Every finding on record at Epic Hospice Care LLC

Based on record review and interview, the hospice agency failed to ensure the right of a patient to receive effective pain management and symptom control for conditions related to the terminal illness, in that Patient #4 received ineffective pain management when Patient #4's pain levels scaled 7-8, on a pain scale 0-10, at the last three skilled nursing visits and constipation for 1 (Patient #4) of 2 patient records reviewed where the patients lived in their homes. The failure resulted in Patient #4 having increased pain. --- Patient #4: Record review of Patient #4's clinical record revealed a Plan of Care dated 7/29/2023 to 10/26/2023. The Plan of Care indicated that Patient #4 started on the agency's services on 4/30/2023. The Plan of Care listed Malignant Neoplasm of Unspecified site of Unspecified Female Breast (breast cancer- aggressive, abnormal, uncontrolled growth of cells in the breast tissue which could spread to other parts of the body) as the terminal diagnosis. The Plan of Care listed Hydromorphone (used to treat moderate to severe pain) 4 milligrams every three hours by mouth as needed and Morphine (used to treat moderate to severe pain) concentrate 20 milligrams/milliliter as needed for pain/shortness of breath- frequency not listed as pain medications. The Plan of Care contained an order for skilled nurse visits once each week for 13 weeks.  Registered Nurse C conducted telephone or telehealth visits on 9/1/23, 9/7/2023, 9/12/2023, and 9/18/2023. Registered Nurse C documented on 9/18/2023 that Patient #4 rated pain as an 8/10 pain scale; advised Patient #4 to use the as needed Hydromorphone liquid, Patient #4 voiced being hesitant to use due to making Patient #4 sleep all day; Patient #4's last bowel movement was on 9/11/2023; and Patient #4 requested an increase in pain medications to Oxycodone IR(immediate release- fast acting) (used to treat moderate to severe pain) three times each day; and Patient #4 continued to have nausea (sensation that contents of the stomach were going to empty out through the mouth). Registered Nurse C documented receiving orders for Patient #4 to take Oxycodone ER (extended release) (used to treat severe pain) twice a day. Registered Nurse C and Nurse Practitioner D conducted a joint visit on 9/27/2023, 9 days after Patient #4 reported a pain level of 8 on a 0-10 pain scale, and no bowel movement in 7 days. Nurse Practitioner D documented on 9/27/2023, that Patient #4 reported uncontrolled pain, nausea with vomiting (expulsion of stomach contents from the stomach through the mouth); new order to stop "Oxy ER"(Oxycodone extended release); add Fentanyl (50 to 100 times stronger than Morphine, used to treat severe chronic pain) 50 micrograms every 3 days, take "Oxy IR" (Oxycodone Immediate Release) twice a day as needed and to continue with Dilaudid as needed for pain; Zofran (used to treat nausea and vomiting) was administered by Registered Nurse C; Patient #4 reported not having a bowel movement for a few days; Patient #4 had distended left upper quadrant and left lower quadrant of the abdomen, had hypoactive bowel sounds and absent bowel sounds to left lower quadrant of the abdomen; refilled suppositories (used for constipation); ordered Lactulose (used to treat constipation); and fleets enema (laxative) administered by Registered Nurse C. Registered Nurse C documented on 9/27/2023, that Patient #4 scaled pain as 8/10; had a bowel movement on 9/26/2023; Fleets enema administered, Patient #4 had small hard bowel movement after fleets enema; Patient #4 reported taking Oxycodone ER (extended release) (used to treat pain) and Oxycodone IR (Immediate release) (used to treat pain) due to pain being severe; compliancy issues with pain medications by Patient #4; new orders for Fentanyl 50 micrograms per hour, change every 3 days, begin Senna (Laxative) twice a day, discontinue Miralax (laxative), Oxycodone ER (extended release) (used to treat pain) , Oxycodone IR (Immediate Release) (used to treat pain).  Registered Nurse E conducted a skilled nurse visit on 10/5/2023, 8 days after Patient #4 reported pain as 8 on a pain scale 0-10, had abnormal bowel sounds, and bowel movements. Registered Nurse E documented on 10/5/2023 that Patient #4 scaled pain as 8/10; was vomiting; complained of constipation- family reported last bowel movement was on 9/29/23.  Registered Nurse C documented a discharge note on 10/6/2026. Registered Nurse C documented that Patient #4 was a live discharge. Patient #4 went to the hospital.  During an interview on 6/6/2026 at 4:27 PM with Patient #4's Family Member 1 and Family Member 2. The Surveyor asked what had transpired with the hospice and Patient #4. Family Member 1 informed the surveyor that the hospice nurse was not coming to the home. Family Member 1 informed the Surveyor that the home had cameras and that was how Patient #4's family knew the hospice nurse was not coming. Family Member 1 informed the Surveyor that the nurse was doing visits by phone. Family Member 1 stated, "(Patient #4) was getting worse and had terrible pain." Family Member 1 informed the Surveyor that Family Member 3 and Family Member 4 took Patient #4 to the hospital. Family Member 2 informed the Surveyor that Patient #4 was in severe pain. Family Member 1 informed the Surveyor that Patient #4's family called Registered Nurse C because they wanted Registered Nurse C to come see Patient #4. Family Member 1 stated, "(Registered Nurse C) started tripping out." Family Member 1 informed the Surveyor that Registered Nurse C had decided to do phone visits, not Patient #4. Family Member 1 stated, "I asked (Patient #4) why the nurse was doing phone visits." Family Member #1 informed the surveyor that (Patient #4) had told Family Member 1 that Patient #4 did not know why, that Registered Nurse C had set Patient #4 up for phone visits.  During an interview on 6/10/2026 at 12:15 PM with the Administrator, Alternate Supervising Nurse, and the Alternate Administrator, the Surveyor discussed Patient #4, phone visits, pain, and bowel movements. The Surveyor asked the Alternate Supervising Nurse what the agency's expectation would be for a nurse to follow-up with a patient when the patient had elevated pain levels and no bowel movement in a week. The Alternate Supervising Nurse stated, "Within 24 hours." The Surveyor asked what the agency's expectation would be for a nurse to follow-up with a patient when the patient had elevated pain level and no bowel sounds in left abdominal quadrant. The Alternate Supervising Nurse stated, "Within 24 hours."  The Alternate Supervising Nurse could not say why Registered Nurse C did not follow-up in an in-person visit with Patient #4. The Alternate Supervising Nurse stated, "I was not in this position (Alternate Supervising Nurse position)." (The agency was in process of hiring a new alternate supervising nurse and would be moving the Alternate Supervising Nurse into the role of Supervising Nurse). The surveyor asked if Registered Nurse C worked at the hospice. The Alternate Supervising Nurse and Administrator informed the Surveyor that Registered Nurse C no longer worked at the hospice.  The Surveyor attempted to contact Registered Nurse C on 6/11/2026 at 4:08 PM. Registered Nurse C did not answer the phone and the Surveyor was unable to leave a message. Review of the agency's policy titled "Patient Rights and Responsibilities RI.10," last reviewed on 10/2/2021, read in part; "Purpose To ensure the patient, their representative (if any), and the Hospice staff acknowledge, protect, observe, and implement the patient's rights and responsibilities...Policy...Procedure I. The Hospice staff will be responsible for knowing, observing, and implementing the patient's rights and patient responsibilities on an ongoing basis, The staff will also be responsible for protecting and promoting these rights...IX. Regarding patient's rights, the patient has a right to the following: A. To receive effective pain management and symptom control from the Hospice for conditions related to the terminal illness..." Review of the agency's policy titled "Pain and Symptom Management PC.135," last reviewed on 9/1/2024 read in part; "Purpose To establish a process with guidelines for pain and symptom assessment, reassessment, prevention and management in order to respond appropriately and timely to the patient's pain and symptoms. Policy I. The Hospice staff are committed to pain and symptoms prevention and management and will respond quickly to provide effective management. II. The Hospice will respect the patient's right to receive effective pain management and symptom control for conditions related to the terminal illness. III. The Hospice will educate direct patient care staff and the patient regarding pain assessment, reassessment, prevention, and management...Procedure...VI. When pain is assessed to be at a level greater than the patient's goal, the patient will be reassessed within a timely manner following this pain intervention...IX. When medication changes occur in relation to pain and symptom management, timely follow up by the nurse will be made to determine the effectiveness of those changes..."

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 20 (10%) clinical records with hospice aide services reviewed revealed that the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s plan of care. Clinical Record 1: The Aide Care Plan dated 02/23/2023 revealed ambulatory with assistance every visit, apply barrier cream every visit, apply deodorant every visit, apply lotion to all extremities every visit. assist to the bathroom every visit, assist with dressing, every visit, change linens every visit, clean nails every visit, comb or brush hair every visit, document last BM every visit notify RN if no BM in 3 days or longer, foot care every visit, full infection control precautions for COVID-19 required every visit, make bed every visit, mouth care with oral swab every visit, partial bed bath two times weekly, perineal care every visit, shower with chair three times a week, and wash hair two times weekly. The Aide Regular Visit note dated 03/06/2023 documented, "clean nails every visit refused and mouth care with oral swab every visit refused." The Aide Regular Visit dated 03/21/2023 documented, "mouth care with oral swab, refused, "refused to let me oral swab... mouth; and shower with chair three times weekly, refused, refused shower but... was able to get a bed bath." The Aide Care Plan dated 06/28/2024 revealed apply barrier cream every visit, apply deodorant every visit, apply lotion to all extremities every visit, assist with dressing every visit, bed bath three times a week, change linens every visit, clean nails every visit, comb or brush hair every visit, document last BM every visit notify RN if no BM in 3 days or longer, make bed every visit, partial bed bath three times weekly, perineal care every visit, and wash hair two times weekly. The Aide Regular Visit notes dated 07/08/2024 and 07/09/2024 documented change linens every visit, not performed, "no clean clothes, linens, towels available all dirty." There was no documented evidence that the registered nurse was notified of changes to the plan of care. Clinical Record 3: The Aide Care Plan dated 05/28/2024 revealed ambulatory with assistance every visit, apply deodorant every visit, apply lotion to all extremities every visit, assist to the bathroom every visit, assist with dressing every visit, brush teeth every visit, change linens every visit, clean nails every visit, comb or brush hair every visit, document last BM every visit notify RN if no BM in 3 days or longer, dress patient every visit, file nails every visit, full Infection Control Precautions for COVID-19 required every visit, make bed every visit, may remove oxygen during bath/shower and replace every visit, shower every visit, and take out trash every visit. The Aide Regular Visit note dated 5/31/2024 documented, "ambulatory with assistance refused, apply deodorant refused, apply lotion to all extremities refused, assist to bathroom refused, assist with dressing refused, brush teeth refused, change linens refused, clean nails refused, comb or brush hair refused, document last BM refused, dress patient refused, file nails refused, full Infection Control Precautions for COVID-19 required every visit refused, may remove oxygen during bath/shower and replace refused, and shower refused." The Aide Regular Visit note dated 06/03/2024 documented, "ambulatory with assistance refused, apply deodorant refused, apply lotion to all extremities refused, assist to bathroom refused, assist with dressing refused, brush teeth refused, clean nails refused, comb or brush hair refused, document last BM refused, dress patient refused, file nails refused, may remove oxygen during bath/shower and replace refused, and shower refused." The Aide Regular Visit note dated 06/04/2024 documented, "ambulatory with assistance refused, assist to bathroom refused, assist with dressing refused, brush teeth refused, clean nails refused, document last BM refused, dress patient refused, may remove oxygen during bath/shower and replace refused, and shower refused." There was no documented evidence that the registered nurse was notified of changes to the plan of care. During a joint clinical record review and interview on 09/19/2024, the Director of Nursing confirmed that the hospice aide documentation lacked notification to the registered nurse of the changes in plan of care.

It is required the drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. THIS IS A FORMER REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 6 (17%) clinical records reviewed, it was revealed that an over-the-counter medication was not documented on the patient's medication profile. The agency's policy, "PC.17 Medication List and Monitoring", stated in part: "The Hospice will maintain a current, accurate Medication Profile of all prescription and over-the-counter (OTC) medications taken by the patient." Clinical Record 1 - In the summary note of the initial comprehensive assessment dated 7/18/2022, it was documented by the RN that the patient was taking "Ibuprofen 200mg (15ml) by mouth as needed for left hip pain". Review of patient's medication profile revealed there was no documented evidence that the medication was added to the profile and included in the review of the patient's medication regimen. In an interview with the Director of Nursing she stated that it is the policy of the agency that over-the-counter medications be added to the medication profiles and that she was unable to locate this medication in the patient's record. Agency policy PC.17 Medication List and Monitoring states in part, "The Hospice will maintain a current, accurate Medication Profile of all prescription and over-the-counter (OTC) medications taken by the patient." In an interview with the Director of Nursing she stated that it is the policy of the agency that over-the-counter medications be added to the medication profiles and that she was unable to locate this medication in the patient's record.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management; and the patient’s current plan of care. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 3 (33%) applicable clinical records reviewed it was revealed that the hospice did not provide a complete discharge summary to the receiving hospice that would be continuing the patient's care. Agency policy, "PE.4 Patient Discharge", stated in part: "The hospice will follow accrediting standards, federal, state and local regulations related to patient discharge... The hospice will forward copies of the following to the patient's Attending Physician upon discharge, a summary of the patient's plan of care (pain management, symptoms and treatments); The patient's current plan of care, latest physician orders, and any other documentation requested or that may assist with the patient's continuity of care." Clinical Record 4 - The patient was admitted to hospice on 5/19/2022 and transferred to another hospice on 6/10/2022. Review of the clinical record revealed the discharge summary was incomplete and did not include documentation of the patient's summary of care and current plan of care, and there was no evidence to confirm a copy of the summary document was sent to the receiving hospice. A series of emails were presented for review, that were not filed in the clinical record, that confirmed a verbal exchange of information between the hospices occurred, however there was no specific information included in the email documentation that described the actual content of the information shared. In an interview with the Director of Nursing she stated they are still learning and had just recently discovered how to correctly complete discharge summaries and notes in the electronic medical record. Also, a performance improvement program had been initiated by the agency in November 2022 to address this discharge summary issue that was self-identified. Agency policy PE.4 Patient Discharge states in part, "The hospice will follow accrediting standards, federal, state and local regulations related to patient discharge." The policy also states in part, " The hospice will forward copies of the following to the patient's Attending Physician upon discharge, a summary of the patient's plan of care (pain management, symptoms and treatments); The patient's current plan of care, latest physician orders, and any other documentation requested or that may assist with the patient's continuity of care. In an interview with the Director of Nursing she stated that they are still learning and had just recently discovered how to do correct discharge summaries and notes in the electronic medical record. A performance improvement was initiated in November for this finding.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) clinical records revealed that the comprehensive assessment was not completed within 5 calendar days after the patient elected the hospice benefit. Record #11864 was reviewed and identified that the patient elected hospice care on 9/8/21. The social worker completed the comprehensive social work assessment on 9/29/21, 21 days after the election of hospice care. There was no documented explanation for the reason for the delay. During an interview on 12/1/21, the administrator confirmed the social work assessment was not completed within 5 days. She stated there was not any additional information to provide.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies or other alternative treatments that could affect drug therapy. The medication review process includes the identification of drug therapy associated with laboratory monitoring. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview and observation. 3 of 11 (27%) records reviewed revealed that the medication lists failed to include all medications ordered and failed to include potential side effects. Record #11864 was reviewed and identified the patient elected hospice care on 9/8/21: the patient had twenty-four medications Ferrous Sulfate, Pantoprazole, Montelukast, Famotidine, Citalopram, Carbidopa/Levodopa, Vitamin D, Carbamazepine, Bupropion, Alendronate, Tylenol, Hydromorphone, Senna S, Xanax, Promethazine Colace, Restoril, Gabapentin, Haloperidol, B-12, Pramipexole, Furosemide and Spironolactone) and only two medications (Carbidopa/Levodopa and Gabapentin) were present on the medication profile. In the recert assessment completed on 10/26/21 that the nurse documented that the patient "takes PRN pain medication less than daily for pain". The patient had Liquid Hydromorphone in the home, however the medication was not present on the medication profile, Record #73689 was reviewed and identified the patient elected hospice care on 9/8/21. The initial assessment included that pain is controlled with Tylenol, Gabapentin and Tylenol with Codeine.Tylenol was not on the medication profile. Record #83353 was reviewed and identified the patient elected hospice care on 10/19/21. The medication profile lacked evidence the patient was on Coumadin. The RN identified "Anticoagulant" as a safety concern on the plan of care, the plan of care lacked evidence of monitoring the patients PT/INR. The administrator was interviewed on 12/1/21 and confirmed that the medication list failed to include all current medications, med reviews and were not included on the plans of care/medication profiles.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. 2 of 11 (18%) of clinical records revealed patients did not receive an initial bereavement assessment. There was no documented evidence as to why the initial bereavement assessments were not completed. Record #11864 was reviewed and identified the patient elected hospice care on 9/8/21. The clinical record did not contain an initial bereavement assessment. Initial and ongoing assessmnets lacked evidence that bereavement needs were met. . Record #14019 was reviewed and identified the patient elected hospice care on 9/8/21. The clinical record did not contain an initial bereavement assessment. Initial and ongoing assessmnets lacked evidence that bereavement needs were met. The administrator was interviewed on 12/1/21, and stated there were no initial bereavement assessments within the records identified nor was there any additional information to provide.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) clinical records involving bereavement revealed that bereavement services were provided without a bereavement care plan. Record # 60376 was reviewed and identified date of death on 2/20/21. There was no documented evidence of a bereavement care plan. Bereavement services were initiated after the patients death. The clinical record lacked evidence that bereavement support had been implemented during the initial, or comprehensive assessments. During an interview on 12/2/21, the administrator and bereavement coordinator confirmed there was no initial bereavement plan of care documented in the records. Interview with the Bereavement Coordinator revealed that all calls and mailings had been completed, but there was no established bereavement plan of care.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review and interview. 1 of 2 (50%) records of discharged patients revealed no documentation that a discharge summary was sent to the attending physician when discharged. Record #40737 was reviewed and identified the patient was discharged on 6/14/21. The clinical record did not contain documentation that a discharge summary was sent to the attending. During an interview on 12/1/21, the administrator confirmed there was not evidence the discharge summary had been provided to the attending.

It is required that the hospice designates a member of each Interdisciplinary Group who is responsible for a patient/resident in a SNF/NF or ICF/IDF. The designated IDG member provides overall coordination of care of the patient/resident, working with the facility staff; with facility staff and others providing care for the terminal illness and related conditions; and is responsible to ensure the quality of care for the patient and family. This standard was not met as evidenced by clinical record review, and interview. 1 of 11 (9%) of clinical records revealed that coordination did not occur with SNF team. Record #73689 was reviewed and identified the patient elected hospice care on 9/8/21. The clinical record did not contain evidence of collaboration with the SNF up to the time of this review on 12/2/21. The administrator was interviewed on 12/1/21 and confirmed that coordination of patient care is not documented in the clinical record.