Every finding on record at Eternal Hope Hospice

Based on clinical record review and staff interview, it was determined the interdisciplinary group failed to ensure that the initial comprehensive assessment was completed within 5 days of admission for one (1) of fourteen (14) patients sampled (P#13). The Finding include: 1.Review of the clinical record for P#13, admitted on 4/11/22, diagnosed with congestive heart failure, respiratory with hypoxia, anxiety, pneumonitis, and coronary artery disease, revealed that the initial spiritual assessment was not done due to their chaplain being sick and the agency having only one chaplain. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 2.During an interview on 5/26/22 at 3:30 p.m., the Administrator stated that the chaplain was admitted in the hospital during that time, and that the agency only had one chaplain. The Administrator confirmed that all available documentation for the patient's record was provided at that time.

Based on clinical record review and staff interview, it was determined that the agency failed to ensure that the bereavement plan of care was developed for the individual needs of the bereaved in two (2) of fourteen (14) sampled patients (P#13 and P#14). Findings include: 1. Documentation in clinical record for P#13 reflected the patient's death was on 4/14/22. Review of the bereavement record revealed that the record lacked an individualized bereavement plan of care, and bereavement initial assessment. 2. Documentation in clinical record for P#14 reflected the patient's death was on 5/11/22. Review of the bereavement record revealed that the record lacked an individualized bereavement plan of care but included an initial assessment. 3.In an interview at the agency location on 5/26/22 at 3:50 p.m., the bereavement coordinator and Administrator stated that chaplain was admitted to the hospital, and there was no backup chaplain to conduct the individual bereavement plan of care.

Based on clinical record review and staff interview, it was determined that the agency failed to obtain physician orders for home health aide to visit patients for two (2) of fourteen (14) sampled patients (P#4 and P#6). The Findings include: 1. Patient #4 was admitted to hospice on 1/11/22, with a diagnosis of senile degeneration of brain, adult to thrive, and hypoxemia. Review of the initial Skilled Nurse (SN) assessment and plan of care (POC) dated 1/11/22, revealed that Certified Nursing Assistant (CNA) should visit P#4 three times a week; it was increased to five times a week, but the Registered Nurse (RN) BB did not obtain physician's order. 2. Patient #6 was admitted to hospice on 4/14/22, with a diagnosis of cerebral infraction and essential primary hypertension. Review of the initial Skilled Nurse (SN) assessment and plan of care (POC) dated 4/14/22, revealed that Certified Nursing Assistant (CNA) should visit P#6 five times a week; it was decreased to three times a week, but the Registered Nurse (RN) CC did not obtain physician's order. 3.During an interview on 5/26/22, at 3:10 p.m., the Director of Nursing (DON) confirmed that the agency did not have physician orders for the aides' visits listed above.

Based on record review and staff interview, it was determined that the agency failed to provide drugs and biologicals related to the management and palliation of the terminal illness and related conditions identified on the patient's hospice plan of care. The agency failed to provide the needed medications related to the co-morbidities in four (4) of fourteen (14) sampled patients (P#2, P#3, P#9 and P#12). The Findings include: 1. Clinical records for P#2 were reviewed for certification date 5/17/22 to 8/15/22. Per the patient's plan of care, the patient was admitted to hospice services on 5/18/22, with a primary diagnosis of malignant neoplasm bronchus or lungs with the following co- morbidities: Malignant pleural effusion and hypertension. The record showed the agency was not providing coverage for payment for the following medication used to manage the co-morbidities: metoprolol tartrate, to manage hypertension. 2. Clinical records for P#3 were reviewed for certification date 5/20/22 to 8/17/22. Per the patient's plan of care, the patient was admitted to hospice services on 5/20/22, with a primary diagnosis of malignant neoplasm of female breast with the following co- morbidities: Deep Vein Thrombosis (DVT), and Osteopenia. The record showed the agency was not providing coverage for payment for the following medication used to manage the co-morbidities: Eliquis (Anticoagulant), to manage deep vein thrombosis. 3. Clinical records for P#9 were reviewed for certification date 5/2/22 to 6/30/22. Per the patient's plan of care, the patient was admitted to hospice services on 11/3/21 with a primary diagnosis of malignant neoplasm of colon, with the following co morbidities: Hypertension, and congestive heart failure. The record showed the agency was not providing coverage for payment for the following medications used to manage the co- morbidities: Lisinopril, metoprolol, hydralazine and isosorbide, to manage hypertension and congestive heart failure. 4. Clinical records for P#12 were reviewed for certification date 5/6/22 to 8/3/22. Per the patient's plan of care, the patient was admitted to hospice services on 5/6/22, with a primary diagnosis of malignant neoplasm colon with the following co-morbidities: Malignant neoplasm of liver, lungs and pancreas. The record showed the agency was not providing coverage for payment for the following medication used to manage the co- morbidities: megestrol appetite stimulant, to manage diagnosis. 5.On 5/26/22 at 2:38 p.m., an interview was conducted with the Administrator and Director of Nursing (DON). Both stated they were unaware that it was a requirement to pay for medications related to listed co-morbidities on the patient's plan of care.

Based on observation, clinical record reviews and staff interviews, it was determined that the hospice agency failed to destroy expired medications in the inpatient unit (IPU) medication cart one (1) of one (1) medication cart. The Findings include: 1.During an observation on 5/25/22, at approximately 11:30 a.m., with Registered Nurse (RN) AA, the surveyor observed that expired medications located in the medication storage room in the medication cart were mixed with patients' current medications. 2.Observation of the medications inside the medication room revealed the following expired medications: 3.Dulcolax 10 milligrams (MG) suppository, a medication used to treat constipation, expired 6/20/20, twelve suppositories. 4.Biscodyl 10 mg suppository, a medication used to treat constipation, expired 2/20/21, nineteen suppositories. 5,Tuberculin 5 TU/0.1 milliliter (ML), a medication used to detect Tuberculosis, one bottle opened undated and pharmacy tag instructions was to discard 30 days after opening bottle. 6.On 5/25/22 at 12:00 p.m., an interview was conducted with (RN) AA, who stated that she was unaware of expired dulcolax suppositories, and of the undated opened Tuberculin solution found in the medication cart in the medication room.