Every finding on record at Deer Valley Hospice Care LLC

Upon patient record review 2 of 14 (Patient #4, 9) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 4: The patient was admitted on 4/5/23, the psychosocial assessment was completed on 4/30/23. Patient 9: The patient was admitted on 7/21/22, the psychosocial assessment was completed on 8/3/22.

Upon patient record review 9 of 14 (Patient #1, 2, 6, 7, 9, 10, 11, 13, 14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 1: The patient was admitted on 5/22/23, there is no evidence in the patient record of a psychosocial assessment within 5 days or to date. (Corrected during survey period.) Patient 2: The patient was admitted on 5/1/23, there is no evidence in the patient record of a psychosocial assessment within 5 days or to date. (Corrected during survey period.) Patient 6: The patient was admitted on 7/9/22, there is no evidence in the patient record of a spiritual care assessment within 5 days or to date. Patient 7: The patient was admitted on 1/20/23, there is no evidence in the patient record that the psychosocial or spiritual care assessment was completed. Patient 9: The patient was admitted on 7/21/22, there is no evidence in the patient record of a spiritual care assessment. Patient 10: The patient was admitted on 7/11/22, there is no evidence in the patient record of a spiritual care assessment or a psychosocial assessment. Patient 11: The patient was admitted on 1/1/23, there is no evidence in the patient record of a psychosocial assessment. Patient 13: The patient was admitted on 1/10/23, there is no evidence in the patient record of a psychosocial assessment or spiritual care assessment. Patient 14: The patient was admitted on 2/10/23, there is no evidence in the patient record of a psychosocial assessment.

Upon patient record review, 5 of 14 (Patient #1, 2, 3, 4, 6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: The medication profile indicates the use of menthol-zinc oxide 0.44-20.65% apply 2 x daily, it does not include an application site. Upon admit on 5/22/23, the record indicates that the patient utilizes oxygen 2L per minute via NC, as needed for shortness of breath, this is not included in the medication/treatment profile. (Corrected on site.) Patient 2: The medication profile includes Diclofenac Sodium 1% apply three times per day, the profile does not include an application site. (Corrected on site.) Patient 3: The patient record indicates that the patient uses oxygen 2L via trach QHS, this is not included in the medication profile. The hospice medication profile was reviewed during the home visit and compared to the facility medication profile. The facility medication profile includes orders on 6/7/23 for Alendronate 70mg via g-tube every 7 days, and orders on 5/31/23 for Vitamin D3 10mcg via g-tube daily, these medications are not included in the hospice medication profile. (Corrected on site.) Patient 4: The medication profile includes "Triamcinolone Acetonide 0.1% apply to affected area prn skin breaks." The instructions do not specify an application site. The patient received a dose of Dulcolax 10mg on 6/15/23, this is not included in the medication profile. Patient 6: The medication profile includes the use of Ondansetron 4mg tab dissolve 1 tab on the tongue PRN, there is no indicator for the PRN use of the medication.

Upon patient record review, 2 of 14 (Patient #1, 7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The patient was admitted on 5/22/23 with noted evidence of 3 decubitus ulcers, the initial plan of care does not include interventions for the wound care. The patient is incontinent of bladder and bowel and has a foley catheter and a rectal tube, the plan of care does not include interventions for the management of the incontinence devices. The patient has a g-tube, the plan of care does not include interventions for the management of the g-tube. Patient 7: The patient was admitted on 1/20/23 for alcoholic cirrhosis of the liver with ascites, the patient also had complaints of chronic constipation. The plan of care does not include a problem statement with interventions and goals for the management of the ascites or the constipation.

Upon patient record review, 5 of 14 (Patient #1, 2, 3, 4, 6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The medication order on 5/22/23 for menthol-zinc oxide 0.44-20.65% apply 2 x daily, does not include an application site. Patient 2: Medication orders on 5/1/23 for Diclofenac Sodium 1% apply three times per day, does not include an application site. Patient 3: Medication orders on 4/11/23 for Polyethylene Glycol 3350 17gram scoop via G-Tube QHS, does not include a diluent for mixing. Upon admit, the patient was receiving Jevity 1.2cal 120cc Q3 hours bolus feedings, this in not included in the orders. The IDG note for 6/13/23, indicates that the patient is receiving a continuous feeding of Jevity 1.2cal 85cc/hr, there is no order for the change. The patient record indicates that the patient uses oxygen 2L via trach QHS, there is no order for the use of oxygen in the plan of care. The facility medication profile includes orders on 6/7/23 for Alendronate 70mg via g-tube every 7 days, and orders on 5/31/23 for Vitamin D3 10mcg via g-tube daily, there are no orders in the hospice record for these medications are not included in the hospice medication profile. Patient 4: During the RN home visit on 6/15/23, it was documented that the patient was given a Dulcolax suppository 10mg, there is no order in the patient record for Dulcolax. The medication orders on 4/5/23 includes "Triamcinolone Acetonide 0.1% apply to affected area prn skin breaks." The instructions do not specify an application site. Patient 6: Orders on 7/9/22 include Ondansetron 4mg tablet dissolve 1 tablet on top of the tongue PRN. The order does not include indicators for the PRN use.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 6: The patient passed away on 12/21/22, the record reflects that bereavement services were accepted by the bereaved. The bereavement plan of care includes a sympathy card is to be sent within 7 days, with subsequent mailings at 30 days, 3 months, 6 months, 9 months and 12 months. There is no evidence in the patient record of contact or mailings sent to the bereaved family member at any time since the patient death.

Upon patient record review, 2 of 14 (Patient #1, 3) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: The hospice aide assignment for shampooing patient's hair and providing nail care are ordered as PRN. (Corrected on site.) Patient 3: The hospice aide assignment for shaving, shampooing and showering with a shower chair is ordered as "upon request." The tasks for providing foot care and nail care are ordered as PRN. (Corrected on site.)

Upon patient record review 2 of 14 (Patient #3 and 8) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 3: The plan of care includes orders for hospice aide visits 3 x per week. The hospice aide completed 2 visits during the weeks of May 7th, May 14th, May 21st, and June 11th. Patient 8: The visit frequency for the hospice aide is ordered for 2 x week, there are no visits made by the hospice aide in the patient record, there is no order to discontinue aide services.

Upon patient client record review, 2 of 14 (Patient #3, 5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 3: A patient visit was performed on 4/7/23 by the social worker, the documentation has not been electronically signed and dated by the SW to date, the hospice policy indicates that documents are to be signed and authenticated within 3 days. (Corrected) The bereavement assessment was made on 4/8/23, the documentation was not completed until 4/17/23. The agency policy indicates that all documentation will be completed and authenticated within 72 hours. Patient 5: The bereavement assessment visit was made on 4/7/23, the documentation was completed on 4/17/23. The agency policy indicates that all documentation will be completed and authenticated within 72 hours.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the discharge summary includes all required information. Patient 12: The patient was discharged on 4/9/23 for "extended prognosis" The visiting nurse documented interaction with the nurse practitioner at the Veterans Administration, but there is no evidence in the patient record that the discharge summary was completed or sent to the VA for post-discharge continuity of care.

Based on policy review, record review, grievance file review, and interview, the agency failed to promote and protect the following patient 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); and - To receive effective pain management and symptom control from the hospice for conditions related to the terminal illness (L512). The cumulative effect of these deficient practices resulted in a finding of immediate jeopardy for one patient (Patient/Record #2) and has the potential to affect all patients served by the agency.

Based on policy review, record review, complaint log review, and interview, the agency failed to conduct/document timely grievance investigations and resolution in two (Record/Patient #1 and #2) of two applicable records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of an agency policy revised 06/2019 and titled, "Complaint Resolution," showed that, but not limited to: - A patient complaint may be formal or informal and in writing or verbal. The complaint may be made to any hospice employee, volunteer, or individual furnishing services under arrangement. The complaint may be made by the patient or patient representative; - Patients are encouraged to make suggestions for improving care and/or register complaints to hospice without fear of coercion, discrimination, or reprisal for doing so or unreasonable interruption of care: * Hospice will investigate complaints made by patient, patient's family or guardian regarding treatment or care that is (or fails to be) furnished; * Hospice will document both the existence and the resolution (or attempts at resolution) of the complaint; and - Employees will follow the normal chain of command in pursuing resolutions to any problem. RECORD/PATIENT #1: During an interview on 10/14/21 at 10:37 AM, INT2 stated that: - During the course of care by the agency they were unable to reach staff members to ask questions; - They felt that no one would explain the role of hospice and how hospice worked, and that the agency provided terrible customer service; - They had problems with one nurse and requested that the nurse never return to the home; - Did call the after hours nursing staff multiple times; and - The agency did not provide a medication list when it was requested. Review of the faxed call logs failed to show documentation of any calls to the agency. Review of the complaint log showed that the record failed to contain documentation of the report of, or the investigation of, the patient's caregiver requesting that a particular nurse not return to his/her home. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted for hospice services in their own home with a terminal diagnosis of prostate cancer with metastasis (spreading) to the bone. The patient's primary caregiver was an unrelated person who resided in their home. Review of the faxed call logs showed that the patient's caregivers had called the answering service on: - Tuesday, 09/28/21 at 08:32 AM, and left a message stating they were, "needing to know when the nurse will be coming, he/she was there Friday but haven't heard anything yet, and has some questions;" and - Wednesday, 09/29/21 at 08:35 AM, and left a message stating that, "nurse still hasn't shown up or called, the last they spoke to him/her was 2:10 today and they are getting upset." Review of the complaint log showed that the log failed to contain documentation of the report of, or the investigation of, the patient's caregiver requesting nursing care, and becoming "upset" because the nurse hadn't shown up or called. During an interview on 10/07/21 at 12:10 PM, RN1 stated that: - He/She was the case manager for this patient; - Notified the patient and caregiver that they would visit on Wednesday and Friday of each week; and - The patient's caregiver did call the on-call nurse's cell phone because they wanted a catheter; and an order was received for catheter placement. During an interview on 10/14/21 at 11:00 AM, RN1 stated that; - Patients frequently call the nurse's cell phone to report issues and they don't always use the answering service; and - The patient's caregiver had called their cell phones asking about when the nurses would visit. During an interview on 10/12/2021 at 10:48 AM, the complainant stated that he/she had called on multiple occasions asking for the nurse to make a visit and the nurse never did, until the day he/she died (the patient). During an interview on 10/14/21 at 11:30 AM the administrator stated they were unaware of the complaints made by the patient's caregiver.

Based on professional guidance, agency policy, clinical record review, and interview, the agency failed to assure that patients received effective pain management and symptom control from the hospice for conditions related to the terminal illness in one (Record/Patient #2) of three records reviewed. This deficient practice has the potential to affect the pain and symptom management of all of the agency's patients. Findings included: Review the Centers for Disease Control (CDC) Prescribing Guideline Mobile Application on 10/12/21 showed the following conversions of opioid medications to an oral morphine milligram equivalent (Morphine milligram equivalents (MME) are values that represent the potency of an opioid dose relative to morphine. MME is intended to help clinicians make safe, appropriate decisions concerning changes to opioid regimens.) : - The MME for a Fentanyl patches, 100 mcg every three days was the MME of morphine 240 mg daily; and - The MME for hydromorphone 1 mg per day was the MME of morphine 4 mg per day. Review of agency policy dated 01/2020 and titled, "Pain Assessment and Reassessment," showed: - A comprehensive assessment of the patient's pain using a standardized pain assessment tool appropriate to the patient's age, condition, ability to understand, development and cognitive status may include: * History of pain and its treatment; * Characteristics of pain including intensity, descriptor, pattern, location and radiation, frequency/timing/duration, impact of pain on quality of life, factors that precipitate or exacerbate pain, strategies/factors that reduce pain, additional symptoms associated with pain; * Physical examination; * Current medical conditions and medications; and * Patient/family's goals for pain management and their satisfactions with the current level of pain control; - Each patient will have pain reassessed on an ongoing basis using established criteria, including: * Locations * Intensity; * Duration; * Frequency; * Character; * Current pain therapy or treatment; * Effectiveness of current therapy or treatment to pain interventions; * Progress toward pain goals (including functional ability); and * Side effects and risk factors for adverse events; - When a patient's pain is not relieved, the nurse will intervene appropriately. Such interventions may include notification of the patient's physician, change in pain and symptom management medications, patient education regarding alternative pain relief measures, and referral of pain treatment; and - When pain is assessed/reassessed as a problem, a pain treatment plan will be included in the interdisciplinary group (IDG) careplan. Review of agency policy dated 06/2019 and titled, "Initial Assessment/Comprehensive Assessment," showed: - The initial assessment includes the patient's immediate physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions. severity of symptoms; and - Each patient's comprehensive assessment includes a review of all medications the patient is currently taking (prescription, non-prescription, herbs, home remedies, other alternative treatments) to identify drug effectiveness, side effects, noncompliance with medications, duplicate therapy, and ineffective therapy. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted for hospice services in their own home with a terminal diagnosis of prostate cancer with metastasis (spreading) to the bone. The patient's primary caregiver was an unrelated person who resided in their home. Review of the hospital discharge orders dated 09/22/21 showed: - Diagnoses of anasarca (severe and generalized edema throughout the body), prostate cancer with metastasis to the bone; - Medications including, but not limited to: * Acetaminophen (a medication used to reduce pain and fever) 500 milligram (mg) capsule, take two capsules by mouth every six hours; * Celecoxib (a non-steroidal, anti-inflammatory drug used to treat the pain and inflammation) 100 mg capsule, take one capsule by mouth two times per day; * Cyclobenzaprine (a muscle relaxer used to control muscle spasms) 10 mg tablet, take 10 mg by mouth three times a day as needed; * Diclofenac sodium (a non-steroidal, anti-inflammatory drug used to treat pain) 1% gel, apply 2 grams topically three times a day as needed for cancer pain; * Duloxetine DR (an antidepressant) 60 mg capsule, take one capsule by mouth nightly; * Fentanyl (a powerful opioid used as a pain medication) 100 microgram/hour (mcg/hr), place one patch on the skin every third day (MME 240 mg/24 hours); * Gabapentin (an anticonvulsant used to treat nerve pain) 800 mg tablet, take one tablet by mouth three times per day; * Hydromorphone (an opioid used to treat moderate to severe pain) 2 milligram/milliliter (mg/ml), infuse 0.75 milliliter (ml) (1.5 mg) into a venous catheter (vc) every two hours as needed for pain from metastatic cancer for up to seven days (MME 72 mg/24 hours); * Hydromorphone 4 mg tablet, take three tablets (12 mg total) by mouth every four hours as needed for pain up to seven days (MME 288 mg/24 hours); * Lidocaine (a local anesthetic patch used to treat pain) 5% patch, place two patches on the skin daily, remove and discard patch within 12 hours; * Naloxone (a medication used to block the effects of opioids, used to treat opioid overdose) 0.4 mg/ml injection, infuse 1 ml (0.4 mg) into a vc every 10 minutes as needed for opioid reversal or respiratory depression (call physician if thinking about giving it) for up to 3 doses; and * The patient's total MME on this schedule was 600 mg/24 hours. Review of the document signed by the patient on 09/22/21 and titled, "Hospice Patient's Bill of Rights and Responsibilities," showed that the patient had the right to receive pain management and symptom control for conditions related to terminal illness. Review of the initial comprehensive assessment dated 09/22/21 showed: - The patient had generalized, severe pain all of the time. The patient's goal for pain management was to have pain rated 0-8, on a 0-10 high scale. The patient felt the pain medications were ineffective and the patient was uncomfortable due to pain. The pain character was throbbing and aching all of the time. The pain was constant. The pain was rated a 10 on a 0-10 high scale at the beginning of the nursing visit; - The patient requested oral, liquid morphine for pain control; - The patient had a history of IV (intravenous) drug use and administered oral hydromorphone via the heplock in his/her left arm that was inserted during his/her hospital stay; - The initial comprehensive assessment failed to contain documentation of: * A medication reconciliation between the medications in the home, the medications listed on the hospital discharge instructions, and the medications provided by the agency; * The efforts of the nurse to prevent the patient from administering oral medications through his/her heplock; and * A plan for the management of the patient's pain including, but not limited to, the lack of IV hydromorphone in the home and non-pharmacological methods of pain control. Review of the hospice plan of care dated 09/23/21 showed the patient would: - Remain comfortable during care; - Receive optimal level of pain and/or symptom management on short-term basis; - Use non-pharmacological pain control measures e.g. relaxation, positioning; and - Use fentanyl patches, acetaminophen, celecoxib, and hydromorphone for pain control. The record failed to contain further documentation of assessments related to pain or symptom management for 44 hours, until the next nursing visit dated 09/24/21. Review of nursing visit note dated 09/24/21 showed: - Orders were received to modify the pain management regimen including: * Discontinue fentanyl and lidoderm patches; * Start morphine 20 mg/ml every 2 hours as needed for pain rated 6-10 on a 0-10 high scale (MME 240 mg/24 hours); * Start hydromorphone 8 mg every 8 hours as needed for pain rated 1-5 on 0-10 high scale (MME 96 mg/24 hours); * Total MME for 24 hours 336 mg/24 hours (a MME decrease of 264 MME in each 24 hour period); and - The patient rated his/her pain at the time of the medication change an 8 on a 0-10 high scale, and that the pain occurred "all of the time". (The pain rating was not within the patient's pain goal.) The record failed to contain further documentation of assessments related to pain that was not controlled within the patient's pain goal, or symptom management until the patient expired at home six days later on 09/30/21. During an interview on 10/12/2021 at 10:48 AM, the complainant stated: - He/she had called the nurse on 09/28/21 and asked that a catheter be placed (a tube inserted into the bladder to control urine) to control the patient's urine since he/she had developed a wound on his/her buttocks, and was too weak to use a urinal and he/she was told: * That the agency did not have catheter bags and that catheter insertion would have to wait until a catheter bag was delivered; * He/She stated that he/she had wondered about why a hospice would not have catheter bags in stock; * When he/she received a call that the catheter bag was available on 09/29/21, it was after 07:00 PM. The complainant stated that he/she requested the nurse come visit the next day, 09/30; and * The patient passed away 09/30 with no catheter. - The patient was in constant pain: * His/her pain worsened after the intravenous access (IVA) was removed; and the agency discontinued the fentanyl patches, started morphine and reduced the hydromorphone dosage; * He/she was giving the medications routinely; * He/she called on multiple occasions asking for the nurse to come and visit; and * He/she was so desperate to give the patient pain relief he/she reapplied a fentanyl patch, without direction from agency staff, the day the patient died.