Every finding on record at Fortitude Hospice, Inc

Based on observation, interview, and record review, the Hospice agency (HA, agency providing care to the terminally ill patients who have six months or less to live) failed to ensure that the Conditions of Participation ( condition that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) regarding Initial and Comprehensive Assessment ( an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to terminal illness that must be address in order to promote the hospice patients wellbeing, comfort, and dignity throughout the dying process of Patients was met as follows: --- 1. The HA failed to conduct a comprehensive assessment, that reflected the patient's current health status, for two of fourteen sampled patients (Patient 9, and Patient 10). For Patient 9 & 10, the HA did not conduct a pain assessment that included symptoms of pain and the effectiveness of the intervention and current medication. This deficient practice had the potential for Patient 9 and Patient 10 to endure pain. (Refer to L524). 2. The HA failed to monitor and ensure the medication Norco (drug used to relieve moderate to severe pain) was presence and available for Patient 9 at the skilled nursing facility were he resided and to ensure it was available and used for pain management and assess for the potential side effects (a secondary, typically undesirable effect of a drug or medical treatment) for the use of psychotropic medications (any drug that affects the mental function, behavior, and mood) for two of five sampled patients (Patient 9 and Patient 11). Refer to L530. The cumulative effect of this systemic practices resulted in the failure of the hospice to deliver statutorily mandated (State law) compliance with the Federal regulations for Initial & Comprehensive Assessment of Patients to ensure the highest quality of care is being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview and record review, HA failed to conduct an accurate comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to terminal illness that must be address in order to promote the hospice patient's wellbeing, comfort, and dignity throughout the dying process), that reflected the patient's current health status, for two of fourteen sampled patients (Patient 9, and Patient 10). For Patient 9 and Patient 10, the HA did not conduct pain assessment that included symptoms of pain and the effectiveness of the intervention and current medication. This deficient practice has the potential to result in Patient 9 and Patient 10s lack of relief from pain management that could cause the patient experience discomfort --- A record review of Patient 9's "Patient Information" indicated the patient was admitted for hospice care on 10/25/2023. The diagnoses included terminal diagnosis of Atherosclerosis heart disease of native coronary artery ( a thickening/hardening of arteries caused by the buildup of plaque in the inner lining of the artery), and Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with late onset. A record review of Patient 9s care plan "Pain," dated 1/3/2024, indicated the patient has acute pain related to terminal illness and disease process as evidenced by verbal report of pain, facial grimacing, guarding behavior, and altered medication-related to pain. The care plan goal indicated patient will report and demonstrate a reduction in pain or relief from pain after taking Tylenol ( drug , use to treat minor aches and pain) and will not show signs of medication-related complications and to be re-evaluated on the next Interdisciplinary Group Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the hospice beneficiary) meeting. The care plan interventions indicated, to assess and monitor pain and severity every visit, instruct family/caregiver and assess non-verbal (not using words) signs of pain such as moaning, restlessness and body language indicative (likely to happen) of pain. Teach the caregiver on immediate use, efficacy (desired results) and precautions on prescribed medications. Monitor and assess effectiveness of current medications. A record review of Patient 9s physician's order dated 10/25/2023, indicated to give Tylenol 325 milligram( mg, unit of measurement) tablet 2 tablets (650 mg) oral every 4 hours as needed for mild pain.( a pain scale from 1-3), Norco (narcotic-combination of hydrocodone [opioid/acetaminophen], used for moderate pain) 5-325 milligram (mg, unit of measurement) 1 tablet by mouth every 6 hours as needed for pain.( a pain scale from 4-6) , an to give Morphine Sulfate Concentrated Solution ( drug use to treat moderate to severe pain) 20MG/ML( mg/ml unit of measurement) 0.25 ml sublingual ( under the tongue0 every 2 hours as needed for severe pain.( pain scale of 7-10 or respiratory distress). A joint home visit was conducted on 1/3/2024, at 10:45 a.m., with the Licensed Vocational Nurse 2 (LVN2) at the skilled nursing facility (SNF) where Patient 9 resided. LVN 2 stated this was his first time at this SNF and he was not Patient 9 s regular visiting nurse. During an observation, Patient 9's both eyes were closed, she was lying flat on her back, calm, and not in distress. LVN 2 initiated nursing care to Patient 9, and the patient was observed with contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) on right arm and both legs. During an observation and interview, Patient 9 started moaning, with facial grimace when LVN 2 started to provided care. LVN 2 stated, Patient 9's body severely contracts when tried to get the patient's vital signs. Patient 9 remained moaning, while LVN 2 conducted head to toe assessment, and LVN2 was able to take Patient 9s blood pressure which read 149 (systolic-pressure heat beats)/66 (diastolic-pressure heart at rest) mmhg. ( mmhg unit measurement.) During an concurrent interview and medication review on 1/3/2024, at 11:25 a.m.,, Patient 9s Caregiver, stated the patient will start moaning and will severely contract her arms and legs when in pain. The Caregiver stated, she gave Patient 9 Tylenol 650 mg suppository in the morning when the bathing nurse arrived to give the patient a bed bath. The Caregiver also stated that Patient 9 was non-verbal and mostly moans and mumbles when repositioned or touched. Caregiver stated she gave Tylenol for his pain. During a continued review of Patient 9s medication with the caregiver at the nurses station with the HAs medication profile and the SNFs Medication Administration Record (MAR), both listed the Morphine sulfate concentrated to be used as needed for severe pain and the Norco to be used for moderate pain. During an interview on 1/3/2024 at 11:30a.m. the caregiver stated she was not aware of the Norco, and it was not listed in the SNFs MAR, and no one has given Patient 9 his Morphine that was observed in the facilities medication cart. However, LVN 2 reviewed with the Patient 9s caregiver the Norco and Morphine which were both ordered by the physician at the start of care date of 10/25/2023 A review of Patient 9's ";Visit Note LVN" dated 12/19/2023,12/25/2023, 12/29/2023, , and ";Visit Note RN" dated 9/18/2023, under the pain assessment questionnaire: Is pain level controlled, the reply was ";Yes", with all having a pain level of ";3". However, there was no pain assessment completed by the skilled nurse that included characteristic of pain, treatment both pharmacological/nonpharmacological, and pain re-assessment. A record review of Patient 10's "Patient Information" indicated the patient was admitted for hospice care on 12/9/2023. The diagnoses included terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with late onset. A record review of Patient 10 s care plan "Pain," dated 1/2/2024, indicated the patient has chronic pain related to underlying terminal illness and other. disease process with PRN (as needed) Acetaminophen as part of her comfort kit., guarding. The care plan goal indicated patient will report/exhibit effective pain management, with pain levels maintained at a tolerable level to provide maximal comfort during hospice care. The care plan interventions indicated, to regularly asses pain using appropriate scales, and observe for non-verbal signs of pain, especially in patients with communication difficulties. Provide acetaminophen suppository as per the patients pain and as prescribed. Reinforce teachings to patients and family members about pain assessment, proper administration of medications, and signs to report to healthcare team. Work closely with the interdisciplinary hospice team, including the physicians, for ongoing pain management assessment and potential adjustments in the pain management. A record review of Patient 10s physician's order dated 12/9/2023, indicated to give Acetaminophen 650 mg suppository 1 suppository rectal every 4 hours as needed for mild pain.( a pain scale from 1-3), an to give Morphine Sulfate Concentrated Solution 20MG/ML( mg/ml unit of measurement) 0.25 ml sublingual ( under the tongue every 2 hours as needed for severe pain.( pain scale of 7-10 or respiratory distress) A joint home visit was conducted on 1/3/2024, at 12:00 p.m., with the Licensed Vocational Nurse 2 (LVN2) at the skilled nursing facility (SNF) where Patient 10 resided. LVN 2 stated this was his first time at this SNF and he was not patient 10 s regular visiting nurse. During an concurrent interview and medication review on 1/3/2024, at 11:45 a.m., , Patient 10s Caregiver, stated the patient will start moaning when touched or moved. The caregiver stated, she give Patient Acetaminophen 650 mg suppository for pain however patient ran out of the acetaminophen a few days ago. During a review of patient 10s medication with the caregiver at the nurses station with the HAs medication profile and the SNFs Medication Administration Record (MAR), both listed the Morphine sulfate concentrated to be used as needed for severe pain and the caregiver stated they have never given patient 10 morphine they usually give her Acetaminophen suppository. During an observation, Patient 10 was observed lying flat on her back in her bed, awake , calm, and not in distress. Patient 10 was asked her current pain level in which she stated was at a level of 10 stated. LVN 2 initiated nursing care to patient 10 observed with contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) on left hand and right knee. . During an observation and interview, Patient 10 started moaning, with facial grimace when LVN 2 started to assess and provided care. Patient 10s caregiver stated patient 10 does not liked to be touched or moved. Patient 10 remained moaning, while LVN 2 conducted head to toe assessment, and LVN2 was able to take patient 10s blood pressure which read 148/80 mmhg. ( mmhg unit measurement.) During a concurrent interview and record review on 1/5/2024, at 3:25 p.m., the Administrator/Director of Patient Care Services (ADM./DPCS), the DPCS stated that both the LVN and RN visiting the both patients in the SNF should have evaluated pain interventions, ,the RN and LVN should have assessed non- pharmacological and pharmacological interventions, and reassessed pain level which should be reflected in the nurse's notes. DPCS stated, the nurses should use the Pain Assessment in Advanced Dementia (PAINAD, a tool used to assess pain in older adults who have cognitive impairment) and the (Face, Legs, Activity, Cry, Consolability (FLACC scale, is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain) should be used as pain assessment. The DPCS stated the Norco for patient 9 should have been reviewed and onsite, written in the SNF MAR and available at the SNF During a review of the agency's policy and procedure titled, "Pain Assessment", dated November 2021, indicated all patients will receive pain assessments. The patient will be reassessed every visit for the existence and intensity of pain and the effectiveness of interventions to relieve pain. If the patient is unable to communicate pain using the rating scale, is cognitively impaired or is a child, the clinician will assess behavioral factors that signal pain or discomfort and include this information in the assessment.

Based on observation, interview and record review, the hospice agency failed to ensure all medications were accurate and matched the medication profile for two of 14 sample patients (Patient 9, Patient 11). The deficient practice had the potential to result in patients not receiving medication proscribed by the physician or not receiving the accurate dosage of medication prescribed by the physician. --- A review of Patient 9's electronic medical , indicated the HA admitted Patient 9 was admitted for hospice care on 10/25/2023, with a diagnoses of Atherosclerosis heart disease of native coronary artery ( a thickening/hardening of arteries caused by the buildup of plaque in the inner lining of the artery). A review of Patient 9 's Current Treatment/Medication List dated 8/7/2023, indicated a physician's order to administer Norco (narcotic-combination of hydrocodone [opioid/acetaminophen], used for moderate pain) 5-325 milligram (mg, unit of measurement) 1 tablet by mouth every 6 hours as needed for pain A review of Patient 9 s Plan of Care (POC) dated 1/3/2024, indicated the frequency of the visits for skilled nurse (SN) was twice per week for pain and symptom management, comfort measures. A joint home visit was conducted on 1/3/2024, at 10:45 a.m., with the Licensed Vocational Nurse 2 (LVN2) at the skilled nursing facility (SNF) where Patient 9 resided. LVN 2 stated this was his first time at this SNF and he was not patient 9 s regular visiting nurse. During an observation, Patient 9's both eyes were closed, was lying flat on her back, calm, and not in distress. LVN 2 initiated nursing care to patient 9 observed with contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) on right arm and both legs. During an observation and interview, Patient 9 started moaning, with facial grimace when LVN 2 started to provided care. LVN 2 stated, Patient 9's body severely contracts when tried to get the patient's vital signs. Patient 9 remained moaning, while LVN 2 conducted head to toe assessment, and LVN2 was able to take patient 2s blood pressure which read 149/66 mmhg. ( mmhg unit measurement.) During a telephone interview in the HAs conference room on 1/5/2024, at 3p.m., with LVN 1. He stated he reviews patients medications at the SNF every visit and discussing them with the caregiver. LVN 1 could not explain the reason the caregivers at the SNF did not know about the Norco nor was it listed in the SNFs medication administration record (MAR) or available at the facility for use. During an interview with the Registered Nurse (RN2) via telephone in the HAs conference room on 1/5/2024, at 3:30 p.m., RN 2 stated when she visits the patients at the SNF she reviews all medications from the HAs medication profile with the SNFs MAR. RN 2 could not explain the reason the Norco medication had never been ordered since the start of care date of 10/25/2023, and the reason the SNF staff did not have knowledge or documented evidence of the medication on their MAR. During a concurrent interview and a record review, on 1/5/2024, at 12 p.m., with the Director of Patient Care Services (DPCS), Patient 9's Visit Notes were reviewed, along with the SNFs MAR and the HAs medication profile. The DPCS stated Patient 9's medication should be reviewed every visit by both the LVN and RN. HA unable to provide policy and procedure upon request. B. During a record review of Patient 11s Facesheet, indicated start of care for was 9/2/2022 with a primary diagnosis of Senile degeneration of the brain, not elsewhere classified (a progressive disease that destroys memory and other important mental functions). During a record review of Patient 11's ";Physician Certification for Hospice Benefit" (CTI) certification #8, for the recertification for the next 60 day period from 12/26/2023 to 2/23/2024, indicated a terminal diagnosis of Senile degeneration of the brain. During record review of the Patient 11s ";Current Treatment/Medication/Dme List", the medication list indicated: a. Acetaminophen 500mg/5ml strength and dosage 5ml by mouth every 4 hours as needed for mild pain (pain 1-3) or fever, b. Levsin (medication to dry up excessive oral secretions) 0.125 mg 1 tablet by sublingual (under the tongue) every four hours as needed. During a concurrent observation and interview on 1/3/2024 at 11:30 a.m. with the Registered Nurse 1 (RN 1) in Patient 11s house, the acetaminophen label supplied by the pharmacy indicated Acetaminophen 500mg/15ml strength and dosage 15ml by mouth every 4 hours as needed for mild pain (pain 1-3) or fever. RN 1 stated ";the concentration is different. the one on our order is different than the one that the pharmacy supplied. It should match. I will check with the office and the pharmacy and get this fixed right away." During an interview on 1/3/2024 at 11:40 a.m. with the RN 1, the RN 1 stated, ";Levsin is missing. I will check with the office. Since I'm not the regular nurse for P 11 I'm not sure what happened. It's supposed to be here. It's part of our comfort kit. The nurse is supposed to check the medications on every visit." During an interview with the Patient 11s daughter, she stated, ";I don't know where that medication is. I don't even remember having that medication. Maybe it expired and the other nurse threw it away I'm not sure. I haven't seen it." During an interview on 1/4/2024 at 10:30 a.m. with the DPCS, DPCS stated for Patient 11 , the nurses are supposed to do a medication reconciliation on every visit. She stated the nurse didnt catch the Levsin and the Tylenol concentration discrepancy. During a record review of the Hospice agencies policy and procedure titled, ";Medication Reconciliation", revised November 2021, the policy and procedure indicated ";The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.....2. A drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of new medication."

Based on observation, record review, and interview, the hospice failed to ensure an on-going communication between the HA and the Skilled Nursing Facility (SNF) regarding pain assessment, pain management and the various medications ordered for pain were reviewed and communicated with the staff providing care at the SNF for two pf fourteen sample patients (Patient 9 and Patient 10). This deficient practice resulted in both patients pain not being properly assessed and the medications per the patients pain level not being administered which potential affected their highest level of wellbeing --- A record review of Patient 9's "Patient Information" indicated the patient was admitted for hospice care on 10/25/2023. The diagnoses included terminal diagnosis of Atherosclerosis heart disease of native coronary artery ( a thickening/hardening of arteries caused by the buildup of plaque in the inner lining of the artery), and Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with late onset. A record review of Patient 9s care plan "Pain," dated 1/3/2024, indicated the patient has acute pain related to terminal illness and disease process as evidenced by verbal report of pain, facial grimacing, guarding behavior, and altered medication-related to pain. The care plan goal indicated patient will report/demonstrate a reduction in pain or relief from pain after taking Tylenol and will not show signs of medication-related complications and to be re-evaluated on the next Interdisciplinary Group Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the hospice beneficiary) meeting. The care plan interventions indicated, to assess/monitor pain and severity every visit, instruct family/caregiver and assess non-verbal (not using words) signs of pain such as moaning, restlessness and body language indicative of pain. Teach caregiver on immediate use, efficacy and precautions on prescribed medications. Monitor /assess effectiveness of current medications. A record review of Patient 9s physician's order dated 10/25/2023, indicated to give Tylenol 325 mg tablet 2 tablets (650 mg) oral every 4 hours as needed for mild pain.( a pain scale from 1-3), Norco (narcotic-combination of hydrocodone [opioid/acetaminophen], used for moderate pain) 5-325 milligram (mg, unit of measurement) 1 tablet by mouth every 6 hours as needed for pain.( a pain scale from 4-6) , an to give Morphine Sulfate Concentrated Solution 20MG/ML( mg/ml unit of measurement) 0.25 ml sublingual ( under the tongue0 every 2 hours as needed for severe pain.( pain scale of 7-10 or respiratory distress) A joint home visit was conducted on 1/3/2024, at 10:45 a.m., with the Licensed Vocational Nurse 2 (LVN2) at the skilled nursing facility (SNF) where Patient 9 resided. LVN 2 stated this was his first time at this SNF and he was not patient 9 s regular visiting nurse. During an observation, Patient 9's both eyes were closed, was lying flat on her back, calm, and not in distress. LVN 2 initiated nursing care to patient 9 observed with contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) on right arm and both legs. During an observation and interview, Patient 9 started moaning, with facial grimace when LVN 2 started to provided care. LVN 2 stated, Patient 9's body severely contracts when tried to get the patient's vital signs. Patient 9 remained moaning, while LVN 2 conducted head to toe assessment, and LVN2 was able to take patient 2s blood pressure which read 149/66 mmhg. ( mmhg unit measurement.) During an interview and medication review on 1/3/2024, at 11:25 a.m., (the same date and time) Patient 9s Caregiver, stated patient will start moaning and will severely contract her arms and legs when in pain. Caregiver stated, she gave Patient 9 Tylenol 650 mg suppository in the morning when the bathing nurse arrived to give him a bed bath. The Caregiver also stated that Patient 9 was non-verbal and mostly moans and mumbles when repositioned or touched. Caregiver stated she gave Tylenol for his pain. During a continued review of patient 2s medication with the caregiver at the nurses station with the HAs medication profile and the SNFs Medication Administration Record (MAR), both listed the Morphine sulfate concentrated to be used as needed for severe pain and the Norco to be used for moderate pain. During an interview with the caregiver, she stated she was not aware of the Norco, and it was not listed in the SNFs MAR, and no one has given patient 2 his morphine that was observed in the facilities medication cart. However, LVN 2 reviewed with the patient 2s caregiver the Norco and Morphine which were both ordered by the physician at the start of care date of 10/25/2023 A record review of Patient 9's ";Visit Note LVN" dated 12/19/2023,12/25/2023, 12/29/2023, , and ";Visit Note RN" dated 9/18/2023, under the pain assessment questionnaire: Is pain level controlled, the reply was ";Yes", with all having a pain level of ";3". However, there was no pain assessment completed by the skilled nurse that included characteristic of pain, treatment both pharmacological/nonpharmacological, and pain re-assessment. A record review of Patient 10's "Patient Information" indicated the patient was admitted for hospice care on 12/9/2023. The diagnoses included terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with late onset. A record review of Patient 10 s care plan "Pain," dated 1/2/2024, indicated the patient has chronic pain related to underlying terminal illness and other. disease process with PRN (as needed) Acetaminophen as part of her comfort kit., guarding. The care plan goal indicated patient will report/exhibit effective pain management, with pain levels maintained at a tolerable level to provide maximal comfort during hospice care.The care plan interventions indicated, to regularly asses pain using appropriate scales, and observe for non-verbal signs of pain, especially in patients with communication difficulties. Provide acetaminophen suppository as per the patients pain and as prescribed. Reinforce teachings to patients and family members about pain assessment, proper administration of medications, and signs to report to healthcare team. Work closely with the interdisciplinary hospice team, including the physicians, for ongoing pain management assessment and potential adjustments in the pain management. A record review of Patient 10s physician's order dated 12/9/2023, indicated to give Acetaminophen 650 mg suppository 1 suppository rectal every 4 hours as needed for mild pain.( a pain scale from 1-3), an to give Morphine Sulfate Concentrated Solution 20MG/ML( mg/ml unit of measurement) 0.25 ml sublingual ( under the tongue every 2 hours as needed for severe pain.( pain scale of 7-10 or respiratory distress) A joint home visit was conducted on 1/3/2024, at 12:00 p.m., with the Licensed Vocational Nurse 2 (LVN2) at the skilled nursing facility (SNF) where Patient 10 resided. LVN 2 stated this was his first time at this SNF and he was not patient 10 s regular visiting nurse. During an interview and medication review on 1/3/2024, at 11:45 a.m., (the same date and time) Patient 10s Caregiver, stated patient will start moaning when touched or moved. The caregiver stated, she give Patient Acetaminophen 650 mg suppository for pain however patient ran out of the acetaminophen a few days ago. During a continued review of patient 10s medication with the caregiver at the nurses station with the HAs medication profile and the SNFs Medication Administration Record (MAR), both listed the Morphine sulfate concentrated to be used as needed for severe pain and the caregiver stated they have never given patient 10 morphine they usually give her Acetaminophen suppository. During an observation, Patient 10 was observed lying flat on her back in her bed, awake , calm, and not in distress. Patient 10 was asked her current pain level in which she stated was at a level of 10 stated. LVN 2 initiated nursing care to patient 10 observed with contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) on left hand and right knee. . During an observation and interview, Patient 10 started moaning, with facial grimace when LVN 2 started to assess and provided care. Patient 10s caregiver stated patient 10 does not liked to be touched or moved. Patient 10 remained moaning, while LVN 2 conducted head to toe assessment, and LVN2 was able to take patient 10s blood pressure which read 148/80 mmhg. ( mmhg unit measurement.) During a concurrent interview and record review on 1/5/2024, at 3:25 p.m., the Administrator/Director of Patient Care Services (ADM./DPCS), the DPCS stated that both the LVN and RN visiting the both patients in the SNF should have evaluated pain interventions, ,the RN and LVN should have assessed non- pharmacological and pharmacological interventions, and reassessed pain level which should be reflected in the nurse's notes. DPCS stated, the nurses should use the Pain Assessment in Advanced Dementia (PAINAD, a tool used to assess pain in older adults who have cognitive impairment) and the (Face, Legs, Activity, Cry, Consolability (FLACC scale, is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain) should be used as pain assessment. The DPCS stated the Norco for patient 9 should have been reviewed and onsite, written in the SNF MAR and available at the SNF During a review of the agency's policy and procedure titled, "Pain Assessment", dated November 2021, indicated all patients will receive pain assessments. The patient will be reassessed every visit for the existence and intensity of pain and the effectiveness of interventions to relieve pain. If the patient is unable to communicate pain using the rating scale, is cognitively impaired or is a child, the clinician will assess behavioral factors that signal pain or discomfort and include this information in the assessment.

Based on interview and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for Core Services as follows: --- 1.The HA failed to ensure the Chaplain followed up with patient family request for regular spiritual emotional support visits on a monthly basis for one of fourteen sampled patients (Patient 14). (Refer to L595). 2. The HA failed to ensure two of fourteen sampled patients (Patient 3 and Patient 13) received monthly spiritual counseling assessments as prescribed by the physician to meet Patient's spiritual needs. (Refer to L598). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations to ensure Core Services were provided to all the patients.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Chaplain followed up with patient family request for regular spiritual emotional support visits on a monthly basis for one of fourteen sampled patients (Patient 14). The deficient practice had the potential to result in patients not receiving spiritual and emotional support as necessary to cope with the terminal diagnosis and disease process which could result unmet spiritual needs. --- A review of Patient 14's undated medical record form Patient Information, indicated Patient 14 was admitted to the hospice care on 11/8/2023 with a terminal diagnoses of hypertensive heart disease without heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 14's medical record form "Plan of Care" dated 1/3/2024, "Spiritual" section indicated the issue was created on 11/9/2023 with the goal of healing road to peace through pastoral dialogue. The Plan of Care indicated intervention for the Chaplain to visit Patient 14 initially to provide support spiritual support and encouragement consistent with patients belief system. A review of Patient 14's medical record form "Spiritual Assessment" dated 11/9/2023 and documented by the chaplain, under the narrative section indicated, "The patient welcomed regular visits from the chaplain for spiritual and emotional support. The Chaplain plans to continue once monthly visits as needed in every recertification providing pastoral presence, as well as spiritual and emotional support." There was no other documented evidence in patient's medical record to indicate that the Chaplain revisited Patient 14 once a month for emotional and spiritual support. During a telephone interview with the Chaplain on 1/5/2023 at 3:00 p.m., in the conference room of the Hospice agency, the Chaplain stated that he should have visited the patient more often as documented but he did not. During a concurrent interview and record review of Patient 14s medical record with the Director of Patient Care Services (DPCS) on 1/5/2023 at 3:40 p.m. in the Hospice agencies conference room, the DPCS stated that usually the chaplain only has to visit every recertification period, however, if he documented that the patient requested more visits and he would visit monthly or as needed, then he should have followed up. A review of the HA's policy and procedure, titled, ";Spiritual Care Counseling Services", revised November 2021, the policy and procedure indicated, ";Hospice will provide spiritual care counseling and keeping up with the patients families/caregivers belief system and practice, and in accordance with the plan of care." A review of the HA's policy and procedure titled, ";Spiritual Assessment", revised November 2021, the policy and procedure indicated, ";After the spiritual assessment is performed, ongoing contact will be maintained by phone and or home visits by the hospice chaplain if requested by the patient and family/caregiver and will be included in the comprehensive assessment and the plan of care."

Based on record review and interview, the hospice agency (HA) failed to ensure two of fourteen sampled patients (Patient 3 and Patient 13) received monthly spiritual counseling assessments as prescribed by the physician to meet Patient's spiritual needs. The deficient practice had the potential to result in patients not receiving spiritual and emotional support as necessary to cope with the terminal diagnosis and disease process. --- A. A review of Patient 3s Electronic Medical Record (EMR) form titled Face Sheet, indicated start of care date of 10/22/2023 with a primary diagnosis of Alzheimers disease with late onset (a progressive disease that destroys memory and other important mental functions). A review of Patient 3's electronic medical record form titled ";Physician Certification for Hospice Benefit" (CTI) certification #1, for the first 90 day period from 10/22/2023 to 1/19/2024, indicated a terminal diagnosis of Alzheimers disease with late onset. A review of Patient 3s electronic medical record form titled ";Plan of Care/IDG (Interdisciplinary Group) Review", dated 11/25/2023, indicated Spiritual Counselor (SC) to visit patient every month, as needed and in every recertification to provide patient and family's spiritual needs, issues and concerns and to provide spiritual support. A review of Patient 3s electronic medical record form titled ";Spiritual Assessment", dated 10/24/2023, indicated, ";the daughter expressed a desire for her mother's comfort and requested regular visits from the Chaplain. As a response, the chaplain offered a prayer intervention to help sustain the patient's faith. The caregiver responsible for the patient reported no other issues at this time. The Chaplain of plants to visit the patient once a month and as needed to provide spiritual and emotional support." During a concurrent record review and interview on 1/4/2024 at 12:45 p.m. of Patient 3s electronic medication record, with DPCS, there was only one spiritual assessment dated 10/24/2023. DPCS stated, ";I see only one spiritual assessment in the system. Per doctors orders and the narrative note written by the Chaplain, he was supposed to visit the patient once a month. This was not done." During a phone interview on 1/4/2024 at 3:15 p.m. with the Chaplain, the Chaplain stated, ";I was supposed to see Patient 3 once a month, I havent done that." B. A review of Patient 13s electronic medical record form titled Face Sheet, indicated start of care date on 9/6/2023 with a primary diagnosis of malignant neoplasm of rectum (disease in which cancer cells form in the tissues of the rectum). A review of Patient 13's electronic medical record form titled ";Physician Certification for Hospice Benefit" (CTI) certification #2, recertification for the second 90 day period from 12/5/2023 to 3/3/2024, indicated a terminal diagnosis of malignant neoplasm of rectum. A review of Patient 13s electronic medical record form titled ";Plan of Care", dated 1/3/2024, under section Order -Treatment/Med/Other, Frequency, dated 9/6/2023, indicated Spiritual Counselor (SC) to continue to visit once a month and as needed and to provide a pastoral presence and offer spiritual and emotional support. A review of Patient 13s electronic medical record form titled ";Spiritual Assessment" dated 9/8/2023, indicated ";Patient 13s son expressed his desire for regular visitation by the Chaplain to provide spiritual and emotional support for his father. The caregiver responsible for the patient reported no issues concerning the patients care period. The Chaplain intends to continue visiting the patient once a month and as needed to provide a pastoral presence and offer spiritual and emotional support." A review of Patient 13s electronic medical record ";Spiritual Assessment" dated 11/22/2023, indicated ";the Chaplain plans to maintain regular visits, offering spiritual and emotional support as necessary." During a concurrent record review and interview on 1/4/2024 at 1:15 p.m. of Patient 13s electronic medical record, with DPCS, there is only two spiritual assessments dated 9/8/2023 and 11/22/2023. DPCS stated, ";I see only two spiritual assessments in the system. Per doctors orders and the narrative note written by the Chaplain, he was supposed to visit the patient once a month. This was not done." During a phone interview on 1/4/2024 at 3:20 p.m. with the Chaplain, the Chaplain stated, ";I was supposed to see Patient 13 once a month, I havent done that." A review of the HAs policy and procedure, titled, ";Spiritual Care Counseling Services", revised November 2021, the policy and procedure indicated, ";Hospice will provide spiritual care counseling and keeping up with the patients families/caregivers belief system and practice, and in accordance with the plan of care." A review of the Hospice agency's policy and procedure titled, ";Spiritual Assessment", revised November 2021, the policy and procedure indicated, ";After the spiritual assessment is performed, ongoing contact will be maintained by phone and or home visits by the hospice chaplain if requested by the patient and family/caregiver and will be included in the comprehensive assessment and the plan of care."

Based on record review and interview the hospice agency (HA, providing care to terminally ill patients who have six months or less to live) failed to ensure to document accurate information in the clinical record for one of 14 sampled patients (Patient 2). This deficient practice had the potential to result in information not being accurate in Patient 2s health record and clinical notes regarding discharge date. --- During a review of Patient 2s Facesheet (admission record), the Facesheet indicated a start of care for Patient 2 was 2/3/2023 with a primary diagnosis of Alzheimers disease with late onset (a progressive disease that destroys memory and other important mental functions). During a review of Patient 2's Physician Certification for Hospice Benefit (CTI, illness with a prognosis of having six months of life or less) certification number one, for the first 90 day period from 2/3/2023 to 5/3/2023, indicated a terminal diagnosis of Alzheimers disease with late onset. During a review of Patient 2's CTI certification number three for the recertification for the next 60 day period from 8/2/2023 to 9/30/2023, indicated a terminal diagnosis of Alzheimers disease with late onset. During a review of Patient 2s Revocation of Medicare/Medical Hospice Benefit, dated 9/2/2023, indicated the patient revoked hospice services on 9/2/2023. During record review of Patient 2s ";Discharge Summary," dated 9/2/2023, the discharge summary indicated, ";Patient was discharged in the Period 4 of the benefit period 10/01/2023 to 11/29/2023." During an interview on 1/4/2024, at 10:45 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated, ";my entry for the discharge summary," for Patient 2 "is a clinical error. I will provide a copy of the billing which shows Patient 2 was discharged on 9/2/2023 not 10/1/2023. I made a mistake." When asked who double checked her documentation, DPCS stated, ";we have a QA/Quality Assurance that does this. I guess this was missed." During a record review of the agencys policy and procedure titled, ";Contents of Clinical Record", revised November 2021, the policy and procedure indicated, ";... The clinical record will contain sufficient information to identify the patient, describe the patient's problems and needs, justified care, accurately document care provided and results in detail, and facilitate continuity of care among Hospice interdisciplinary group members and contract personnel."

Based on interview, observation, and record review, the Hospice Agency (HA) failed to provide a copy of written information regarding advance directive (a legal document that outlines person's wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions for one of five sampled patients (Patient 2). This failure had the potential to result in the patients family and/or caregivers not knowing what the patients medical decisions are, which can result in psychological distress to the patient/patients family/caregiver. --- Findings: A review of Patient 2's ";Personal Information" indicated a Start of Care date of 9/2/22, with a primary diagnosis of Senile degeneration of the brain (is characterized by a decrease in cognitive abilities or mental decline). A review of Patient 2s POC (Plan of Care)/IDG (Interdisciplinary Group-a team responsible for the holistic care of the hospice beneficiary) form dated 6/10/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 2 PRN (pro re nata, which means ";as needed") visits for pain and symptom management, the Master of Social Work (MSW) to visit one time then on every recertification for psychosocial issues, needs and concerns and spiritual counselor to visit one time then on every recertification for spiritual issues and concerns. The hospice aide and volunteer (VOL) services were declined. During a home visit on 7/27/2023, at 11 a.m., Registered Nurse (RN 1) was observed performed hand hygiene prior to providing assessment and care to Patient 2. During a home visit on 7/27/2023, at 11:40 a.m., a hospice folder was observed in Patient 2s home. The folder had the name of the agency. Inside the folder was a copy of Patient 2s plan of care, active medication list and signed notice of patients rights. No other documents in the folder were observed. During interview with Patient 2s family member/daughter (FM3), she stated that she was unable to remember if the hospice nurse discussed the POLST (Physician Orders for Life-Sustaining Treatment to her and Patient 2. FM3 stated that Patient 2 has a POLST before from her previous facility where she stayed but she did not know where the copy was, did not have a copy with them, and further stated was unsure about the code status but she thinks Patient 2 had DNR (Do not Resuscitate) status. During an interview on 7/27/2023, at 12 p.m., RN 1 stated Patient 2s folder did not have any copy of her POLST. LVN 3 stated P2 should have copy of POLST. RN 1 stated it was Patient 2s right to have copies and information of what she signed. During an interview and concurrent review with the Director of Patient Care Services (DPCS) on 7/28/23, at 10:30 a.m., Patient 2s POLST, signed by both patient and physician, original copy was in the agencys office in clinical records. DPCS stated that a copy should have been provided to Patient 2s hospice agencys home folder for future reference. A review of the hospice agencys policy and procedure entitled, ";Do Not Resuscitate/Do Not Intubate Orders", revised November 2021, indicated that a written Do Not Resuscitate (DNR) order signed by the patients physician (or authorized independent practitioner) must be on file in the patients clinical record and admission folder in the patients home.

Based on an interview and record review, the hospice agency failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of Patients was met as follows: 1. The hospice agency failed to ensure the patients' comprehensive assessment (describes in detail a patient's medical, physical, and psychosocial condition and needs) were completed within five days after the election of hospice care for two of 5 sampled patients (Patient 3 and Patient 4). (Refer to L523). 2. The hospice agency failed to ensure interventions and reassessment for pain were implemented for one of 5 sampled patients (Patient 4). (Refer to L524). The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily (right or legal way) mandated compliance with the Federal regulations for Initial & Comprehensive Assessment of Patients to ensure the highest quality of care is being provided to patients certified to receive the Medicare hospice benefits. --- .

Based on interview and record review, the hospice agency (HA) failed to ensure the patients comprehensive assessment (describes in detail a patient's medical, physical, and psychosocial condition and needs) were completed within five days after the election of hospice care for two of 5 sampled patients (Patient 3 and Patient 4). For Patient 3, the initial spiritual assessment was not conducted within 5 days from the start of care date. For Patient 4, the initial spiritual and psychosocial assessment was not conducted within 5 days from the start of care. This deficient practice has the potential to cause in the delay in the development of an individualized plans of care (POC). --- Findings: a. A review of Patient 3's clinical record indicated a start of care (SOC) date of 11/28/2022, with a terminal diagnosis of chronic systolic congestive heart failure (a serious, chronic condition that occurs when the left ventricle can't pump blood efficiently). A review of Patient 3s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 11/28/2022, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 2 prn (pro re nata, which means ";as needed") visits for pain and symptom management, for the Master of Social Work (MSW) to visit within 5 days of SOC, and the hospice aide to visit two times a week. The spiritual counselor (SC) and volunteer (VOL) services were declined. . During a phone interview with the spiritual counselor (SC 1), on 7/28/2023 at 11:12 a.m., SC 1 stated spiritual assessment should be conducted within 5 days from the SOC as part of the patients comprehensive assessment. SC 1 stated if patient and/or patients family declined SC service during the initial visit by the registered nurse, he will still contact the patient or the patients family to introduce himself and to explain the service that he provides. SC 1 also stated that initial contact will be documented in the patients clinical record as part of a complete patients comprehensive assessment. A review of Patient 3s clinical records indicated no documented evidence the spiritual counselor (SC) and volunteer (VOL) services assessments were conducted before the patient declined these services. b. A review of Patient 4's clinical record indicated he was admitted to the hospice agency on 4/21/2022, with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with late onset. A review of Patient 4s POC/IDG form dated 4/21/2022, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 2 prn visits for pain and symptom management, hospice aide to visit two times a week, MSW and SC to visit the patient within 5 days of the SOC. Volunteer visits were offered but declined. A review of Patient 4s clinical records indicated Patient 4s psychosocial assessment was conducted on 4/24/2023 and the spiritual assessment was conducted on 4/06/2023 or more than 5 days after the SOC (SOC 4/21/22). During a concurrent interview and record review with the Director of Patient Care Services (DPCS), on 7/28/2023 at 11:25 a.m., the DPCS stated an initial psychosocial and spiritual assessment should be conducted within 5 days from the SOC as part of the patients comprehensive assessment. The DPCS acknowledged there was no spiritual assessment conducted for Patient 3 and Patient 4 within 5 days from the SOC. A review of the hospice agencys policy and procedure titled, ";Comprehensive Assessment", revised November 2021, indicated a comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including the patients psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source and adequacy of environmental and other resources, coping mechanisms and the patients and family/caregivers reaction to illness, as well as an assessment of the patients and family/caregivers spiritual orientation, including, as appropriate, any involvement in a religious group such as a church or synagogue or a support group such as Alcoholic Anonymous and spiritual concerns or needs such as despair, suffering, guilt, etc. A review of the hospice agencys policy and procedure titled, ";Psychosocial Services", revised November 2021, indicated the social worker will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient. Psychosocial assessments and interventions will be documented in the patients clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care. A review of the hospice agencys policy and procedure titled, ";Spiritual Care Counseling Services", revised November 2021, indicated the hospice chaplain will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient and family. Spiritual care assessments and counseling will be documented in the patients clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care.

Based on interviews and record review, the hospice agency (HA) licensed staff failed to ensure patient's pain identified in the comprehensive must be based on accepted clinical standards of practice by gathering the characteristic of pain, treatment including non-pharmacological /pharmacological (relating to treatment that uses drugs) treatment, pain re-assessment, and intervention implemented for one of 5 sampled patients (Patient 4). This deficient practice has the potential to result in an ineffective pain management causing uncontrollable pain, patient discomfort and distress. --- Findings: A review of Patient 4's clinical record indicated he was admitted to the hospice agency on 4/21/2022, with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with late onset. A review of Patient 4s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 6/24/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 2 PRN (pro re nata, which means ";as needed") visits, hospice aide to visit two times a week, MSW and SC to visit the patient within 5 days of the SOC. Volunteer visits were offered but declined. A review of Patient 4s care plan titled "Pain," initiated on 4/23/2022, indicated patient has chronic generalized pain, with 10/10 pain level upon admission. The care plan goal indicated to bring down pain level to less than 3/10 or stated comfort level of pain after nursing intervention and/or medication. The care plan interventions indicated to assess/monitor pain and severity every visit, instruct family/caregiver to give pain medications when pain level is greater than 2/10, instruct on non-pharmacological methods of pain and symptom relief, and monitor/assess effectiveness of current and new medication/treatment. A review of Patient 4s physician's order dated 4/23/2022, indicated to give the patient Norco (narcotic-combination of hydrocodone [opioid/acetaminophen -pain relief]) 5-325 milligram (mg) 1 tablet by mouth every 6 hours as needed for pain. A review of the SN ";Visit Note Short Form" authored by the Licensed Vocational Nurse (LVN 2), dated 6/25/2023 indicated, ";Pain assessment done, patient complaining of severe pain on right arm with pain scale of 10/10 (0-no pain to 10 worst pain). Encouraged patient to take pain medication as prescribed and as needed, stated he will take it after eating." There was no documentation what kind of non-pharmacological methods were provided for pain relief, or if the pain was relieved after interventions. There was no documentation of a follow-up pain evaluation/reassessment if pain medication was effective. During a phone interview, on 7/28/2023 at 10:12 a.m. with LVN 2, LVN 2 stated patient complained of right arm pain, and she encouraged the patient to take Norco for pain relief. LVN 2 stated the patient and the patients family wanted him to take Norco only after he ate his meal. LVN 2 stated she elevated patients right arm and applied warm compress throughout the visit but did not document in her notes. When asked if she did pain reassessment, LVN 2 stated, ";No, I did not. I should have reassessed his pain level before the end of my visit." During a concurrent interview and record review on 7/28/2023 at 11:25 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated the nurse should evaluate pain interventions, assess non- pharmacological and pharmacological interventions, and reassess pain level which should be reflected in the nurse's notes. During a review of the agency's policy and procedure titled, "Pain Assessment", dated November 2021, indicated all patients will receive pain assessments. The patient will be reassessed every visit for the existence and intensity of pain and the effectiveness of interventions to relieve pain.

Based on observation, interview and record review, the hospice agency (HA) failed to maintain an accurate medication profiles of the patient's current and available medication, for one of 5 sampled patients (Patient 3). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. --- Findings: A review of Patient 3's clinical record indicated a start of care (SOC) date of 11/28/2022, with a terminal diagnosis of chronic systolic congestive heart failure (a serious, chronic condition that occurs when the left ventricle can't pump blood efficiently). A review of Patient 3s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/8/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 2 PRN (pro re nata, which means ";as needed") visits for pain and symptom management, and to instruct the patient and/or caregiver regarding new medications or treatments, monitor for side effects, to monitor and assess effectiveness of the current and any new medications or treatments. On 7/27/2023, at 10:40 a.m., a joint home visit was conducted to Patient 3's residence, with the License Vocational Nurse (LVN 1). Patient 3 was observed awake, alert, oriented, and hard of hearing. On 7/27/2023, at 11:10 p.m., during a review of Patient 3s current medications with the patients family member (FM 1), there was a bottle of Mirtazapine (antidepressant) 15 milligram (mg), take ½ tablet by mouth daily at bedtime filled date 6/22/2023, found together with the rest of Patient 3s medications. However, the patients current medication profile provided by the hospice agency did not indicate patient was currently taking this medication. During an interview with FM 1, she stated Patient 3 started taking this medication around June 2023. During an interview with the Director of Patient Care Services (DPCS) on 7/28/2023, at 11:25 a.m., the DPCS stated hospice nursing staff need to review patients current medication on every visit and update the medication profile in the patients clinical record immediately. A review of the hospice agencys policy and procedure titled, ";Medication Profile", revised November 2021, indicated patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.

Based on interview and record review, the hospice agency (HA) failed to ensure the interdisciplinary group (IDG) meetings were held by all the members of interdisciplinary group to discuss the patients comprehensive and ongoing assessments and care planning process for four out of 5 sampled patients (Patient 2, Patient 3, Patient 4, and Patient 5). This deficient practice has the potential for the patients progress or decline will not be identified by the IDG, interventions will not be implemented, and patient care goals will not be achieved. --- Findings: A review of Patient 3's clinical record indicated a start of care (SOC) date of 11/28/2022, with a terminal diagnosis of chronic systolic congestive heart failure (a serious, chronic condition that occurs when the left ventricle can't pump blood efficiently). A review of Patient 3s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 5/27/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 2 PRN (pro re nata, which means ";as needed") visits for pain and symptom management, and the Master of Social Work (MSW) to visit one time then on every recertification for psychosocial issues, needs and concerns. The hospice aide, spiritual counselor (SC) and volunteer (VOL) services were declined. A review of Patient 3s POC/IDG meeting record indicated MSW did not attend the meeting on 5/27/2023, 6/10/2023, 6/24/2023, 7/08/2023 and 7/22/2023. A review of Patient 4's clinical record indicated he was admitted to the hospice agency on 4/21/2022, with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with late onset. A review of Patient 4s POC/IDG form dated 5/27/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week to provide pain and symptom management, hospice aide to visit three times a week, MSW and SC to visit once a month. Volunteer visits were offered but declined. A review of Patient 4s POC/IDG meeting record indicated MSW did not attend the meeting on 6/24/2023, 7/08/2023 and 7/22/2023. A review of Patient 5's clinical record indicated a start of care date of 10/13/2021, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Patient 5s POC/IDG form dated 6/10/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 3 prn visits, and the hospice aide to visit three times a week to assist patient with personal care and activities of daily living. The spiritual counselor, social worker, and volunteer services were offered but declined. A review of Patient 5s POC/IDG meeting record indicated MSW did not attend the meeting on 6/24/2023, 7/08/2023 and 7/22/2023. During a concurrent interview and record review with the Director of Patient Care Services (DPCS), on 7/28/2023 at 11:25 a.m., the DPCS stated that the IDG team meeting should be held every two weeks with participation of all the IDG members (Medical doctor, DPCS, SN, MSW and spiritual counselor). She stated when the IDG members participated in the IDG meeting, they should have signed right away. The DPCS was not able to provide the documented evidence all the IDG members had participated in the IDG meeting for Patients 3, 4, and 5 on the above days. A review of the agency's policy and procedure titled, "Interdisciplinary Group Meeting," revised November 2021, indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor. A review of Patient 2's ";Personal Information" indicated a Start of Care date of 9/2/22, with a primary diagnosis of Senile degeneration of the brain (is characterized by a decrease in cognitive abilities or mental decline). A review of Patient 2s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 6/10/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 2 PRN (pro re nata, which means ";as needed") visits for pain and symptom management, the Master of Social Work (MSW) to visit one time then on every recertification for psychosocial issues, needs and concerns and spiritual counselor to visit one time then on every recertification for spiritual issues and concerns. The hospice aide and volunteer (VOL) services were declined. A review of Patient 2s POC/IDG meeting record indicated MSW did not attend the meeting on 6/10/2023, 6/24/2023, 7/08/2023 and 7/22/2023. During a concurrent interview and record review with the Director of Patient Care Services (DPCS), on 7/13/2023 at 11:50 a.m., the DPCS stated that the IDG team meeting should be held every two weeks with participation of all the IDG members (Medical doctor, DPCS, SN, MSW and spiritual counselor). She stated when the IDG members participated in the IDG meeting, they should have signed right away. The DPCS was not able to provide the documented evidence all the IDG members had participated in the IDG meeting for Patients 2 on the above days. During an interview with the MSW om 7/13/2023 at 12:30 p.m., MSW stated that she attended the previous meetings via zoom video conference but was not able to sign into attendance log in sheet for the IDG meetings. MSW stated that she attended the meeting along with the other members including the medical director, chaplain and registered nurse every 14 days. MSW stated that she is having an issue signing in electronically to POC/IDG review documents, she stated that she already brought up the issue to the DPCS and it has to be resolved in the Hospice MD as she does not have any control in this.

Based on observation, interview, and record review, the hospice agency (HA) failed to develop a comprehensive, individualized care plan for one of 5 sampled patients (Patient 3). For Patient 3, was receiving Coumadin (an anticoagulant [blood thinner] medication but can cause serious bleeding). HA did not develop an individualized plan of care for Coumadin to reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. This deficient practice has the potential for the patient-centered interventions addressing the patients specific needs will not be met resulting in a decline in clinical, emotional, physical, psychosocial well-being, and quality of life. --- Findings: A review of Patient 3's clinical record indicated a start of care (SOC) date of 11/28/2022, with a terminal diagnosis of chronic systolic congestive heart failure (a serious, chronic condition that occurs when the left ventricle can't pump blood efficiently). A review of Patient 3s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 11/28/2022, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 2 prn (pro re nata, which means ";as needed") visits for pain and symptom management, for the Master of Social Work (MSW) to visit within 5 days of SOC, and the hospice aide to visit two times a week. The spiritual counselor (SC) and volunteer (VOL) were declined. The POC Summary indicated a physician order of Coumadin oral tablet 5 milligrams (mg) 1 tablet by mouth every Monday and Sunday, 2.5 mg 1 tablet by mouth every Tuesday, Wednesday, Thursday, Friday, and Saturday. On 7/27/2023, at 10:40 a.m., a joint home visit was conducted to Patient 3's residence, with the License Vocational Nurse (LVN 1). Patient 3 was observed awake, alert, oriented, and hard of hearing. Patient 3 was observed with some mild bruising (skin discoloration from damaged, leaking blood vessels underneath the skin) on his right arm. A review of Patient 3's clinical record indicated there was no documented evidence the HA developed a plan of care for risk of bleeding due to patients used of Coumadin medication. During a concurrent interview and record review with the Director of Patient Care Services (DPCS), on 7/28/2023 at 11:25 a.m., the DPCS stated she could not locate care plans for patients use of Coumadin. DPCS stated the hospice staff should have developed care plans on admission and establish goals and implement interventions for the use of Coumadin in the event the patient experience unusual bleeding the side-effect of the medication. A review of the agency's policy and procedure titled, "The Plan of Care", revised November 2021, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan. The plan of care will be based on the initial, comprehensive, and ongoing assessments by members of the interdisciplinary group and will be reviewed on a regular basis. The plan will focus on identified problems, goals, and interventions.

Based on observation, interview and record review the Hospice Agency (HA) failed to ensure ";Comfort Care Kit" (a prescribed set of medications that are kept in a patient's home in the event of an emergency) medications in the kit are readily available for the palliation (relieve symptoms) and management of terminal illness for one of five sampled patients (Patient 2). This failure had the potential to result in patient not receiving the comfort medications when needed to mitigate pain and discomfort. --- Findings: During record review of Patient 2's ";Personal Information" indicated a Start of Care date of 9/2/22, with a primary diagnosis of senile degeneration of the brain (is characterized by a decrease in cognitive abilities or mental decline). During a home visit on 7/27/23, at 11 a.m., it was observed Registered Nurse (RN 1) was reviewing medications Patient 2 was taking from the patient's medication profile inside the folder. During a concurrent interview and record review on 7/27/23, at 11:25 a.m., Patient 2s record titled, ";Current Treatment/Medication/DME List", was reviewed with RN 1. The record indicated comfort care kit medications (medications used at the end of life, to help relieve symptoms such as pain, anxiety, constipation, excessive salivation) were listed to have been ordered for Patient 2 on 9/4/22. RN 1 stated the comfort care kit medications were incomplete with missing medications of Levsin tablets for excessive secretions and Acetaminophen suppository for mild pain or fever and did not know why they were not there. RN 1 stated that she was not the regular visiting nurse to visit Patient 2, she stated that she does medication reconciliation of her assigned patients on every visit. During an interview on 7/28/23, at 12:30 p.m., the Director of Patient Care Services (DPCS) stated the purpose of comfort kit medications was in case the patient needed relief of symptoms and the visiting nurses should ensure that the medications in the comfort care kit are complete, unexpired, and updated. A review of the hospice agencys policy and procedure entitled, ";Administration and Documentation of Medications", undated, indicated that as part of the assessment process, a drug history will be taken, and a comparison made between the physician's (or other authorized independent practitioner's) orders and the current medication the patient is taking. Any discrepancies or contradictions should be reported to the physician for resolution. The Comfort Care Kit included: Morphine Sulfate 20 mg / ml, 0.25 ml Sublingual Q2hrs PRN for severe pain or respiratory distress. Ativan 2 mg/ ml, 0.5 ml Sublingual Q4hrs PRN for restlessness or agitation. Levsin ODT (Orally Disintegrating Tablet), 0.125 mg 1 Tab q4hrs PRN for increasing oral secretions. Bisacodyl 10 mg Suppository, 1 supp daily PRN if no BM x 3 days Tylenol -650 mg Suppository, 1 supp per rectum q4hrs PRN for mild pain or fever if unable to tolerate orally. Zofran 4 mg 1 Tab, 4 mg Sublingual q4hrs PRN for nausea or vomiting.

Based on interview and record review, the hospice agency (HA) failed to ensure hospice aide services were provided in accordance with the plan of care (POC) for one of 5 sampled patients (Patient 5). This failure had the potential to negatively affect the patients' physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. --- Findings: A review of Patient 5's clinical record indicated a start of care (SOC) date of 10/13/2021, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Patient 5s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 5/27/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 3 prn (pro re nata, which means ";as needed") visits, and the hospice aide to visit three times a week to assist patient with personal care and activities of daily living. The spiritual counselor (SC), social worker (MSW), and volunteer (VOL) services were offered but declined. A review of Patient 5s history of hospice aide visits for the month of June 2023, indicated that for the week starting 6/11/2023 (Sunday) and ending on 6/17/2023 (Saturday), the hospice aide visited the patient only two times. For the week starting 6/18/2023 (Sunday) and ending on 6/24/2023 (Saturday), the hospice aide visited the patient only once. During a concurrent interview and record review with the Director of Patient Care Services (DPCS), on 7/28/2023, at 11:25 a.m., the DPCS stated that if patient refused hospice aide visit, such refusal will be documented in the patients clinical record. DPCS was unable to provide documented evidence that Patient 5 or family refused hospice aide visits on the above days no visit was conducted. A review of the agency's policy and procedure titled, "The Plan of Care", revised November 2021, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on interview and record review, the hospice agency (HA) failed to ensure that a Registered Nurse (RN) supervisory visit for hospice aide was conducted every 14 days for one of 5 sampled patients (Patient 5). This deficient practice resulted in lack of oversight and had the potential to result in services not being provided. --- Findings: A review of Patient 5's clinical record indicated a start of care (SOC) date of 10/13/2021, with a terminal diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Patient 5s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 2/13/2023, indicated the frequency of visits for skilled nurse (SN) to one visit per week plus 3 PRN (pro re nata, which means ";as needed") visits, and the hospice aide to visit three times a week to assist patient with personal care and activities of daily living as assigned by the registered nurse (RN). RN was to visit once every 14 days for supervisory visits, and to assess the patient and to provide pain and symptom management and comfort measures. A review of Patient 5's clinical record indicated that there was no hospice aide supervisory visit conducted by the RN on the dates between 2/22/2023 to 2/28/2023. During a concurrent interview and record review with the Director of Patient Care Services (DPCS), on 7/28/2023, at 11:25 a.m., DPCS stated hospice aide supervisory visit should be conducted every 14 days by the RN. DPCS acknowledged there was no hospice aide supervisory visit conducted by the RN on the dates between 2/22/2023 to 2/28/2023. A review of the agency's policy and procedure titled "Hospice Aide Supervisory Visits", revised November 2021, indicated the hospice RN Case Manager will conduct supervisory visits to the patients residence at regular intervals. The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days. Supervisory visits and overall supervision will be documented in the clinical record.

Based on interview and record review, the hospice agency failed to ensure the patient's clinical record contained accurate documentation for one of five sampled patients with pressure ulcer (Patient 1). For Patient 1, the physician documented stage II pressure ulcer on sacral area (the portion of your spine between lower back and tailbone) inconsistent with what was documented in the comprehensive nursing assessment/skilled nurse visit notes. This deficient practice has the potential to cause ineffective communication among the agency staff that could affect the quality of care provided to the terminally ill patient. --- Findings: A review of Patient 1's clinical record indicated a start of care (SOC) date of 5/22/2023, with a primary diagnosis of paralytic syndrome cerebral infarct (weakness or paralysis that occurs in the arms and legs). A review of Patient 1s Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 5/22/23 indicated an order for Skilled Nurse (SN) to visit twice a week to promote comfort and symptom management, social worker (MSW) for initial assessment to provide psychosocial support to patient and family and hospice aide (CHHA) twice a week to assist with personal care and to promote comfort. A review of Patient 1s MD visit note dated 5/16/2023, indicated in the clinical finding's summary section ";69 y/o female patient admitted to Fortitude Hospice with primary dc of Oth paralytic syndrome fol cerebral infrc aff unsp side and comorbidities: CVA x 2, stage 2 sacral ulcer, Patient has also developed pressure ulcer of the sacrum due to being primarily bed bound and poor PO intake." A review of Patient 1s clinical records indicated inconsistent documentation as follows: -Comprehensive Nursing Assessment dated 5/22/2023 indicated in the Integumentary-Skin section that ";Patient 1s skin is dry and intact. No signs of skin breakdown or impairment observed during the visit. Reinforced proper skin care." -Skilled Nursing Visit Notes dated 5/22/2023, 5/23/2023, 5/25/2023, 5/29/2023 ,6/1/2023, 6/2/2023 and 6/4/2023, indicated in the Integumentary-Skin comments section that ";Patient 1s skin is dry and intact. No signs of skin breakdown or impairment observed during the visit. Reinforced proper skin care." During an interview with the Medical Director on 7/28/2023, at 10:30 a.m., he stated that he did a face-to-face encounter with Patient 1 and as far as he remembered, Patient 1 has a sacral ulcer, but it was healed and he stated that he might have documented it incorrectly, he stated he should have corrected it. During an interview with the Director of Patient Care Services (DPCS) on 7/28/23, at 12:30 pm, she stated that the physician's and nurses documentation must be accurate so that there will be no miscommunication between staff. She also stated that it was an error in documentation and that Patient 1 has no sacral pressure ulcer but rather it was a redness and dry skin and blanchable but was not documented the assessment. A review of the hospice agencys policy and procedure titled ";Contents of Clinical Records", revised on November 2021, indicated that a clinical record will be maintained for each patient receiving care, the clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate the continuity of care among hospice interdisciplinary group members and contract personnel, information will be available in the clinical record as applicable to care, services and documentation which include educational needs of patient and family/caregiver, patient and family education provided, summary of care/coordination of care provided and progress toward goals/outcomes of care.