (CHF; occurs when the heart muscle doesn't pump blood as well as it should). The patient resided in a long-term care facility (LTCF). Review of the patient's initial plan of care (IPOC) dated 07/08/2022 showed the following: -Skilled nurse to visit one time a week with two PRN (as needed) visits; -Hospice aide to visit two times a week; -Social worker to visit one time a month with two PRN visits; and -Chaplain to visit one time a month with two PRN visits. Review of the document titled, "LTC Coordinated Task Plan of Care," dated 07/08/2022, failed to show what services were being provided by hospice and how frequently those services were being provided. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 06/14/2022 with a terminal diagnosis of senile degeneration of brain (decrease cognitive abilities or mental decline). The patient resided in a LTCF. Review of the patient's IPOC dated 06/14/2022 showed the following: -Skilled nurse to visit one time a week with two PRN visits; -Hospice aide to visit two times a week; -Social worker to visit one time a month with two PRN visits; and -Chaplain to visit one time a month with two PRN visits. Review of the document titled, "LTC Coordinated Task Plan of Care," dated 06/14/2022 failed to show what services were being provided by hospice and how frequently those services were being provided. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice on 06/29/2022 with a terminal diagnosis of senile degeneration of brain. The patient resided in a long-term care facility LTCF. Review of the patient's IPOC dated 06/29/2022 showed the following: -Skilled nurse to visit one time a week with five PRN visits; -Hospice aide to visit two times a week; -Social worker to visit one time a month with two PRN visits; -Chaplain to visit two times a month with two PRN visits; and -Volunteer two times a month with two PRN visits. Review of the document titled, "LTC Coordinated Task Plan of Care," dated 06/29/2022 failed to show what services were being provided by hospice and how frequently those services were being provided. Review of the hospice record maintained at the LTCF, during a home visit observation on 09/26/2022 beginning at 2:49 PM, showed no LTC Coordinated Task Plan of Care in the facility record. During an interview on 09/26/2022 at 3:15 PM, the LTCF administrator stated that the hospice agency did not identify what services they were providing and the frequency of those services. During an interview on 09/27/2022 at 3:50 PM, the interim clinical director stated that he/she expected coordination between the agency and the LTCF's. He/she would expect agency staff to identify what services hospice was providing and the frequency of those services.

Based on policy review, record review, home visit observation, and interview the agency failed to ensure the long-term care facility (LTCF) hospice patient record contained a copy of all required hospice documents in one (Record/Patient #3) of one applicable record of patients that resided in a LTCF. This deficient practice has the potential to affect all patients that resided in a LTCF. --- Findings included: Review of the agency's policy titled, "Providing and Coordination of Hospice Care to Residents of a SNF (skilled nursing facility)/NF (nursing facility), LTC (long term care, or ICF (intermediate care facility)/MR (mental retardation)/DD (developmental disability) and Contractual Agreements," dated renewed 05/09/2022, showed in part that the hospice would provide the facility with the following: -Most recent hospice plan of care specific to each patient; -Hospice election form and any advance directives specific to each patient; -Physician certification and recertification of the terminal illness specific to each patient; -Names and contact information for hospice personnel involved in hospice care of each patient; -Hospice medication information specific to each patient; and -Hospice physician and attending physician (if any) orders specific to each patient. RECORD/PATIENT #3: Review of the hospice record maintained at the LTCF, during a home visit observation on 09/26/2022 beginning at 2:49 PM, showed the record failed to contain the following required information: -Current hospice plan of care; -Hospice election form; -Advance directive; -Physician certification of terminal illness; -Names and contact information for hospice personnel involved in hospice care; -Hospice medication information specific to each patient; and -Hospice physician and attending physician orders. During an interview on 09/26/2022 at 3:10 PM, Registered Nurse (RN) B stated that he/she could not find the above missing documents in the patient's hospice record that was maintained at the LTCF. During an interview on 09/27/2022 at 3:50 PM, the interim clinical director stated that he/she expected the hospice records at the LTCF to contain the above documents.