Every finding on record at Endless Journey, LLC

Based on record review, policy and procedure review, and staff interview, the hospice failed to ensure timely collection of a urine specimen for 1 of 1 patients (Patient 3) who had orders to collect a urine specimen. The total sample size was 6 full patient records reviewed. The census was 75. --- Findings are: A.  Review of the hospice policy and procedure titled 9.13 Physicians Orders, revised 8/2024, revealed care and services will be provided according to physician orders. The policy also requires staff to promptly notify the physician of any changes that suggest a need to alter the plan of care. B.  Review of Patient 3’s clinical record revealed:1. A Patient Care Order dated 2/13/25 for a urinalysis with culture and sensitivity (UA with C & S) for signs and symptoms of a urinary tract infection.2. A PhysLab report form showing the results of a urinalysis. The report reveals the urine specimen was collected on 2/27/25 (14 days after the order).3. There was no documentation in the clinical record of a reason for the delay in collecting the UA with C & S, or that the physician was notified of the delay. C.  During an interview on 6/25/25 at 12:00 PM, the Administrator/Executive Director (A/ED) confirmed the UA with C & S was ordered on 2/13/25 and collected on 2/27/25. The A/ED also confirmed the specimen was not collected in a timely manner.

Based on record review, policy and procedure review, and staff interview, the hospice failed to ensure the medication profile for 1 of 6 full patient records reviewed (Patient 1) was updated to reflect all medications the patient was taking. The census was 75. --- Findings are: A.  Review of the hospice policy and procedure titled Medication Reconciliation, revised 3/2013, revealed:1. Medications ordered while the patient is receiving care will be compared to the medication list/profile.2.The medication list/profile will be updated with each new or changed medication.3. Any discrepancies will be reconciled by a registered nurse (RN) with the patient’s physician. B.  Review of Patient 1’s clinical record revealed:1. A Skilled Nursing Visit Note dated 4/17/25. The Skilled Nurse (SN) documented that the caregiver reported starting the patient on Prilosec (a medication used to reduce acid in the stomach).2. A Skilled Nursing Visit Note dated 4/24/25. The SN documented that the caregiver reported the Prilosec was stopped but may begin giving it again.3. A Skilled Nursing Visit Note dated 5/24/25. The SN documented that the caregiver reported giving the patient Pepto Bismol.4. A Skilled Nursing Visit Note dated 6/2/25. The SN documented that the nighttime trazadone (a medication sometimes used for insomnia) was stopped. The note does not indicate if the caregiver stopped the trazadone or if the physician stopped the trazadone.5. The Medication Profile did not include the Prilosec or Pepto Bismol. The trazadone was still present on the profile.6. There was no documentation that the SN reconciled the Prilosec, Pepto Bismol, or trazadone with the patient’s physician. C.  During an interview on 6/24/25 at 2:30 PM, The Administrator confirmed the medication profile was not updated to include the medications that Patient 1’s caregiver reported giving the patient.

Based on Quality Assurance Performance Improvement Plan (QAPI) program review, policy and procedure review, and staff interview, the hospice failed to ensure supplies used to draw blood samples and used needles were disposed of in approved biohazardous waste containers according to the hospice's safe disposal requirements, and the hospice failed to ensure used supplies were not stored in the hospice’s clean supply room when 1 open biohazard bag containing a used syringe, tubing, and needle was found in the clean supplies room. This deficient practice had the potential to affect any of the 51 employees of the hospice gathering supplies from the clean supply room and any of the 75 patients who received supplies obtained from the clean supply room. --- Findings are: A.  Review of the hospice policy and procedure titled Infection Control Plan (overview), undated, revealed:1. Infectious waste includes soiled dressing, used disposable instruments, used internal devices such as catheters, and intravenous (IV) equipment, and sharps such as used needles.2. Materials without the risk of puncturing the handler are to be placed in leak-proof plastic bags, then securely fastened and disposed of in the client’s household trash.3. Disposable needles and syringes and other sharp items are to be placed in puncture resistant containers after use. B.  Review of the hospice policy and procedure titled 1.3 Hazardous Materials/Waste Policy, revised 7/2024, revealed hazardous waste/biohazard bags and containers were to be closed and stored in a designated area in the office. C.  Review of the hospice's QAPI program revealed a Performance Improvement Project (PIP), undated, that identified an infection control problem; used biohazard bag found in clean supply room. D.  During an interview on 6/25/25 at 12:00 PM, the Administrator/Executive Director (A/ED) confirmed:1. An open biohazard bag was found in the clean supply room on 5/27/25. The bag contained a used syringe and needle with tubing attached, that appeared to have been used to draw a blood specimen.2. The used needle was not placed in an approved puncture resistant container.3. The used tubing and attached syringe were not placed in a sealed bag and disposed of in the patient's home after use.4. The biohazard bag was not closed and stored in the designated biohazard disposal area once the items were brought back to the hospice office.

Based on job descriptions review, personnel file review, and staff interview, the hospice failed to ensure the person employed to provide oversight of the hospice staff was credentialed as a registered nurse (RN) as described in the hospice’s Executive Director (ED) job description and failed to have a qualified person to provide staff oversight when the ED position was not filled by an RN. The hospice had 51 employees. --- Findings are: A.  Review of the hospice's Executive Director job description revealed the ED was responsible for:1. Development, implementation, and evaluation of all systems of operations.2. Providing oversight and supervision in providing end-of-life care.3. Supervision of hospice staff.4. Licensure to practice as an RN in the state. B.  Review of Director of Clinical Services (DCS) job description revealed the DCS was responsible for the supervision of nurses, aides and other health care team members and is responsible for the overall supervision and coordination of clinical services. The position requires a Bachelor of Science degree in nursing, equivalent experience, education, or degree. The DCS assumes the overall responsibility for clinical supervision and performance evaluations of all nursing personnel. C.  Review of personnel files revealed:1. Staff-O was employed from 4/4/24 through 4/25/25 as the ED.2. Staff-O was a licensed practical nurse (LPN).3. RN, Staff-CC was employed as the DCS effective 6/2/24 through 8/2/24.4. RN, Staff-D was employed as the DCS effective 10/4/24 through 4/17/25.5. RN, Staff-KK was employed 10/23/23 and was the Director of Pediatric Services.6. There was no RN or DCS for supervision of non-pediatric nursing personnel from 8/2/24 through 10/4/24. D.  During an interview on 6/23/25 at 2:30 PM, the Human Resources Director confirmed:1. Staff-O was employed from 4/4/24 through 4/25/25 as the ED.2. Staff-O was a licensed practical nurse (LPN).3. RN, Staff-CC was employed as the DCS effective 6/2/24 through 8/2/24.4. RN, Staff-D was employed as the DCS effective 10/4/24 through 4/17/25.5. RN, Staff-KK was employed 10/23/23 and was the Director of Pediatric Services.6.There was no RN or DCS for supervision of non-pediatric nursing personnel from 8/2/24 through 10/4/24.

Deficiencies cited at L615 and L629. --- Cross-reference to tag L615.Cross-reference to tag L629.

Based on record review, policy and procedure review, and staff interview, the hospice failed to verify the written and skills competency of 9 of 9 current and past hospice aides (HA-E, P, Q, R, S, T, U, V, and W) prior to allowing the aides to independently provide hospice aide services to the hospice patients. The hospice has a total of 8 hospice aides. The census was 75. --- Findings are: A. Review of the hospice policy and procedure titled 4.19 Staff Competency Program, revised 8/2024, revealed:1. Each new employee was to be competency assessed during orientation and at least annually.2. A registered nurse (RN) was to assess the HA’s competency.3. A policy was not provided that included the type of competency assessments to be completed, the topics to be covered according to regulatory requirements as listed in 418.76(b)(3), passing/non-passing criteria, or what is to be expected if the HA does not meet the established criteria. B.  Review of personnel files revealed:1. There was no documentation a written competency evaluation was completed for HA-E, P, Q, R, S, T, U, V, and W.2. There was no documentation a skills competency evaluation was completed for HA-P, Q, R, S, T, V, and W.3. HA-E and HA-U had unsigned, undated skills competency evaluations in their personnel file. C. During an interview on 6/17/25 at 2:30 PM, the Human Resources Director confirmed that the personnel files of HA-E, P, Q, R, S, T, U, V, and W did not contain evidence of a written and/or skills competency evaluation completed.

Based on record review, policy and procedure review, and staff interview, the hospice failed to conduct an onsite visit by the registered nurse to the patient’s home every 14 days to ensure the services provided by the patient’s hospice aide (HA) were meeting the patient's needs and that the patient's goals were being met for 2 of 3 patient records reviewed (Patient 1 and 2), who received hospice aide services. The total sample size was 6 full patient records reviewed. The census was 75. --- Findings are: A.  Review of the hospice policy and procedure titled 9.22 Hospice Aide Supervision, revised 8/2024, revealed:1. HA are closely supervised to ensure their competence in providing care identified in the plan of care.2. The registered nurse (RN) was to make an onsite visit to the patient's home at least every 14 days to assess relationships and determine whether goals are being met.3. The RN was to assess the adequacy of the aide services in relation to the needs of the patient/family.4. The visit was to be documented in the patient’s clinical record. B.  Review of Patient 1’s clinical record revealed:1. The Interdisciplinary Group Meeting note dated 4/16/25 included orders for HA 1 time a week for 1 week, then 2 times a week for 8 weeks from 3/19/25 through 5/17/25.2. The Interdisciplinary Group Meeting note dated 5/18/25 included orders for HA 2 times a week for 8 weeks, then 1 time a week for 1 week from 5/18/25 through 7/16/25.3. There was no documentation in the clinical record that a HA supervisory visit was conducted, by the RN, from 4/1/25 through 6/1/25. C.  Review of Patient 2’s clinical record revealed:1. The Hospice Plan of Care for the period of 3/5/25 through 5/3/25 included orders for HA 3 times a week for 8 weeks.2. There was no documentation in the clinical record of a HA supervisory visit conducted, by the RN, from 4/1/25 through 4/28/25. D.  During an interview on 6/24/25 at 2:30 PM, the Administrator/Executive Director confirmed the hospice failed to ensure the RN conducted a supervisory visit to ensure the HA services provided to Patient 1 and 2 were meeting the needs of the patient/family and that goals were being met.

Deficiencies cited at L651 and L656. --- Findings are: Cross-reference to tag L651.Cross-reference to tag L656.

Based on observations, job descriptions review, hospice and clinical record review, personnel file review, policy and procedure review, and staff interview, the hospice’s Governing Body failed to ensure responsibility for management for the provision of hospice services, operations, safety, and quality of care, and the Hospice Administrator failed to maintain responsibility for the day-to-day operations of the hospice program.  The census was 75. The hospice had 51 employees. --- Findings are: A.  Review of the policy and procedure titled 7.1 Governing Body, revised 8/2024, revealed the governing body responsibilities include, but are not limited to:1. Annual evaluation of the hospice’s performance in relation to its vision, mission, and goals.2. Meet annually to review the operation of the hospice.3. Assumes full legal authority and responsibility for the management of Endless Journey, LLC, for the provision of all hospice services, its fiscal operations, and assumes responsibility for the safety and quality of care provided. B.  Review of the policy and procedure titled 7.9 Administrator revealed the Administrator is appointed by the Governing Body to run the day-to-day operations of the hospice. C.  Review of the Administrator-President job description revealed responsibilities include, but are not limited to, organizing and directing Endless Journey, LLC, employing qualified personnel, assessing employees on an ongoing basis to ascertain their understanding of policies and procedures, enforcing policies and procedures, evaluating effectiveness and efficiency, maintaining compliance with applicable federal, state and local rules and regulations, planning and directing operations to ensure the provision of adequate and appropriate care and services, evaluating services and programs, ensuring staff development, ensuring policies are developed and implemented, and establishing and overseeing the quality assessment performance improvement program. D.  Review of hospice records and personnel files, and observations revealed deficient practices cited at: 1. Federal tags at L546, L553, L579, L584, L607, L615, L629, L648, L651, L656, L670, L674, L679, L680, L681, L686, L691, L692, L694.2. State tags at D070, D170, D190, Z105, Z163, Z166, Z175, Z176, Z187, Z205, Z206, Z229, Z231, Z238. E.  During an interview on 7/1/25 at 10:00 AM, the Administrator confirmed:1. The hospice Administrator is responsible for planning, developing, and directing the programs, services, activities and employees of the agency. 2.The Administrator is also responsible for ensuring compliance with federal and state regulations governing home health care services and directing daily business activities of the agency. 3.The Governing Body was to assume overall responsibility for management for the provision of hospice services, operations, and safety and quality of care 4.The Administrator and the Governing Body failed to complete their duties as evidenced by the deficient practices being cited during this survey.

Based on observation, policy and procedure review, and staff interview, the hospice failed to obtain approval from Centers for Medicare and Medicaid Services (CMS) prior to operating 1 of 1 multiple location offices in Lincoln, Nebraska. The census was 75. --- Findings are: A.  Review of policies and procedures, the hospice did not have a policy for submitting/notifying CMS with requests for changes prior to implementing those changes. B. An observation conducted on 6/11/25 at 2:20 PM at 575 S. 70th Street, Lincoln, NE 68510 revealed:1. St. Elizabeth Medical Office Building directory listed Endless Journey Hospice in Suite 305.2. 5 Endless Journey Hospice, LLC staff members were present in Suite 305.3. Computers, desks, and office and patient supplies were present.4. Staff-I was working at an office desk. C. During an interview on 6/11/25 at approximately 2:35 PM, Registered Nurse (RN)-II and RN-JJ confirmed Endless Journey Hospice, LLC was currently operating at the “Lincoln” office at 575 S. 70th Street, Suite 305, Lincoln, NE 68510 by conducting staff meetings, daily stand-up meetings, maintaining supplies, and staff office work.  RN-II confirmed the hospice had not notified CMS for approval of this multiple location office prior to operating from this location.

Deficiencies cited at L674, L679, L680, and L681. --- Findings are: Cross-reference to tag L674.Cross-reference to tag L679.Cross-reference to tag L680.Cross-reference to tag L681.

Based on record review, policy and procedure review, and staff interview, the hospice failed to ensure 1 of 6 full patient records reviewed (Patient 3) contained all documentation of treatments and services provided to the patient. The census was 75. --- Findings are: A.  Review of the hospice policy and procedure titled 14.2 Client Record Content, revised 8/2024, revealed the medical record was to include a record of the care provided by all disciplines from admission through patient death.   B.  Review of Patient 3’s clinical record revealed:1. A Patient Care Order dated 2/13/25 for a urine analysis with culture and sensitivity (UA with C & S) for signs and symptoms of a urinary tract infection.2. There was no documentation in the clinical record of the results of the urine analysis until requested by the surveyor on 6/25/25.3. The patient died on 3/19/25. C.  During an interview on 6/26/25 at 10:30 AM, the Administrator/Executive Director (A/ED) confirmed Patient 3’s clinical record did not include the results of the UA until the missing documentation was requested by the surveyor on 6/25/25.

Based on record review, personnel file review, policy and procedure review, and staff interview, the hospice failed to ensure only a person licensed to act as a registered nurse (RN) used RN credentials in the hospice’s electronic medical record system, and failed to have a policy and procedure to ensure accurate authentication of electronic signatures when the electronic signature for 1 of 33 employee records reviewed (Staff- B), who was not an RN, contained the credentials of RN.  The hospice had 51 employees. --- Findings are: A.  Review of the hospice policy and procedures revealed the agency did not have a policy and procedure in place to ensure electronic signatures were accurately authenticated. B.  Review of Patient 3's clinical record revealed:1. The Hospice Plan of Care for the certification period of 2/4/25 through 5/4/25 revealed that Staff-B electronically signed, as an RN, the plan of care on 3/3/25.2. A Patient Care Order (verbal order) dated 2/6/25 for Chaplain to assess and evaluate was electronically signed, as an RN, by Staff-B. C.  Review of Patient 4’s clinical record revealed a Local Coverage Determination Document (a tool/document used by the agency to assist the physician with patient information) was electronically signed, as an RN, by Staff-B on 1/21/25. D.  Review of Patient 10’s clinical record revealed a Local Coverage Determination Document was electronically signed, as an RN, by Staff-B on 1/21/25. E.  Review of Patient 11’s clinical record revealed a Local Coverage Determination Document was electronically signed, as an RN, by Staff-B on 1/16/25. F.  Review of Patient 13’s clinical record revealed a Patient Care Order dated 2/7/25 to discontinue, effective 2/1/25, skilled nurse 2-3 times per month for 3 months, and 3 as needed visits for unanticipated needs. The order was electronically signed, as an RN, by Staff-B on 2/7/25. G. During an interview on 6/12/25 Staff-B (Administrator) confirmed [gender] is not a registered nurse. H. During an interview on 6/24/25 at 4:15 PM, Staff-A (current Administrator) confirmed:1. Staff-B is not an RN.2. Confirmed documentation including a patient's Plan of Care, a Local Coverage Determination Document, and/or Patient Care Orders for Patients 3, 4, 10, 11, and 13 were electronically signed by Staff-B with the credentials of RN.3. The hospice did not have a policy and procedure to ensure accurate authentication of electronic signatures.

Based on record review, policy and procedure review, and staff interview, the hospice failed to ensure 6 of 13 previous hospice employee's (Staff- D, M, T, X, Y, and CC) access to patient records and/or hospice confidential communications was discontinued on the employee's last day of hospice employment, and the hospice failed to have a written process to ensure this access for employees was discontinued on the employee's last day of hospice employment. The hospice had 51 employees. --- Findings are: A.  Review of the hospice policy and procedure titled 4.12 Terminator or Resignation, revised 8/2024, revealed:1. Human Resources was to secure the return of all Hospice property, record, and keys.2. It did not list items that must be deactivated for employees on their last day of hospice employment, including what tasks need completed, who was responsible for completing the tasks, and timeframes when tasks are to be completed.3. It did not include what process was in place to ensure deactivation procedures were completed if the person responsible to complete this task was not available. B.  Review of hospice records/forms provided by the Human Resources Director revealed:1. A sample Termination Checklist- a form that includes a list of tasks to complete on an employee's last day of hospice employment, including but not limited to, deactivation of access to agency information and communication sources such as Backline (a secure chat format), email, electronic medical records (EMR), human resources software, access to building security codes. A copy was to be retained in the personnel file.2. A list of past hospice employees sampled with the date logged when they were removed from Backline. C.  Review of Staff D’s personnel file revealed:1. The employee’s date of termination was 3/31/25.2. The Termination Checklist included check marks indicating completion of the following tasks- email blocked and unlicensed, EMR log-in deactivated, removed from Backline groups, door code disabled, laptop/tablet returned. The checklist did not include the date/time the activity was terminated.3. Backline list logged the deactivation date of 4/2/25 (2 days after hospice employment ended). D. Review of Staff M’s personnel file revealed:1. The employee’s date of termination was 5/9/25.2. The Termination Checklist included check marks indicating completion of the following tasks- email blocked and unlicensed, removed from Backline groups, door code disabled, laptop/tablet returned. The checklist did not include the date/time the activity was terminated.3. Backline list logged the deactivation date of 6/9/25 (1 month after hospice employment ended). E.  Review of Staff T’s personnel file revealed:1. The employee’s date of termination was 5/23/25.2. The Termination Checklist included check marks indicating completion of the following tasks- email blocked and unlicensed, EMR log-in deactivated, removed from Backline groups, door code disabled, laptop/tablet returned. The checklist did not include the date/time the activity was terminated.3. Backline list logged the deactivation date of 5/28/25 (5 days after hospice employment ended). F.  Review of Staff X’s personnel file revealed:1. The employee’s date of termination was 5/30/25.2. The Termination Checklist included check marks indicating completion of the following tasks- email blocked and unlicensed, EMR log-in deactivated, removed from Backline groups, door code disabled, laptop/tablet returned. The checklist did not include the date/time the activity was terminated.3. Backline list logged the deactivation date of 6/3/25 (4 days after hospice employment ended). G.  Review of Staff Y’s personnel file revealed:1. The employee’s date of termination was 5/30/25.2. The Termination Checklist included check marks indicating completion of the following tasks- email blocked and unlicensed, EMR log-in deactivated, removed from Backline groups, door code disabled, laptop/tablet returned. The checklist did not include the date/time the activity was terminated.3. Backline list logged the deactivation date of 6/3/25 (4 days after hospice employment ended). H.  Review of Staff CC’s personnel file revealed:1. The employee’s date of termination was 8/2/25.2. There was no documentation that the Termination Checklist was completed.3. Backline list logged the deactivation date of 8/5/25 (3 days after hospice employment ended). I.  During an interview on 6/24/25 at 10:30 AM, the Human Resources Director (HRD) confirmed:1. Termination checklist does not list actual date/time the checklist items were completed so [gender] was not able to confirm the actual date the checklist items were completed.2. It was the usual practice of the HRD to complete the checklist items on the date of termination.3. HRD was out of office 5/8/25 and 5/9/25 and there was no one available/designated to deactivate employee access for those dates.4. The termination policy and procedure in place did not list items that must be deactivated for employee's leaving hospice employment, including what tasks need completed, who was responsible for completing the tasks, and timeframes when tasks are to be completed.5. There was no policy and procedure in place to ensure a designated back-up was available to complete the employee deactivation process.6. Staff- D, M, T, X, Y, and CC continued to have access to confidential hospice information after the employee’s last day of hospice employment.

Based on policy and procedure review, review of hospice documents, and staff interview, the hospice failed to ensure electronic patient records (EMR) were maintained and accessible after switching electronic medical record systems and failed to have a written policy and procedure to ensure maintenance of records in the discontinued EMR system. This affected all patient records that were documented in the hospice's prior EMR system. The hospice's unduplicated admissions, for the previous 12-month period, were 334. The current census was 75. --- Findings are: A.  Review of the hospice policy and procedure titled 11.13 Destruction of Client Records revealed the policy stated "DELETED-ALREADY ADDRESSED ELSEWHERE." The hospice failed to have a current, written policy and procedure for client records retention. B.  Review of hospice documents revealed:1. An email dated 12/13/24, from the hospice to Careficient (the hospice's EMR contractor), stating the hospicewould be ending services on 1/31/25, with a return email reply from Careficient to the hospice requesting the hospice contact Careficient to discuss the contract.2. An email dated 1/7/25, from the hospice Administrator to Careficient, requesting read only access to Careficient's EMR and informing Careficient that the go live date for the new EMR (MatrixCare) will be 2/1/25.3. A response on 1/7/25, from Careficient to the hospice, stating the contract/service will continue through 3/24/25 (90 days from the hospice's notice to quit).4. An email dated 1/29/25, from the Administrator to Careficient, asking if Careficient was turned off and requesting read only access for one month instead of a year.5. An email dated 5/15/25, from Careficient to the hospice Administrator, stating read-only access can be set-up once an agreement has been signed by both parties.6. A Service Agreement effective 5/19/25 between Careficient and Endless Journey, LLC, to maintain access to client information inquiry and print access only, secure backup and archive of all data, for a period of one year from agreement effective date of 5-19-25. C.  During an interview on 6/12/25 at 1:15 PM, the Administrator (Staff-B) confirmed the hospice staff did not have access to patient records in Careficient EMR from 3/24/25 to 5/19/25. The Administrator also confirmed the hospice did not have a written policy and procedure to ensure maintenance of records in the discontinued EMR system.

Deficiencies cited at L691, L692, and L694. --- Findings are: Cross-reference to tag L691.Cross-reference to tag L692.Cross-reference to tag L694.

Based on the hospice's internal complaint investigation documentation, policy and procedure review, and staff interview, the hospice failed to ensure drugs ordered by the physician were obtained for the patient from an approved pharmacy when 3 of 8 staff (Staff K, LL, and MM) reported obtaining medications for a patient from a supply cabinet kept in the office of the hospice's Executive Director. --- Findings are: A.  Review of the hospice's policy and procedure titled Medication Dispensing, revised 2015, revealed:1. The hospice will obtain drugs and biologicals from community or institutional pharmacies.2. The hospice staff will order medications from contracted pharmacy in advance of patient’s need to ensure timely delivery of medications.3. Hospice provides medications 24 hours per day, 7 days per week through contracted pharmacy providers. B.  Review of the hospice's internal complaint investigation documentation dated 4/23/25 through 5/16/25 revealed:1. The hospice was storing medications in a cabinet in the Executive Director's office, and nurses were using these stored medications for use by other hospice patients. 2. 3 nurses (Staff-K, LL, and MM) confirmed, using the hospice's internal investigation documentation, that they used medications obtained from the hospice office for use by other hospice patients.3. The hospice revised their policies and procedures to ensure proper medication disposal by staff and to ensure no medications were stored at the hospice office. The hospice retrained nursing, and other professional, staff on these revised policies and procedures.  4. A handwritten document titled, Inventory 4/23/25 1523. This inventory list included the following narcotic medications stored at the hospice office for Patients 12 through 21:a. Hydromorphone (a pain medication)- 80 milliliters (ml), 12 microgram (mcg) Fentanyl patches (a pain medication)- 4 in open box, morphine extended release (MS ER) 15 milligrams (mg) tablets- 30 tablets, MS ER 15 mg tablets- 30 tablets, Fentanyl 12 mcg patch- 2, Fentanyl 25 mcg patch- 13, lorazepam (an antianxiety medication) 0.5 mg- 30 tablets, methadone (a pain medication) 10 mg tabs- 30 tablets, Ativan (an antianxiety medication) 1 mg tablets- 30 tablets, Norco (a pain medication) 5/325 mg tablets- 30, Ativan 0.5 mg- 30 tablets, Ativan 0.5 mg- 30 tablets,  Ativan 0.5 mg- 15 tablets,  Ativan 0.5 mg- 30 tablets, Ativan 0.5 mg- 60 tablets, Ativan Solution 2 mg/ml- 30 ml,  a medication with strength only of 100 mg/ 5 ml- 30ml.b. the inventory sheet included the notation "*all above medications wasted in presence of 2 RN's" and was signed and dated 4/23/25 by Staff-JJ and Staff-KK. C.  During an interview on 6/12/25 at 2:30 PM, Staff- K confirmed [gender] obtained medication previously prescribed to another patient from the hospice office for use by another hospice patient instead of ordering the medication from the pharmacy. D.  During an interview on 6/12/25 at 9:50 AM, Staff- LL confirmed [gender] obtained medication previously prescribed to another patient from the hospice office for use by another hospice patient instead of ordering the medication from the pharmacy. E.  During an interview on 6/16/25 at 9:30 AM, Staff- II (Acting Executive Director during the hospice's complaint investigation process) confirmed the hospice's complaint investigation found that staff nurses obtained medications previously prescribed to another patient from the hospice office for use by other hospice patients instead of obtaining the medications from an approved pharmacy. Staff-II also confirmed the medications were obtained from a cabinet in the hospice's Executive Director's office.

Based on record review, policy and procedure review, and staff interview, the hospice failed to include documentation of the patient’s continued ability to safely self-administer medications in the Interdisciplinary Group (IDG) updates for 5 of 6 full patient records reviewed (Patient 1, 2, 3, 4, and 5). The census was 75. --- Findings are: A.  Review of the hospice policy and procedure titled Medication Administration, revised 2014, revealed:1. The IDG will determine initially and ongoing the ability of the patient/family/caregiver to safely self-administer drugs and biologicals to the patient in his/her home.2. The individualized IDG plan of care must identify if the patient/family/caregiver are self-administering drugs and biologicals.3. If the patient/family/caregiver is not capable of safely administering drugs and biologicals, the issue will be addressed in the IDG plan of care. B.  Review of clinical records revealed:1. Patient 1’s IDG Meeting updates for the record review period of 3/1/25 through 6/19/25 did not include documentation of the IDG’s ongoing assessment of the patient/family/caregiver’s continued ability to safely self-administer medications.2. Patient 2’s IDG Meeting updates for the record review period of 3/5/25 through 6/23/25 did not include documentation of the IDG’s ongoing assessment of the patient/family/caregiver’s continued ability to safely self-administer medications.3. Patient 3’s IDG Meeting updates for the record review period of 2/4/25 through 3/26/25 did not include documentation of the IDG’s ongoing assessment of the patient/family/caregiver’s continued ability to safely self-administer medications.4. Patient 4’s IDG Meeting updates for the record review period of 2/20/25 through 6/16/25 did not include documentation of the IDG’s ongoing assessment of the patient/family/caregiver’s continued ability to safely self-administer medications.5. Patient 5’s IDG Meeting updates for the record review period of 4/17/25 through 6/24/25 did not include documentation of the IDG’s ongoing assessment of the patient/family/caregiver’s continued ability to safely self-administer medications. C.  During an interview on 6/24/25 at 2:30 PM, the Administrator confirmed the hospice failed to include documentation of the IDG's ongoing assessment of the patient/family/caregiver’s ability to safely self-administer medications for Patient 1, 2, 3, 4, and 5.

Based on review of the hospice's internal complaint investigation documentation, record review, policy and procedure review, and staff interview, the hospice failed to ensure medications were safely disposed of in the patient's home and the medication disposal was accurately documented for 2 of 10 patient records reviewed (Patient 12 and Patient 13) for the disposal of medications and the hospice failed to have clear and concise policies and procedures which clearly delineated the process for nurses to follow in the disposal of medications in patient's homes, when patients reside in assisted living facilities (ALF), and when patients reside in long term care (LTC) facilities.  The census was 75. --- Findings are: A.  Review of the hospice policy and procedure titled Management and Disposal of Controlled Drugs for Patients and Families, revised 2015, revealed a policy for educating patients and families on how to safely store and dispose of controlled substances in the patient's home. This policy did not pertain to the disposal of medications by staff. B.  Review of the hospice policy and procedure titled 8.10 Medication Disposal, revised 5/2025, revealed the policy was to educate patient/family/caregivers on the policy and procedure for the management and disposal of medications in the patient's home. C.  Review of the hospice policies and procedures revealed there was no policy or procedure that specifically delineated the nurse’s role in the disposal of medications in various settings in which the patient resides (in home, ALF, LTC), when to dispose of medications, how and where to document the disposal of medications, and any exceptions to medication disposal. D.  Review of the hospice's internal complaint investigation documentation dated 4/23/25 through 5/16/25 revealed:1. Hospice nurses were storing medications at the hospice office and later re-using those medications for use by other hospice patients. The medications being stored were brought to the hospice office after the death of a hospice patient instead of being disposed of in the patient's homes. 2. Processes were reviewed and policies and procedures were updated for the storage, disposal, and dispensing of medications by the hospice. 3. Nurse sign-in sheet and meeting notes for a meeting conducted on 5/1/25. During this meeting the nurses were instructed on the hospice's new processes; staff are not allowed to store medications at the hospice, when medications are destroyed in the patient's home the nurse is to use the Medication Disposal Log form to record details of the medication disposal, and medications are to be obtained from the appropriate community pharmacies. 4. Professional staff sign-in sheet with attached agenda for a meeting conducted on 5/15/25.During this meeting the professional staff were instructed on the hospice's new processes; staff are not allowed to store medications at the hospice, when medications are destroyed in the patient's home the nurse is to use the Medication Disposal Log form to record details of the medication disposal, and medications are to be obtained from the appropriate community pharmacies. These staff were also updated on the internal complaint investigation. 5. A handwritten document titled, Inventory 4/23/25 1523. This inventory list included the following narcotic medications stored at the hospice office for Patients 12 through 21:a. Hydromorphone (a pain medication)- 80 milliliters (ml), 12 microgram (mcg) Fentanyl patches (a pain medication)- 4 in open box, morphine extended release (MS ER) 15 milligrams (mg) tablets- 30 tablets, MS ER 15 mg tablets- 30 tablets, Fentanyl 12 mcg patch- 2, Fentanyl 25 mcg patch- 13, lorazepam (an antianxiety medication) 0.5 mg- 30 tablets, methadone (a pain medication) 10 mg tabs- 30 tablets, Ativan (an antianxiety medication) 1 mg tablets- 30 tablets, Norco (a pain medication) 5/325 mg tablets- 30, Ativan 0.5 mg- 30 tablets, Ativan 0.5 mg- 30 tablets,  Ativan 0.5 mg- 15 tablets,  Ativan 0.5 mg- 30 tablets, Ativan 0.5 mg- 60 tablets, Ativan Solution 2 mg/ml- 30 ml,  a medication with strength only of 100 mg/ 5 ml- 30ml.b. This inventory sheet included the notation "*all above medications wasted in presence of 2 RN's" and was signed and dated 4/23/25 by Staff-JJ and Staff-KK. E.  Review of Patient 12’s clinical records revealed:1. The patient died on 4/21/25.2.  A Skilled Nursing Visit Note, by Staff-LL, dated 4/21/25. The nurse documented in the note that controlled medications were disposed of by the registered nurse (RN). The documentation revealed the medications were disposed of in kitty litter and co-signed by the patient’s spouse.3. An Endless Journey Medication Disposal Log, with signature by Staff-LL and the patient’s spouse, dated 4/21/25. The log listed the patient's medications by name, strength, and amount for each medication (the form had an arrow from the top to the bottom of the patient's medication list indicating all medications on the form were destroyed in the patient's home). The medication list contained 3 starred items: *Fentanyl (a narcotic pain medication) 12 microgram patches in the quantity of 4 patches, *morphine sulfate 15 milligram extended-release tabs in the quantity of 15 tablets, and *morphine sulfate 15 milligram extended-release tabs in the quantity of 15 tablets with a notation showing a total of 30 morphine sulfate tablets. F.  During an interview on 6/26/25 at 9:35 AM, Staff-LL clarified that the 3 starred items, listed on Patient 12’s Endless Journey Medication Disposal Log, with signature by Staff-LL and the patient’s spouse, dated 4/21/25, were medications that were returned to the hospice office and were not destroyed in the patient’s home. There was no documentation on Staff LL's visit note that these 3 starred medications were returned to the hospice office. G.  Review of Patient 13’s clinical record revealed:1. The patient died on 3/18/25.2.  A Skilled Nursing Visit Note, by nurse, Staff-M, dated 3/18/25. The nurse’s documentation on this note included, under the section titled:a.  Disposal of controlled medications, "Instructions were provided regarding mail-back programs, take-back events, collection receptacle."b. Other, "Facility dispose of drugs per policy. Facility to dispose of used controlled substances per policy, unused/unopened to be returned to the hospice."3. The specific unused/unopened medications that were returned to the hospice were not documented. H.  During an interview on 6/9/25 at 12:35 PM, Staff-M confirmed unused/unopened medications from Patient 13 were returned to the hospice office without being destroyed in the patient’s home on 3/18/25.I.  During an interview on 7/1/25 at 10:30 AM, the Administrator (Staff-A) confirmed medications for Patient 12 and Patient 13 were not properly destroyed in the patient’s home and were returned to the hospice office, and documentation was not a complete/accurate account of the medication destruction. The Administrator also confirmed the hospice did not have clear and concise policies and procedures which clearly delineated the process for nurses to follow in the disposal of medications in patient's homes, when patients reside in assisted living facilities (ALF), and when patients reside in long term care (LTC) facilities.