Every finding on record at Eh Health Hospice of Northwest LLC

Based on record review, observation and interview, the hospice agency failed to ensure the patients' right to be involved in developing his or her plan of care(POC) for 2 out of 2 home visit observations (Patients #3 and #4) with a skilled nurse. This failed practice had the potential to decrease the likelihood that Patients' (#3 and #4) physical, psychosocial, and personal care needs at the end of life were met. --- Findings:   Patient #3 Record review from 4/28-5/2/25 revealed a start of care (SOC) date of 4/23/25 and diagnosis of essential hypertension (high blood pressure) with an election date of 4/23/25 and benefit period from 4/23/25 to 7/21/25. "The Informed Consent for Hospice services," dated 4/23/25 and signed by Patient #3's representative or Power of Attorney (POA), revealed: "My family and I will have the opportunity to join the hospice team in making decisions about the type, frequency and intensity of services provided by the hospice agency. We may review the hospice plan of care. My primary caregiver is [Patient #3's representative] and he/she will be the person responsible for coordinating my care with the hospice." Further review of the record failed to reveal hospice aide services were included on the Hospice Certification and Plan of Care for the certification period from 4/23/25 to 7/21/25. Record review from 4/28/25 - 5/2/25 revealed a Hospice IDG (interdisciplinary Group) Comprehensive and POC Update Report for the benefit period from 4/23/25 to 7/21/25.  This document revealed the patient was to receive routine home care from 4/23/25 to 4/28/25 and  "Aide POC. Frequency and Coordination of Care reviewed.  Updates if needed.  N/A [not applicable]."Record review included a "Visit Note Report," signed by LN (Licensed Nurse) #5,dated 4/23/25, which revealed:  "RN Start of care...Patient lives with others in the home...What is the level of in-person assistance from available and willing caregivers excluding hospice staff at the time of the assessment... around the clock...indicate burden of care patient's care causes extra physical stress...community resources needed...indicate any limitations the caregiver appears to have...mobility/endurance, inability to cope with potential loss, difficulty with own ADLs [activities of daily living]...[POA]reports heavy decline in the last week.  Dependent for all cares...Wound care performed to coccyx, left buttock and mid back...POA [has] poor mobility and personal health issues. No support from other family...[POA] is experiencing high care burden." Record review included "Visit Note Report," signed by LN #1,dated 4/29/25; revealed, "Care Coordination... Coordinated with [POA] at visit on Patient EOL [end of life] comfort.  Coordinated with [POA of Patient #3] at visit on Patient EOL [end of life] comfort. Coordinated with [LN #5] prior to visit to confirm wound care had been provided yesterday 4/28 And Foley status at last visit. Coordinated after visit with Master's of Social Work (MSW #1) to arrange prn [as needed] MSW phone visit to educate on PCA [Personal Care Assistant] Companies and help [POA] assess care options...[POA] shares it is difficult for [him/her] to reposition patient due to [his/her] own health and being primarily chair bound, states [he/she] has POA that comes in and helps with patient as well...message sent to MSW requesting she reach out to schedule visit with [POA)."  Visit notes revealed the patient had a Stage II Pressure Ulcer (partial-thickness skin loss). on the coccyx area, a Stage II Pressure Ulcer on the lower left buttock area, and a Stage I Pressure Ulcer ( a Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness in a localized area, often over a bony prominence.) During an observation and concurrent interview on 4/29/25 at 3:00 PM, Patient #3 was lying in a hospital bed with the patient's POA at the bedside in a recliner and was visited by LN #1. The patient was asleep in the hospital bed. The patient's hair was tangled and in disarray. The patient was lying on his/her right side with his/her toes pressing on the wall of the house.  The patient's bed was placed against the wall, and it was noted the patient was lying on his/her right side with his/her toes pressing on the wall of the house. The POA stated the patient needed to be turned frequently and that he/she was unable to turn the patient or complete any personal care due to the POA's declined physical condition. The POA stated the patient had not had the brief changed since yesterday and had not been turned since yesterday. LN #1 changed the brief which was soiled with light brown soilage, repositioned the patient, and completed mouth and perineal care.  LN #1 stated the Social Worker would talk to the POA about what personal care services might be available since the hospice agency did not have hospice aide services available. POA was crying and stated that he/she wished he/she could do more for Patient #3 but was unable due to his/her lack of ability and declined physical health. The POA stated that a Personal Care Attendant (PCA) from another personal services agency who came to take care of the POA had provided some physical care to Patient #3 and this personal care was provided when the PCA visited the POA. The POA stated aide services had not been offered by the agency and were needed since there was a lack of physically able caregivers able to provide physical care including repositioning the patient in bed, bathing and peri-care. LN #1 proceeded to complete oral care and peri care to Patient #3.  In the right groin area, a small reddened area approximately 1/4 inch in diameter was noted.  Other areas were covered with dressings including the coccyx area and left buttock area. The nurse did not complete a full bed bath or comb the patient's hair.  During an interview on 5/1/25 at 9:50 AM, the Chaplain stated the agency supplied services such as end-of -life care, compassionate care, and respite care. When asked if he/she had any concerns with patients needing hospice aide services, the Chaplain stated, "I was concerned with [the caregiver/POA of Patient #3] who moved poorly." The Chaplain stated the caregiver was unable to provide personal care to the patient because of lack of mobility. During an interview on 5/1/25 at 12:30 PM, MSW #1 stated not he/she did not complete a visit or call with Patient #3 due to the lack of a physician order since no visit was plotted on the schedule. MSW #1 stated LN #1 had contacted him/her on Teams stating a need for a visit.  MSW #1 stated that LN #1 had written on Teams that the patient had no oral intake and there was a lack of caregivers that were able to provide personal care to the patient. MSW #1 stated that LN #1 had stated the caregiver of Patient #3 would appreciate a chat.  During an interview on 5/1/25 at 4:00 PM, LN #1 stated, "I would have liked to get [patient #3] a personal care attendant to help."  Patient #4Record review from 4/28/25 to 5/2/25 revealed Patient #4 was admitted to the hospice with a terminal diagnosis of lymphoma (a type of cancer that affects the lymph system). The SOC date and election date were 4/16/25 and the benefit period was from 4/16/25 to 7/14/25.  The "Informed Consent for Hospice services " dated 4/16/25 and signed by Patient #4, revealed, "My family and I will have the opportunity to join the hospice team in making decisions about the type, frequency and intensity of services provided by the hospice agency. We may review the hospice plan of care. My primary caregiver is [Caregiver #1 of Patient #4] and he/she will be the person responsible for coordinating my care with the hospice." Further review of the record revealed hospice aide services were not included on the Hospice Certification and Plan of Care for the certification period from 4/16/25 to 7/14/25.  Record review from 4/28/25 - 5/2/25 revealed a Hospice IDG Comprehensive and POC Update Report for the benefit period from 4/16/25 to 7/14/25.  This document revealed the patient was to receive "Aide POC (Plan of care) frequency, and coordination of review reviewed.  Updates made if needed. N/A."  This meeting was dated 4/24/25. During an interview on 4/30/25 at 10:30 AM, Caregiver #1 of Patient #4 stated no hospice aide services had been offered by the hospice agency.  Caregiver #1 stated this would have been beneficial to Patient #4's care to assist the Patient's caregivers to complete personal care tasks like bed baths.  During an interview on 4/30/25 at 2:28 PM, the Director of Operations stated that hospice nursing services will perform hospice aide services since the hospice does not have a Certified Nursing Assistant at this time.  Review of the "Patient Handbook," dated 9/24, revealed, "Hospice provides palliative care and support services to patients, families and other loved ones. A coordinated team of professionals and volunteers provide physical, intellectual, emotional, social, and spiritual support, and focus on pain and symptom management to optimize quality of life.  Hospice provides the supplemental care needed to ease the burden on patients and caregivers facing a serious and advanced illness. Levels of care: Routine: Majority of care provided, included the services of all the members of the hospice team who are scheduled to provide the necessary visits to meet your needs ... Your hospice team:  Medical director ... nursing staff... social worker...hospice aides, provide personal care and light housekeeping as well as emotional support and compassionate care to you and your family members ... spiritual counselor and chaplain...volunteers...As a patient you have the right to participate in developing your hospice plan of care."  Review of the agency policy "Scope of Services," revised 3/6/25, revealed, "Home Health Aide (hospice aide) is a person who meets the state requirements for CNA and is registered with the state nurse aide registry...The Agency provides...home health (hospice) aide services... the agency provides home health (hospice) aide services by qualified home health aides under the supervision of a registered nurse and in accordance with the plan of care and established policies and procedures...Home health duties include ... hands on personal care, the performance of simple procedures as an extension of nursing or therapy services, assisting with ambulation or exercises, reporting changes in the patient's condition and needs, completing appropriate records, household services essential to health care at home."Review of the Patient Handbook, dated 9/24, revealed a section titled, "Your Rights and Responsibilities," on pages 17 and 18. This section stated, "As a patient you have the right 1. to exercise your right as a hospice patient ... 5. to participate in developing your hospice plan of care... 11. to receive information about the services covered under the hospice benefit."

Based on record review, observation and interview, the agency failed to ensure the Masters of Social Work (MSW) #1 completed a visit in accordance with the patient and Power of Attorney's (POA's) needs and the patient's individualized written plan of care (Patient #3). This failed practice had the potential to create a lack of quality of care provided to Patient #3. --- Findings:   Patient #3 Record review from 4/28 - 5/2/25 revealed a start of care (SOC) date of 4/23/25 and diagnosis of essential hypertension (high blood pressure) with an election date of 4/23/25 and benefit period from 4/23/25 to 7/21/25 for Patient #3. "The Informed Consent for Hospice services," dated 4/23/25 and signed by Patient #3's representative, revealed, "My family and I will have the opportunity to join the hospice team in making decisions about the type, frequency and intensity of services provided by the hospice agency. We may review the hospice plan of care. My primary caregiver is [Patient #3's representative] and he/she will be the person responsible for coordinating my care with the hospice." Further review of the record revealed a Hospice Certification and Plan of Care for the certification period of 4/23/25 to 7/21/25. This was signed by the physician on 4/25/25. This plan of care revealed: "MSW to evaluate patient and develop plan of care to be signed by physician. MSW will participate in interdisciplinary care planning and bereavement activities without additional visits at this time, per patient request. MSW will resume visits if/when patient or caregiver needs are identified."  Further review of the record revealed a MSW visit was not completed after it was requested on 4/29/25 by the POA for Patient #3 and Licensed Nurse (LN) #1. Record review included "Visit Note Report," signed by LN #1 and dated 4/29/25. The note stated, "Coordinated after visit with [MSW #1] to arrange prn [as needed] MSW phone visit to educate on PCA [personal care attendant] Companies and help [POA] assess care options...[POA] shares it is difficult for [him/her] to reposition patient due to [his/her] own health and being primarily chair bound, states [he/she] has POA that comes in and helps with patient as well...message sent to MSW requesting [he/she] reach out to schedule visit with [POA)."   During an observation and concurrent interview on 4/29/25 at 3:00 PM, Patient #3 was lying in a hospital bed with the patient's POA at the bedside in a recliner and was visited by LN #1. The patient was asleep in the hospital bed. The patient's hair was angled and in disarray. The patient was lying on his/her right side with his/her toes pressing on the wall of the house.  The patient's bed was placed against the wall, and it was noted the patient was lying on his/her right side with his/her toes pressing on the wall of the house. The POA stated the patient needed to be turned frequently and that he/she was unable to turn the patient or complete any personal care due to the POA's declined physical condition. The POA stated the patient had not had the brief changed since yesterday and had not been turned since yesterday. LN #1 changed the brief which was soiled with light brown soilage, repositioned the patient, and completed mouth and perineal care.  LN #1 stated the Social Worker would talk to the POA about what personal care services might be available since the hospice agency did not have hospice aide services available. POA was crying and stated that he/she wished he/she could do more for Patient #3 but was unable due to his/her lack of ability and declined physical health. The POA stated that a Personal Care Attendant (PCA) from another personal services agency who came to take care of the POA had provided some physical care to Patient #3 and this personal care was provided when the PCA visited the POA. The POA stated aide services had not been offered by the agency and were needed since there was a lack of physically able caregivers able to provide physical care including repositioning the patient in bed, bathing and peri-care. LN #1 proceeded to complete oral care and peri care to Patient #3.  In the right groin area, a small reddened area approximately 1/4 inch in diameter was noted.  Other areas were covered with dressings including the coccyx area and left buttock area. The nurse did not complete a full bed bath or comb the patient's hair. During an interview on 5/1/25 at 12:30 PM, MSW #1 stated not completing a visit or call with Patient #3 with the patient due to the lack of a physician order since no visit was plotted on the schedule. MSW #1 stated LN #1 had contacted him/her on Teams stating a need for a visit. MSW #1 stated that LN #1 had written on Teams that the patient had no oral intake, and there was lack of caregivers able to provide personal care to the patient. MSW #1 stated that LN #1 had stated the caregiver of Patient #3 would appreciate a chat.  During an interview on 5/1/25 at 4:00 PM, LN #1 stated, "I would have liked to get [patient #3] a personal care attendant to help."  LN #1 also stated that the expectation was that an order be completed within 24 hours. Review of the agency document titled "Licensed Master of Social Work Hospice," dated 12/17/24, revealed, "Position objective:  Administer social services to patients requiring intermittent professional services and teach the patient, family, and other members of the health care team. Perform services in accordance with physician's orders and the established plan of care."

Based on record review, observation and interview, the hospice failed to ensure that hospice aide services had been offered and/or later provided for 2 out of 2 patients observed (Patients #3 and #4) at two skilled nursing home visits. This failed practice had the potential to decrease the likelihood of quality of care for Patients (#3 and #4) and decreased the assistance the patients' caregivers received from the hospice. --- Findings:   Patient #3 Record review from 4/28-5/2/25  revealed a start of care (SOC) date of 4/23/25 and diagnosis of essential hypertension (high blood pressure) with an election date of 4/23/25 and benefit period from 4/23/25 to 7/21/25 for Patient #3. "The Informed Consent for Hospice services," dated 4/23/25 and signed by Patient #3's representative, revealed, "My family and I will have the opportunity to join the hospice team in making decisions about the type, frequency and intensity of services provided by the hospice agency. We may review the hospice plan of care. My primary caregiver is [Patient #3's representative] and he/she will be the person responsible for coordinating my care with the hospice."  Further review of the record revealed hospice aide services were not included on the Hospice Certification and Plan of Care for the certification period from 4/23/25 to 7/21/25.  Further review revealed a Hospice IDG (interdisciplinary Group) Comprehensive and Plan of Care Update Report for the benefit period from 4/23/25 to 7/21/25.  This document revealed the patient was to receive routine home care from 4/23-28/25 and "Aide POC [plan of care]. Frequency and Coordination of Care reviewed.  Updates if needed.  N/A [not applicable]."  Record review included a "Visit Note Report," signed by LN #5 and dated 4/23/25. This note revealed, "RN Start of care...Patient lives with others in the home...What is the level of in-person assistance from available and willing caregivers excluding hospice staff at the time of the assessment...around the clock...indicate burden of care patient's care causes extra physical stress...community resources needed...indicate any limitations the caregiver appears to have...mobility/endurance, inability to cope with potential loss, difficulty with own ADLs [activities of daily living]...[Power of Attorney-POA]reports heavy decline in the last week.  Dependent for all cares...Wound care performed to coccyx, left buttock and mid back...POA [has] poor mobility and personal health issues. No support from other family...[POA] is experiencing high care burden." Record review included "Visit Note Report," signed by LN #1 and dated 4/29/25, revealed, "Care Coordination...Coordinated with [POA] at visit on Patient EOL [end of life] comfort.  Coordinated with [POA of Patient #3] at visit on Patient EOL [end of life] comfort. Coordinated with [LN #5] prior to visit to confirm wound care had been provided yesterday 4/28 And Foley status at last visit. Coordinated after visit with MSW [Master's of Social Work]#1 to arrange prn [as needed] MSW phone visit to educate on PCA Companies and help [POA] assess care options...[POA] shares it is difficult for [him/her] to reposition patient due to [his/her] own health and being primarily chair bound, states [he/she] has POA that comes in and helps with patient as well...message sent to MSW requesting she reach out to schedule visit with [POA])."  Visit notes revealed the patient had a Stage II Pressure Ulcer (partial thickness skin loss)on the coccyx area, a Stage II Pressure Ulcer on the lower left buttock area, and a Stage I Pressure Ulcer( a Stage 1 Pressure Ulcer is characterized by intact skin with non-blanchable redness in a localized area, often over a bony prominence) on the mid upper back area. During an observation and concurrent interview on 4/29/25 at 3:00 PM, Patient #3 was lying in a hospital bed with the patient's POA at the bedside in a recliner and was visited by LN #1. The patient was asleep in the hospital bed. The patient's hair was tangled and in disarray. The patient was lying on his/her right side with his/her toes pressing on the wall of the house.  The patient's bed was placed against the wall, and it was noted the patient was lying on his/her right side with his/her toes pressing on the wall of the house. The POA stated the patient needed to be turned frequently and that he/she was unable to turn the patient or complete any personal care due to the POA's declined physical condition. The POA stated the patient had not had the brief changed since yesterday and had not been turned since yesterday. LN #1 changed the brief which was soiled with light brown soilage, repositioned the patient, and completed mouth and perineal care.  LN #1 stated the Social Worker would talk to the POA about what personal care services might be available since the hospice agency did not have hospice aide services available. POA was crying and stated that he/she wished he/she could do more for Patient #3 but was unable due to his/her lack of ability and declined physical health. The POA stated that a Personal Care Attendant (PCA) from another personal services agency who came to take care of the POA had provided some physical care to Patient #3 and this personal care was provided when the PCA visited the POA. The POA stated aide services had not been offered by the agency and were needed since there was a lack of physically able caregivers able to provide physical care including repositioning the patient in bed, bathing and peri-care. LN #1 proceeded to complete oral care and peri care to Patient #3.  In the right groin area, a small reddened area approximately 1/4 inch in diameter was noted.  Other areas were covered with dressings including the coccyx area and left buttock area. The nurse did not complete a full bed bath or comb the patient's hair.   During an interview on 5/1/25 at 9:50 AM, the Chaplain stated the agency supplied services such as end-of-life care, compassionate care, and respite care.  The Chaplain, when asked if he/she had any concerns with patients needing hospice aide services, stated, "I was concerned with [the caregiver of Patient #3] who moved poorly." The Chaplain stated the caregiver was unable to provide personal care to the patient because of lack of mobility. During an interview on 5/1/25 at 12:30 PM, MSW #1 stated not completing a visit or call with Patient #3 with the patient due to the lack of a physician order since no visit was plotted on the schedule.  MSW #1 stated LN #1 had contacted him/her on Teams stating a need for a visit.  MSW #1 stated that LN #1 had written on Teams that the patient had no oral intake and there was lack of caregivers able to provide personal care to the patient.  MSW #1 stated that LN #1 had stated the caregiver of Patient #3 would appreciate a chat.  During an interview on 5/1/25 at 4:00 PM, LN #1 stated, "I would have liked to get [Patient #3] a personal care attendant to help."  Patient #4Record review from 4/28/25 to 5/2/25 revealed Patient #4 was admitted to the hospice with a terminal diagnosis of lymphoma (a type of cancer that affects the lymph system).  The SOC date and election date were 4/16/25 and the benefit period was from 4/16/25-7/14/25.  The Informed Consent for Hospice services 4/16/25 and signed by Patient #4, revealed, "My family and I will have the opportunity to join the hospice team in making decisions about the type, frequency and intensity of services provided by the hospice agency. We may review the hospice plan of care. My primary caregiver is [Caregiver #1 of Patient #4] and he/she will be the person responsible for coordinating my care with the hospice." Further review of the record revealed hospice aide services were not included on the Hospice Certification and Plan of Care for the certification period from 4/16/25 to 7/14/25.  Record review from 4/28/25 - 5/2/25 revealed a Hospice IDG Comprehensive and Plan of Care Update Report for the benefit period from 4/16/25 to 7/14/25.  This document revealed the patient was to receive Aide POC (Plan of care) frequency, and coordination of review reviewed.  Updates made if needed. N/A."  This meeting was dated 4/24/25. During an interview on 4/30/25 at 10:30 AM, Caregiver #1 for Patient #4 stated that no hospice aide services had been offered by the hospice agency.  Caregiver #1 for Patient #4 stated that this would have been beneficial to Patient #4's care.   During an interview on 4/30/25 at 2:28 PM, the Director of Operations stated that hospice nursing services will perform hospice aide services since the hospice does not have a Certified Nursing Assistant at this time.  Review of the "Patient Handbook," dated 9/24, revealed, "Hospice provides palliative are and support services to patients, families and other loved ones. A coordinated team of professionals and volunteers provide physical, intellectual, emotional, social, and spiritual support, and focus on pain and symptom management to optimize quality of life.  Hospice provides the supplemental care needed to ease the burden on patients and caregivers facing a serious and advanced illness. Levels of care:  Routine: Majority of care provided, included the services of all the members of the hospice team who are scheduled to provide the necessary visits to meet your needs ... Your hospice team:  Medical director ... nursing staff... social worker...hospice aides, provide personal care and light housekeeping as well as emotional support and compassionate care to you and your family members ... spiritual counselor and chaplain...volunteers...As a patient you have the right to participate in developing your hospice plan of care."  Review of the agency policy "Scope of Services," revised 3/6/25, revealed, "Home Health Aide (hospice aide) is a person who meets the state requirements for CNA and is registered with the state nurse aide registry...The Agency provides...home health (hospice) aide services... the agency provides home health (hospice) aide services by qualified home health aides under the supervision of a registered nurse and in accordance with the plan of care and established policies and procedures...Home health duties include ... hands on personal care, the performance of simple procedures as an extension of nursing or therapy services, assisting with ambulation or exercises, reporting changes in the patient's condition and needs, completing appropriate records, household services essential to health care at home."

Based on record review, interview, and policy review, the facility failed to provide effective pain management and symptom control for 1 out of 3 closed records (Patient #10). This tag is cross referenced with L687. Specifically, patient #10 did not receive Ativan for 4 days. This failed practice had the potential to negatively affect the quality of life for all elected hospice patients if medications are not available/given timely. Findings: Record review on 4/4-8/22 revealed Patient #10 elected for hospice/start of care on 3/19/22 with diagnoses that included Alzheimer's Disease, Dementia, need for assistance with personal care, bed confinement status and history of falls. Review of this record revealed lack of documentation of the Registered Nurse's communication with the physician that the Ativan was not available. Record review of "Visit Note Report," dated 3/19/22 at 10:54 AM revealed, "MEDICATION EDUCATION, CAREGIVER WILL PICK THEM UP THIS EVENING." Record review of "Visit Note Report," dated 3/20/22 at 12:03 PM revealed, "PHARMACY DID NOT DISPENSE ATIVAN [Lorazepam], RN [Registered Nurse] CALLED, THEY ARE CLOSED TODAY SUNDAY. THIS RN [RN#2] WILL FOLLOW UP ON THIS TOMORROW." Record review of "Visit Note Report," dated 3/21/22 at 12:10 PM revealed, "NO LORAZEPAM [Ativan] IN STOCK, PHARMACY WILL GET IN TOMORROW. [Caregiver] IS AWARE, [he/she] WILL PICK IT UP." Record review of "Visit Note Report," dated 3/22/22 at 11:57 AM revealed, "CALLED PHARMACY AGAIN REGARDING LORAZEPAM [Ativan]. PHARMACY WILL CONTACT [caregiver] TODAY FOR PICK UP." Record review of "Visit Note Report," dated 3/23/22 at 1:25 PM revealed, "THIS RN [RN #2] COLLECTED LORAZEPAM [Ativan] FROM PHARMACY PRIOR TO VISIT." Record review of "Client Medication Report," dated 3/19/22 revealed, "LORAZEPAM INTENSOL 2 MG/ML ORAL CONCENTRATE (0.25 mL) EVERY 4 HOURS Reason: Anxiety and SOB [Shortness of Breath]." During an interview on 4/6/22 at 10:18 AM with the Administrator and Branch Manager when asked the process of medications being delivered timely to patients, they stated every Thursday medications were delivered, a comfort pack was available, and the hospice had an emergency contract with an Assisted Living Facility to obtain medications. The Administrator stated there are no 24-hour pharmacies in Alaska. During an interview on 4/6/22 at 3:00 PM with the Branch Manager when asked why the patient did not receive the Ativan in a timely manner, he/she stated that there was no evidence of need for Ativan for this patient. During an interview on 4/7/22 at 8:19 AM with the Medical Director he/she stated the comfort pack starts with Morphine (a pain medication) and Ativan (a medication for anxiety). When asked about medications getting to patients in a timely manner, he/she stated there are pharmacies open 24 hours/7 days a week in Anchorage and if there was an issue recently, he/she was not aware of any and hoped the medications get to the patient as soon as possible. Review of policy, "Service delivery Patient rights S03," revealed, "2.1.10 To have an appropriate assessment and management of pain and other symptoms." Record review of, "Encompass Health Hospice Patient Handbook," dated 2016 revealed, "Your Rights and Responsibilities ... 4. To receive effective pain management and symptom control." Record review of a trifold flyer titled "Bringing dignity and comfort home" within the admission folder, dated 2020, revealed "What's included in hospice care, In addition to 24/7 access to our clinical experts, hospice care also includes: ? Medication for symptom and pain management ..." .

Based on record review, interviews, and policy review, the hospice failed to inform and educate the primary caregiver (PCG) as appropriate in 2 of 11 records reviewed (#3 and #10). This failed practice had the potential to affect all patients receiving oral medications from their caregivers. Findings: Regarding Record #3 Record review 4/4/22 - 4/8/22 of the "Hospice Certification and Plan of Care" with a certification period of 3/25/22 - 6/22/22 revealed the patient's medication orders including Morphine Concentrate 100 mg (milligrams) / 5 ml (milliliters)20 mg / ml oral solution Reason: pain, shortness of breath Dose: 0.1 ml Route: Oral, Frequency: Hourly. Instructions: Can increase by 0.1 ml to a maximum of 0.5 ml. Record review of a "Visit Note Report" dated 3/28/22 at 5:54 PM completed by Licensed Nurse (LN)#1 (a licensed practical nurse revealed "Twenty 0.5 ml morphine Sulfate syringes was filled at this time." This note did not state who had filled the syringes, the volume of the syringe, or what education had occurred and to whom the education had been given concerning the prefilled syringes. Regarding Record #10 Record review on 4/4-8/22 revealed Patient #10 elected for hospice / start of care on 3/19/22 with diagnoses which included Alzheimer's Disease, Dementia, need for assistance with personal care, bed confinement, and history of falls. Record review of the visit note report 3/23/22 revealed, "This RN [Registered Nurse #2] collected Lorazepam from the pharmacy prior to visit. Pre-filled syringes for both Morphine and Lorazepam. Advised to give Morphine hourly and Ativan every 4 hours." During an interview on 4/6/22 at 10:26 AM, the Administrator stated that the LN # 1 was not prefilling the syringes but instead instructing and observing the PCG as she / he prefilled syringes with medication. The Administrator agreed that this practice was not best practice and that the licensed nurses should not instruct the PCG to prefill syringes. Review on 4/8/22 of the agency policy titled "Licensed practical or vocational nurse hospice" dated 6/25/20 stated, "The duties and responsibilities are outlined below ... Clinical ... 4. Render skilled nursing care, as assigned by the registered nurse, according to the physician's orders and in conformance with recognized nursing techniques and procedures, established standards, and branch policies and procedures." Review on 4/8/22 of the undated agency policy titled "Controlled Medication Management and Disposal" stated, "The Registered Nurse [RN] will instruct the patient / family in a manner that they are able to correctly demonstrate the safe storage, use and disposal of controlled substances. 4.1.2 The instruction and return demonstration will be documented in the patient's medical record." Review on 4/8/22 of the undated agency policy titled "Scope of Services" stated, "The agency ... confirms that staff ... complies with accepted professional standards and principles that apply to professionals furnishing services ... the agency provides services by licensed vocational nurses / licensed practical nurse in accordance with the plan of care and established policies and procedures ... complies with accepted nursing standards and principles." .

Based on record review, observation, and interview, the hospice failed to ensure Licensed Nurse (LN) #2 assessed Patient #3's oxygen tubing for 1 of 1 nurse home visit with oxygen administration use observed at a home visit. Failure of LN #2 to complete an assessment of the oxygen tubing and its connections, the oxygen concentrator (this is a machine that gives the patient extra oxygen)and its airflow had the potential to negatively affect the amount of oxygen delivered to the patient and to reduce the patient's oxygen saturation rate with the additional risk of hypoxemia (low oxygen level in the blood). Findings: Record review on 4/4/22 - 4/8/22 revealed Patient #3 was admitted on 3/25/22 with a primary diagnosis of malignant neoplasm of unspecified part of right bronchus or lung. During a home visit observation on 4/5/22 at 8:45 AM, LN #2 was observed to assess Patient #3 who was lying in bed with the primary caregivers present at the bedside. LN #2 was observed to assess the patient's vital signs and oxygen saturation rate. The primary caregiver stated, "[Patient #3] is having trouble breathing." The patient was observed to have a respiration rate of 20 respirations a minute and an oxygen saturation level of 90%. It was also observed that an oxygen concentrator had a humidifier bottle, which was bubbling with air. This machine was approximately 10 feet away from the patient and was functioning. The oxygen level was set at 5 liters. The oxygen tubing was observed to be connected to the concentrator. The tubing was longer than needed and was bundled underneath the bed. A supply basket was observed to be placed on top of the bundle of tubing under the bed. The nurse did check the rate of oxygen but did not assess the airflow coming out of the nasal cannula part(this is where the tubing administers the oxygen into the patient's nostrils) of the tubing. LN # 2 did not look at the tubing, its connections, or take the basket off the tubing. During an interview on 4/5/22 at 4:10 PM, LN #2, when asked if he / she checked the oxygen tubing and nasal cannula airflow, stated the assessment did not occur. During an interview on 4/6/22 at 2:30 PM, the Administrator stated that if the patient's oxygen saturation rate was dropping the oxygen tubing should be assessed. The agency procedure titled "Oxygen administration, humidified high - flow nasal cannula, respiratory therapy" reviewed November 18, 2021, stated, "Implementation ... Trace the tubing from the patient to its point of origin to ensure that you've set up the device properly and to prevent misconnections. Make sure that the connections are securely attached to prevent dangerous disconnections." .

Based on record review and interviews, the hospice failed to designate a physician to act in the absence of the medical director. This failure had the potential to place the 11 active patients at risk for not receiving quality hospice and palliative care services. Findings: Review of The Medical Director Service Agreement for the Medical Director dated April 1,2022 stated, "Professional Standards: Compliance with Law. Medical Director shall comply with the ethics and professional standards of the medical profession; applicable federal, state, and local laws, rules and regulations including those related to the health and safety of patients; Hospice's policies and procedures and the rules and regulations that are applicable to Hospice, including accreditation and certification requirements ... Call coverage. Provide on - call coverage ... when Medical Director is unavailable to provide call coverage and / or Services, Medical Director shall ensure that the designated back - up medical director is available to provide call coverage and / or services." During an interview on 4/7/22 at 8:20 AM, the Medical Director stated that the hospice did not have a designated back - up physician serving as a back - up for the Medical Director. During an interview on 4/8/22 at 2:00 PM, the Administrator stated there was no back up for the medical director except Nurse Practitioner #1 was available for a back - up at times. .

Based on record review, interview, and policy review, the facility failed to provide the drugs and biologicals needed for palliative care (care that improves quality of life) and management of the terminal illness for 1 out of 3 closed records (Patient #10). This failed practice had the potential to negatively affect all elected hospice patients if medications are not available. Findings: Record review on 4/4-8/22 revealed Patient #10 elected for hospice/start of care on 3/19/22 with diagnoses that included Alzheimer's Disease, Dementia, need for assistance with personal care, bed confinement status and history of falls. Review of this record revealed lack of documentation of the Registered Nurse's communication with the physician that the Ativan was not available. Record review of "Visit Note Report," dated 3/19/22 at 10:54 AM revealed, "MEDICATION EDUCATION, CAREGIVER WILL PICK THEM UP THIS EVENING." Further review of this note under "Assessment," revealed, "The patient should meet many of the following Alzheimer's Disease Criteria (Mark all that apply): ... Increased Agitation ... Mood related signs: Irritability (Easily annoyed, short tempered) 1. Mild or intermittent." Record review of "Visit Note Report," dated 3/20/22 at 12:03 PM revealed, "PHARMACY DID NOT DISPENSE ATIVAN [Lorazepam], RN [Registered Nurse] CALLED, THEY ARE CLOSED TODAY SUNDAY. THIS RN WILL FOLLOW UP ON THIS TOMORROW." Further review of this note under "Narrative Objective Findings," revealed, "[Primary care giver] will be returning Wednesday (primary care giver out of state). [He/she] is the primary caregiver and performs baths and changes." Record review of "Visit Note Report," dated 3/21/22 at 12:10 PM revealed, "NO LORAZEPAM [Ativan] IN STOCK, PHARMACY WILL GET IN TOMORROW. [Caregiver] IS AWARE, [HE/SHE] WILL PICK IT UP." Record review of "Visit Note Report," dated 3/22/22 at 11:57 AM revealed, "CALLED PHARMACY AGAIN REGARDING LORAZEPAM [Ativan]. PHARMACY WILL CONTACT [caregiver] TODAY FOR PICK UP." Record review of "Visit Note Report, "dated 3/23/22 at 1:25 PM revealed, "THIS RN [RN #2] COLLECTED LORAZEPAM [Ativan] FROM PHARMACY PRIOR TO VISIT." Record review of "Hospice Certification and Plan of Care," dated 3/19/22 revealed, "LORAZEPAM INTENSOL 2 MG/ML ORAL CONCENTRATE (0.25 mL) EVERY 4 HOURS/PRN [As needed] Reason: Anxiety and SOB [Shortness of Breath]." During an interview on 4/6/22 at 3:00 PM with the Branch Manager when asked why the patient did not receive the Ativan in a timely manner, he/she stated that there was no evidence of need for Ativan for this patient. Review of policy, "7.63 Medication management & Comfort Pak," not dated, revealed, "Each new Hospice patient's initial comprehensive assessment will include all prescription and over the counter medications. The Registered Nurse who is developing the initial plan of care will ensure the inclusion of all drugs necessary for the palliation of current and potential pain and symptom management." Review of policy, "Service delivery Medications S07," revised 10/04/21 revealed "3.1.2 The licensed personnel informs the physician of any concerns related to medications and documents physician contact and any orders according to the established procedure. 3.9 Hospice Agencies will have a contractual arrangement with vendor(s) pharmacy(ies) to ensure effective and efficient dispensing of all medications that the Hospice Agency is financially responsible for." .