Every finding on record at Heart to Heart Hospice of Central Indiana, LLC

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #TX.06 stated in part, "The plan of care includes, but it not limited to: Interventions to manage pain and symptoms and identified issues/problems. In 5 of 19 (26%) clinical records reviewed, the agency did not ensure that all problems identified in the initial and updated comprehensive assessment were documented with interventions for care. Clinical Record 1: The patient elected hospice care on 02/16/2024 with a diagnosis of congestive heart failure (CHF). The updated comprehensive assessment on 04/23/2024 documented that the patient was "quite restless and becoming agitated and combative" and Lorazepam was started. The plan of care was not updated to include interventions for the patient's identified problems with restlessness, agitation, and combativeness as of the patient's revocation for aggressive care on 05/02/2024. During an interview, the Regional Director stated that this update was not documented. Clinical Record 8: The patient elected hospice care on 01/27/2024 with the diagnoses of cerebral vascular accident (CVA) and dementia. The patient resided in a SNF. The updated comprehensive assessment dated 01/18/2024 documented an emergent nursing visit made for a fall and a skin tear on the right wrist requiring a gauze dressing. On 01/23/2024, a skin tear was identified on the left wrist, requiring a dressing. The plan of care was not updated to include documentation of interventions for skin integrity problems. Clinical Record 10: The patient elected hospice care on 03/10/2024 with a diagnosis of breast cancer. The updated comprehensive assessments dated 03/26/2024 and 05/07/2024 documented the patient's symptoms of a UTI (urinary tract infection) treated with antibiotics. The updated comprehensive assessment dated 05/21/2024 documented a repeat UTI and the decision to treat prophylactically. The plan of care was not updated with interventions to address the identified problems with multiple UTIs. Additionally, the updated assessment dated 03/18/2024 documented the patient's problem with anxiety, and the updated assessment dated 05/07/2024 documented the patient's increased confusion. The plan of care was not updated to include interventions to address the patient's anxiety and increased confusion as of this review on 08/01/2024. Clinical Record 11: The patient elected hospice care on 05/22/2024 with a diagnosis of CHF. The patient resided in a SNF. The updated comprehensive assessment dated 01/17/2024 documented the patient's need for oxygen related to dyspnea. The plan of care for the patient’s cardiopulmonary problem identified interventions related to edema and fluid retention relief but did not address the patient's increased dyspnea and need for oxygen. The plan of care did not include documentation of an intervention to address the patient's identified problems with dyspnea. During an interview, the Executive Director and Regional Manager confirmed that the plans of care were not updated to include all interventions for care.

It is required that each patient’s individualized written plan of care: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the plan of care included drugs and treatments necessary to meet the needs of the patient. Clinical Record 12: The patient elected hospice care on 05/06/2024 with the diagnosis of chronic obstructive pulmonary disease (COPD). The patient had a right nephrostomy tube. The nursing assessments dated 05/07/2024 documented the nephrostomy tube was dressed using a drain sponge. The nursing assessment dated 05/31/2023 documented that the nephrostomy dressings at times were a T-Drain sponge, non-adherent pad, and transparent film. The nursing visit note dated 06/11/2024 documented that the nephrostomy tube was dressed with a border foam dressing. The initial plan of care dated 05/06/2024 and updated every two weeks included documentation of a problem for drains with an intervention to change the dressings weekly and pro re nata/as needed (prn). The plan of care did not include specific orders for the nephrostomy tube dressing. During an interview, the Regional Director stated that there was no documented physician orders in the record.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 5 of 17 (29%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the Registered Nurse (RN) prepared a HA care plan that contained clear and specific instructions to meet the patient's needs. Clinical Record 2: The patient elected hospice care on 02/01/2024 with a diagnosis of congestive heart failure (CHF). Oxygen for the patient was started on 02/15/2024. The HA care plan dated 02/01/2024 and updated on 02/19/2024 did not document oxygen precautions. Clinical Record 4: The patient elected hospice care on 03/18/2024 with a diagnosis of esophageal cancer. The patient resided in a skilled nursing facility (SNF). The initial and updated comprehensive assessments documented the patient's need for continuous oxygen until the patient's death on 04/04/2024. The HA care plan dated 03/18/2024 and updated on 03/28/2024. The HA care plan did not document oxygen precautions. Clinical Record 8: The patient elected hospice care on 01/27/2024 with the diagnoses: cerebral vascular accident (CVA) and dementia. The patient resided in a SNF. The updated comprehensive assessment dated 01/18/2024 documented falls and a skin tear on the right wrist requiring a gauze dressing. On 01/23/2024, a skin tear was identified on the left wrist, requiring a dressing. The HA care plan dated 01/22/2024 and updated through 03/22/2024 assigned the HA the relevant task: showering two times a week. The HA care plans did not provide the HA with instructions of what to do with the kerlix dressings on the right and left wrists during the showers. The skin tear resolution date was unclear but continued to be documented on the nursing visit notes through 02/22/2024. Clinical Record 11: The patient elected hospice care on 05/22/2024 with a diagnosis of CHF. The patient resided in a SNF. The nursing assessment dated 07/17/2024 documented that the patient had increased dyspnea and was using oxygen at 2 liters. Oxygen at 2 liters was added to the medication profile as a prn (as needed) medication. The HA care plan last updated on 07/17/2024 assigned the HA the relevant task: shower every visit. The HA care plan did not document oxygen precautions and instructions for the patient's use of oxygen during personal care and the shower. Clinical Record 12: The patient elected hospice care on 05/06/2024 with the diagnosis of chronic obstructive pulmonary disease. The patient had a right nephrostomy tube. The HA care plan dated 05/06/2024, assigned the HA the relevant task: shower every visit. There were no documented updates to the HA care plan. The HA care plan did not document the presence of the nephrostomy tube ( and dressing, instructions for the HA regarding the care of the nephrostomy tube, and what to do if the dressing was saturated or fell off during the shower. There was no identification of the nephrostomy tube on the aide plan of care as of review 08/01/2024. During an interview, the Executive Director and the Regional Director confirmed that the aide care plans did not include the required details.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care. Clinical Record 6: The patient elected hospice care on 12/08/2022 with a diagnosis of senile dementia. The HA care plan dated 12/08/2022 and updated HA care plans through 08/11/2023, assigned the HA the relevant task: weekly weights. The HA documented the patient's weights on 01/09/2023 and 01/23/2023, with 12 days outstanding; 06/05/2023 and 06/26/2023, with 21 days outstanding; and 07/10/2023 and 08/11/2023, with 32 days outstanding. A review of the clinical record revealed no documented reasons for the weights not obtained weekly. Clinical Record 8: The patient elected hospice care on 01/27/2024 with the diagnoses: cerebral vascular accident (CVA) and dementia. The patient resided in a SNF. The HA care plan dated 01/22/2024 and updated through 03/22/2024, assigned the HA the relevant task: showering 2 times a week. For the week of 02/26/2024, a shower was provided all five (5) days. A review of the clinical record revealed no documented reason the patient was showered five (5) times that week. During the interview with the executive director and regional director stated that the aide did not provide care included in the care plan.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of: The hospice discharge summary described in HCDT 40.I; and The patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy #PE.4 stated in part, "Documentation that the patient's attending physician or practitioner was notified of the date of discharge...The Hospice will forward copies of the following to the patient's attending physician upon discharge from the hospice services: The hospice discharge summary, which includes but is not limited to... A summary of the patient care. the patient's current plan of care, including the current medication profile, the last physician orders, and any other documentation requested or that may assist with the patient's post-discharge continuity of care." In 1 of 1 (100%) clinical record review of a patient that was discharged to a hospital, the agency did not ensure that a discharge summary was sent to the hospital. Clinical Record 1: The patient elected hospice care on 02/16/2024 with a diagnosis of congestive heart failure (CHF). The patient was transferred to the hospital to seek aggressive treatment and revoked the hospice benefit on 05/01/2024. The discharge summary was documented. There was no evidence that the discharge summary was sent to the hospital. During an interview, the Regional Director stated that there was no documentation that any part of the clinical record was sent to the hospital. The hospice Medical Director had agreed to follow this patient at his practice after the patient was discharged from the hospital.

Based on record review and interview, the hospice failed to fully investigate each complaint to ensure the complaint was not a systemic issue. Findings include: 1. A document titled "Responsibilities of the Administrator," indicated " ...The Agency defines the responsibilities of the Administrator to be include, but not limited to ... conflict and complaint management and resolution ...." A document titled "Patient Rights and Responsibilities," indicated " ...Every patient and family has the right ... A patient or resident [sic] is entitled to exercise his or her rights as a patient ... and to this end may present grievances or recommend changes in policies and services on behalf of himself or herself or other to the facility staff, to governmental offices or to another person of his or her choice within or outside of the facility ... to be assured the hospice will immediately investigate all alleged violations ...." 2. During a review of the agency complaint log, a complaint dated 6/4/21 was reviewed. The complaint indicated " ...Date reported ... 6/4/21 ... Date of Event ... 6/4/21 ... Complaint ... Revocation ... Type ... H [Billing/Payment Issue] ... Patient had fall in her home that resulted in possible hip fx [fracture] ... Family and Patient chose to seek aggressive treatment outside of the hospice POC [plan of care] ... Date Resolved ... 6/16/21 ...." 3. During a review of the agency complaint log, a complaint dated 9/25/21 was reviewed. The complaint indicated " ...Date reported ... 9/26/21 ... Date of Event ... 9/25 & 9/26 [sic] ... Complaint ... FSN [sic] nurse called with medication concerns ... Type ... D [Communication] ... Actions Taken ... [Former Patient Care Manager B] and administrator on-call spoke with FSN [sic] and [Registered Nurse D] made PRN [as needed] visit ... Date Resolved ... 9/27/21 ...." 4. During an interview on 11/9/21 at 2:00 PM, when asked if all complaints should show proof of a system wide approach to investigating complaints, Administrator E, indicated "Yes."

Based on record review, observation, and interview, the hospice failed to ensure the Registered Nurse (RN) effectively managed symptoms related to the patient's terminal illness for 2 of 30 (#2, 3) clinical records reviewed. Findings include: 1. A document titled "Patient Rights and Responsibilities," indicated " ...Every patient and family has the right ... to receive effective pain management and symptom control from the hospice for the conditions related to the terminal illness ...." 2. A document titled "Patient Assessments," indicated " ...The comprehensive assessment will identify physical, psychosocial, emotional, and spiritual needs related to terminal illness that will be addressed in order to promote the patient's well-being, comfort, and dignity throughout the dying process ... A comprehensive pain assessment based on accepted clinical standards of practice will include ... history of pain and its treatment ... characteristics of pain ... intensity ... descriptors ... patterns ... location and radiation of pain ... frequency ... timing ... duration ... impact of pain ... factors such as activities, care, or treatment that precipitate or exacerbate pain ... strategies and factors to reduce pain ... additional symptoms associated with pain ...nausea ... pain ...." 3. The clinical record of Patient #2 was reviewed on 11/8/21 at 12:00 PM and indicated a hospice election date of 9/23/21 with a primary diagnosis of cerebral atherosclerosis (thickening and hardening of the walls of the arteries in the brain). During a home visit on 11/9/21 at 10:00 AM with Patient #2, Registered Nurse F was observed completing wound care. The Registered Nurse failed to assess the patient's pain before starting wound care. 4. The clinical record of Patient #3 was reviewed on 11/8/21 at 1:00 PM and indicated a hospice election date of 8/14/21 with a primary diagnosis of cerebral atherosclerosis (thickening and hardening of the walls of the arteries in the brain). During a home visit on 11/9/21 at 11:30 AM with Patient #3, Registered Nurse G was observed completing wound care. The Registered Nurse failed to assess the patient's pain before starting wound care. 5. During an interview on 11/9/21 at 2:00 PM, when asked if an assessment of pain take place before wound care starts, Administrator E, indicated "Yes."

Based on record review and interview, the Registered Nurse (RN) failed to assess the patient's ongoing medication use as part of the comprehensive assessment for 2 of 30 (#2, 3) clinical records reviewed. Findings include: 1. A document titled "Patient Assessments," indicated " ...The comprehensive assessment will identify physical, psychosocial, emotional, and spiritual needs related to terminal illness that will be addressed in order to promote the patient's well-being, comfort, and dignity throughout the dying process ... current medical conditions, medications and co-morbid psychiatric diagnoses or history ...." 2. The clinical record of Patient #2 was reviewed on 11/8/21 at 1:00 PM and indicated a hospice election date of 9/23/21 with a primary diagnosis of cerebral atherosclerosis (thickening and hardening of the walls of the arteries in the brain). During a home visit on 11/9/21 at 10:00 AM with Patient #2, Registered Nurse F was observed completing wound care. The Registered Nurse failed to assess the patient's current medications for any changes. 3. The clinical record of Patient #3 was reviewed on 11/8/21 at 1:00 PM and indicated a hospice election date of 8/14/21 with a primary diagnosis of cerebral atherosclerosis (thickening and hardening of the walls of the arteries in the brain). During a home visit on 11/9/21 at 11:30 AM with Patient #3, Registered Nurse G was observed completing wound care. The Registered Nurse failed to assess the patient's current medications for any changes. 4. During an interview on 11/9/21 at 2:00 PM, when asked if an assessment should include looking at all medications to ensure accuracy of current medication use, Administrator E, indicated "Yes."

Based on observation, record review, and interview, the hospice failed to ensure all employees followed agency infection control policies and procedures and standard precautions for 2 of 3 home visit observations (#2, 3). Findings include: 1. A policy titled "Infection Control Program," indicated " ...The Agency's infection control program will be based on the following criteria ... Current federal, state, and local laws and regulations ... The Infection Control Program will include ... Implementing appropriate preventative procedures ... implementing appropriate measures to control infection ... Management will be responsible for coordinating all activities related to the Infection Control Program ...." 2. A policy titled "Bag Technique," indicated " ...The bag is placed on a clean, safe surface ... If this is not possible, a barrier ... is to be placed under the bag ... When the visit is completed, reusable equipment is cleaned using alcohol, disinfectant wipe and/or antimicrobial soap and water as appropriate, hands are washed, and equipment and supplies are returned to the bag ...." 3. A policy titled "Hand Hygiene," indicated " ...All Agency staff providing patient/client care will observe proper hand hygiene techniques ... if hands are not visibly soiled, staff may use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described below ... Alternatively, staff may wash hands with an antimicrobial soap and water in all clinical situations described below ... Decontaminate hands after contact with patient's/client's intact skin, even when gloves are worn ... Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled ... Decontaminate hands if moving from a contaminated body sit to a clean body site during patient/client care ... Decontaminate hands after contact with inanimate objects [including medical equipment] in the immediate vicinity of the patient/client ...." 4. A policy titled "Cleaning and Management of Supplies and Equipment," indicated " ...Item ... Nurse/HHA [home health aide] Bag ... Notes ... Prevent contamination by ... not placing contaminated supplies back inside bag ... Stethoscope ... Frequency ... between each patient ... Nurse Scissors ... Frequency ... After each use ... Pulse Oximeter ... Frequency ... after each use ... Thermometer ..." 5. During a home visit on 11/9/21 at 10:00 AM with Patient #2 (election date of 9/23/21), Registered Nurse F was observed completing wound care. The Registered Nurse (RN) was observed touching multiple areas of the wound with the same gauze, pulling glasses from their pocket without changing gloves or completing hand hygiene, and touching their charting tablet after touching the wound then not cleaning the tablet. 6. During a home visit on 11/9/21 at 11:30 AM with Patient #3 (election date of 8/14/21), Registered Nurse G was observed completing wound care. The Registered Nurse (RN) was observed not using proper bag technique, not using proper barrier technique, and touching multiple areas of the wound with the same gauze. 7. During an interview on 11/9/21 at 2:00 PM, when asked if all nurses and aides should follow the hospice's policies on infection control, Administrator E, indicated "Yes."

Based on observation, record review, and interview, the hospice failed to ensure COVID infection control precautions were followed for 3 of 3 patient home visit observations (#2, 3, 4). Findings Include: 1. A policy titled "Infection Control Program," indicated " ...The Agency's infection control program will be based on the following criteria ... Current federal, state, and local laws and regulations ... The Infection Control Program will include ... Implementing appropriate preventative procedures ... implementing appropriate measures to control infection ... Management will be responsible for coordinating all activities related to the Infection Control Program ...." 2. A policy titled "Infection Control Program Addendum Infectious Disease Pandemic," indicated " ...The Agency will stay abreast of current information and practice guidelines provided by local, state, and federal agencies related to any infectious outbreak, pandemic, or epidemic ... The Agency will identify patients/client and staff will signs and symptoms of the infection as well as those considered at risk for the infection ...The Clinical Manager/Supervising Nurse will ensure all patients/clients and staff are screened for risk factors as well as signs and symptoms of the disease as defined by the most recent data available ...." 3. During a home visit on 11/9/21 at 10:00 AM with Patient #2 (election date of 9/23/21), Registered Nurse F was observed completing wound care. The Registered Nurse (RN) was observed screening patient for COVID symptoms after already having physical contact with the patient. 4. During a home visit on 11/9/21 at 11:30 AM with Patient #3 (election date of 8/14/21), Registered Nurse G was observed completing wound care. The Registered Nurse (RN) was observed screening patient for COVID symptoms after already having physical contact with the patient. 5. During a home visit on 10/18/21 at 10:00 AM with Patient #4 (election date of 8/14/21), Certified Nurse Aide H was observed completing wound care. The Certified Nurse Aide was observed screening patient for COVID symptoms after already having physical contact with the patient. 6. During an interview on 11/9/21 at 2:00 PM, when asked if all staff needed to screen patients for COVID symptoms before they have physical contact with them, Administrator E, confirmed "Yes."

Based on record review, observation, and interview, the hospice failed to ensure patients received medications from a pharmacy (L691); failed to ensure medications were labeled correctly (L693); failed to ensure medications were disposed of properly (L694); and failed to ensure discrepancies for controlled drugs were immediately investigated by the pharmacist and administrator (L700). The cumulative effect of these systemic problems resulted in the hospice's inability to ensure safe hospice care was provided as required by the Condition of Participation 42 CFR 418.106 Drugs and biologicals, medical supplies, and durable medical equipment.

Based on record review, observation, and interview, the hospice failed to ensure the patient received medications from a pharmacy for 1 of 30 patient records reviewed (#1). Findings include: 1. A document titled "Medication Disposal," indicated " ...Upon Patient's death, medications will be disposed of unless the family refuses ... Any unused medications will not be returned ...." 2. A document titled "Medication Possession and Transport," indicated " ...The hospice contract pharmacy will be responsible for delivery of all medications, when possible ... Agency will not store any medication stock for patient ... use at the Agency's office ... the employee documents transportation in the clinical note ...." 3. A document titled "Medication Administration and Management," indicated " ...Agency nurse will administer therapies according to administrative and clinical policies and procedures, in accordance with all applicable federal, state laws, and regulations [sic] ... Medications are administered as per Agency's Clinical Procedure Manual and per physician orders ...." 4. During an agency office tour on 10/22/21 at 10:00 AM, a tall, two door, off-white cabinet (found in the clinical manager's office) was observed and found to have multiple medications with deceased patients' names on the medication packages. These medications included, but were not limited to a brand new, sealed bottle of liquid morphine. 5. The clinical record of Patient #1 was reviewed on 10/22/21 at 1:00 PM and indicated a hospice election date of 5/19/21, with a primary diagnosis of acute myeloblastic leukemia not having achieved remission (cancer of the blood and bone marrow with excess immature white blood cells). The record contained a document titled "Visit Note Report," dated 10/21/21, indicated " ...Agent name ... [Registered Nurse I] ... Narrative ... New dose of Morphine also delivered with visit ...." 6. During an interview on 10/22/21 at 1:35 PM, when asked if they had ever reused medications from the metal cabinet in Former Patient Care Manger B's office, Registered Nurse I indicated, "We do have an emergency supply in the manager's office. I used liquid morphine for [Patient #1]. It was a brand new, sealed bottle."

Based on observation, record review, and interview, the hospice failed to ensure medications were labeled correctly for 1 of 30 patient records reviewed (#6). Findings Include: 1. A document titled "Medication Disposal," indicated " ...Upon Patient's death, medications will be disposed of unless the family refuses ... Any unused medications will not be returned ...." 2. A document titled "Pharmacy Services," indicated " ...The pharmaceutical needs of the hospice's patients are managed in a manner consistent with applicable State and Federal laws and accepted standards of practice ... Prescription containers for individual prescriptions are properly labeled in accordance with the state Board of Pharmacy regulations and contain ... Patient's full name ... Prescribing physician's name ... name and strength of drug ... dose, method, and frequency of administration ... lot and control number ... accessory and cautionary instructions ... expiration date ..." 3. During an agency office tour on 10/22/21 at 10:00 AM, a tall, two door, off-white cabinet was observed and found to have multiple medications with deceased patients' names on the medication packages. A gray, Dyno brand, laser label maker was observed to be placed on the side of cabinet in the open office area. The medications that were not labeled correctly included, a bottle with a pharmacy prescription label that had the name of the patient covered by a laser-printer label, which indicated that it was for "Michael," a bottle that had no pharmacy prescription label, but was labeled with a laser-printer label that indicated "Dilaudid [a strong narcotic pain medication]," which had twenty-two small, white pills with an "M" on one side of the pill and a "2 [two]" on the other side, five bottles of sterile water (used for making solutions that will be given by injection) in a clear bag with no name on the label, two boxes of Narcan (treats narcotic overdose in an emergency situation) that were sealed with no type of label on them, ten suppositories of bisacodyl (treats constipation) in a clear bag with the name of the original patient marked out, one unopened bottle of Biotene (treats dry mouth and throat), one CVS Health branded unopened green box of suppositories of bisacodyl (treats constipation) with no label on them, one orange bottle with a white top with thirty small white round pills that had an "EP904" scored into one side with no patient name on the label, one white unopened bottle of ferrous sulfate (treats iron deficiency anemia), one orange bottle with a white cap of hyoscyamine (used to treat excessive secretions) with no name on the prescription label that had thirty small white round pills in it, and three packs of five vials each of Albuterol (prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease). 4. The clinical record of Patient #6 was reviewed on 10/22/21 at 1:25 PM and indicated a hospice election date of 10/7/21, with a primary diagnosis of cerebral atherosclerosis (thickening and hardening of the walls of the arteries in the brain). The record contained a plan of care for the certification dates 10/7/21 to 1/4/22, which indicated orders for, but not limited to, " ...Hyoscyamine [used to control symptoms associated with disorders of the gastrointestinal tract] 0.125 mg [milligram] every 4 [four] hours PRN [as needed] for increased secretions ...." The record also contained a document titled "Visit Note Report," dated 10/13/21, completed by Registered Nurse J, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... RNCM [Registered Nurse Case Manager] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Registered Nurse J] ...." During an agency office tour on 10/22/21 at 10:00 AM, a tall, two door, off-white cabinet was observed and found to have a clear bag with 19 of 20 doses of Ondansetron with a laser label made for Patient #6. Upon peeling back the laser label, a blacked out name can be observed but not the full name of the prior patient. 5. During an interview on 10/22/21 at 2:15 PM, when asked why anyone in the agency had ever relabeled medications or improperly labeled them, Former Administrator A indicated, "I have not relabeled them, but the count is right," and Former Patient Care Manager B indicated, "The meds were needing to be destroyed. Some families bring them in [sic]."

Based on observation, record review, and interview, the hospice failed to ensure medications were disposed of properly for 6 of 30 patient records reviewed (#5, 7, 8, 9, 10, 11). Findings include: 1. A document titled "Medication Disposal," indicated " ...Upon Patient's death, medications will be disposed of unless the family refuses ... Any unused medications will not be returned ...." 2. A document titled "Pharmacy Services," indicated " ...Controlled drugs are disposed of in compliance with State and Federal regulations ... The hospice maintains current and accurate records of the receipt and disposition of all controlled drugs ... the pharmacist and registered nurse dispose of the medications ...." 3. A document titled "Medication Administration and Management," indicated " ...The individual administering the medication/controlled drug is responsible for knowledge of ... disposal of medications/controlled drugs ...." 4. A document titled "Medication Disposal," indicated " ... Agency nurse will instruct the patient/caregiver in the proper technique for disposal of discontinued medication, including controlled drugs ... the caregiver legally authorized to dispose of medications will be instructed in the following procedure ... Take unused, unneeded, or expired drugs out of their original containers ... mix the drugs with an undesirable substance, like used coffee grounds or cat litter ... put them in impermeable, nondescript containers, such as empty cans or sealable bags, further ensuring that the drugs are not diverted or accidentally ingested by children or pets ... Throw these containers in the outside trash ... Upon Patient's death, medications will be disposed of unless the family refuses ... Any unused medications will not be returned ...." 5. During an agency office tour on 10/22/21 at 10:00 AM, a tall, two door, off-white cabinet was observed and found to have multiple medications with deceased patients' names on the medication packages. A gray, Dyno brand, laser label maker was observed to be placed on the side of cabinet in the open office area. The medications found were, but not limited to, lorazepam (treat anxiety disorders), morphine sulfate extended release (treats severe ongoing pain), diazepam (treats anxiety and muscle spasms), Oxycodone (treats moderate to severe pain), Dilaudid (relieves moderate to severe pain), Norco (treats pain), ABHR gel (lorazepam, diphenhydramine, haloperidol, and metoclopramide; treats nausea and vomiting), and fentanyl (treats severe pain). 6. The clinical record of Patient #5 was reviewed on 10/22/21 at 1:15 PM and indicated a hospice election date of 9/15/21, with a primary diagnosis of malignant neoplasm of colon (abnormal cells divide uncontrollably and destroy body tissue). The record contained a plan of care for the certification dates 9/15/21 to 12/13/21, which indicated orders for, but not limited to, " ...Ativan [Lorazepam] 0.5 mg [milligram] every 4 [four] hours PRN [as needed] for anxiety/restlessness ...." The record also contained a document titled "Visit Note Report," dated 9/24/21, completed by Registered Nurse I, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Lorazepam 0.5 mg ... 12 tabs [tablets] ...." During an agency office tour on 10/22/21 at 10:00 AM, a tall, two door, off-white cabinet was observed and found to have an orange bottle with a white top and twenty-five small white pills with a pharmacy prescription label made for Patient #5. 7. The clinical record of Patient #7 was reviewed on 10/22/21 at 1:30 PM and indicated a hospice election date of 7/16/21, with a primary diagnosis of chronic obstructive pulmonary disease (a group of progressive lung disorders characterized by increasing breathlessness). The record contained a plan of care for the certification dates 7/16/21 to 10/13/21, which indicated orders for, but not limited to, " ...Oxycodone [treats moderate to severe pain] 2.5 [two and a half] mg [milligram] every 2 [two] hours PRN [as needed] for pain/sob [shortness of breath] ...." The record also contained a document titled "Visit Note Report," dated 10/9/21, completed by Registered Nurse J, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... RNCM [Registered Nurse Case Manager] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Registered Nurse J] ...." During an agency office tour on 10/22/21 at 10:00 AM, a tall, two door, off-white cabinet was observed and found to have a brand new, sealed bottle of Oxycodone with a pharmacy label for Patient #7. 8. The clinical record of Patient #8 was reviewed on 10/22/21 at 1:35 PM and indicated a hospice election date of 5/7/21, with a primary diagnosis of squamous cell carcinoma of skin (cancer starting in the surface of the skin, lining of hollow organs, and lining of the respiratory and digestive tracts). The record contained a plan of care for the certification dates 5/7/21 to 8/4/21, which indicated orders for, but not limited to, " ...Morphine [used to treat treats ongoing severe pain] 15 [fifteen] mg [milligram] every 2 [two] hours PRN [as needed] for pain/sob [shortness of breath] ... Fentanyl [treats severe pain] 50 mcg ... every 72 [seventy-two] hours for pain ...." The record also contained a document titled "Visit Note Report," dated 6/4/21, completed by Registered Nurse K, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine 18 [eighteen] ml ... Fentanyl 100 mcg #2 [sic] patches ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Patient #8's husband] ...." During an agency office tour on 10/22/21 at 10:00 AM, a tall, two door, off-white cabinet was observed and found to contain two unopened, sealed boxes of Morphine and one box of unopened, sealed Fentanyl patches, with a pharmacy-made label for Patient #8. 9. The clinical record of Patient #9 was reviewed on 10/22/21 at 1:40 PM and indicated a hospice election date of 9/11/21, with a primary diagnosis of malignant neoplasm of unspecified kidney (abnormal cells divide uncontrollably and destroy body tissue). The record contained a plan of care for the certification dates 9/11/21 to 12/9/21, which indicated orders for, but not limited to, " ...Oxycodone [treats moderate to severe pain] 5 [five] mg [milligram] every 4 [four] hours PRN [as needed] for pain ... Oxycodone [treats moderate to severe pain] 10 [ten] mg [milligram] 2 [two] times daily for pain ...." The record also contained a document titled "Visit Note Report," dated 9/16/21, completed by Registered Nurse J, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... RNCM [Registered Nurse Case Manager] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... OxyContin [brand name for Oxycodone] 30 [thirty] mg 5 tabs [tablets] ... Oxycodone 20 [twenty] mg 1 [one] tab ...." During an agency office tour on 10/22/21 at 10:00 AM, a tall, two door, off-white cabinet was observed and found to contain one orange bottle with a white cap with small yellow, round pills with an "OP" sketched on one side and a "40 [forty]" on the other, of Oxycodone, and one orange bottle with a white cap, white and gold capsules with "ANI" printed on one side and "167" printed on the other side, with a pharmacy-made label for Patient #9. 10. The clinical record of Patient #10 was reviewed on 10/22/21 at 1:45 PM and indicated a hospice election date of 7/15/21, with a primary diagnosis of malignant neoplasm of middle lobe, bronchus, or lung (abnormal cells divide uncontrollably and destroy body tissue). The record contained a plan of care for the certification dates 7/15/21 to 9/12/21, which indicated orders for, but not limited to, " ... Fentanyl [treats severe pain] 25 [twenty-five] mcg [microgram] ... every 72 [seventy-two] hours for pain ...." The record also contained a document titled "Visit Note Report," dated 6/4/21, completed by Registered Nurse L, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Fentanyl . [sic] 50 [fifty] mcg patch ... Destroyed in cat litter, [sic] per policy ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... Daughter N law [sic] ...." During an agency office tour on 10/22/21 at 10:00 AM, a tall, two door, off-white cabinet was observed and found to contain two unopened, sealed boxes of Fentanyl patches, with a pharmacy-made label for Patient #10. 11. The clinical record of Patient #11 was reviewed on 10/22/21 at 1:55 PM and indicated a hospice election date of 7/15/21, with a primary diagnosis of personal history of malignant neoplasm of pancreas (abnormal cells divide uncontrollably and destroy body tissue). The record contained a plan of care for the certification dates 4/17/21 to 7/15/21, which indicated orders for, but not limited to, " ... Hydromorphone [brand name is Dilaudid; relieves moderate to severe pain] 8 [eight] mg [milligram] ... every 4 [four] hours PRN [as needed] for pain ...." The record also contained a document titled "Visit Note Report," dated 5/9/21, completed by Registered Nurse M, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Was family educated on safe disposal of controlled drugs and medications? ... Disposed of per facility protocol ...." During an agency office tour on 10/22/21 at 10:00 AM, a tall, two door, off-white cabinet was observed and found to contain one orange bottle with a white top that had small triangular-shaped white pills with an "8" etched on one side and a "p/d" etched on the other side, with a pharmacy-made label for Patient #11. 12. During an interview on 10/22/21 at 1:35 PM, when asked if they had ever seen medications from the metal cabinet in Former Patient Care Manger B's office, Registered Nurse I indicated, "We do have an emergency supply in the manager's office. There is no sign out sheet. There are partially used mediations in there, but I've never used the partial ones." 13. During an interview on 10/22/21 at 2:15 PM, when asked why anyone in the agency had ever relabeled medications or improperly labeled them, Former Administrator A indicated, "I have not relabeled them, but the count is right," and Former Patient Care Manager B indicated, "The meds were needing to be destroyed. Some families bring them in [sic]." When asked why medications had not been destroyed in the patients' homes, Former Administrator A, Former Patient Care Manager B, and Area Manager N indicated, "I do not know."

Based on observation, record review, and interview, the hospice failed to ensure a discrepancies for controlled drugs were immediately investigated by the pharmacist and/or administrator for 23 of 30 patient records reviewed (#5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29). Findings include: 1. A document titled "Patient Rights and Responsibilities," indicated " ...Every patient and family has [sic] the right ... To be assured that the hospice will ensure that all alleged violations involving ... misappropriation of patient property by anyone furnishing services on behalf of the hospice, are reported immediately by hospice employees and contracted staff to the hospice administrator ... The hospice will immediately investigate all alleged violations involving anyone furnishing services on behalf of the hospice and will immediately take action to prevent further potential violations while the alleged [sic] is being investigated ... The hospice will take appropriate action in accordance with state laws as verified by the hospice administration and ensure that verified violations are reported to the State and local bodies [sic] immediately of becoming aware of the violations ...." 2. A document titled "Medication Disposal," indicated " ...Upon Patient's death, medications will be disposed of unless the family refuses ... Any unused medications will not be returned ...." 3. A document titled "Occurrence/Incident Reporting," indicated " ...Agency will document and report all occurrences/incidents ... safety hazards, employee unprofessional and misconduct ... that deviate from the Agency operations and might result in injury or potential harm to a patient/caregiver or Agency staff ... Adverse Events include, but are not limited to ... provision of care errors ... procedure error which results in trauma and/or injury, falls, medication errors ... unusual occurrences/incidents ... safety hazards that endanger staff and/or patients ... unprofessional conduct by licensed staff and employee misconduct of unlicensed staff including abuse, neglect, and misconduct ... Procedure ... An Occurrence/Incident Report will be completed on all occurrences or incidents as defined in policy, by the staff member involved or the first person to become aware of the incident ...The report will be submitted to the immediate supervisor ... supervisor will review ...will document awareness ... report will be forwarded to management and the QAPI committee ... 4. A document titled "Pharmacy Services," indicated " ...Discrepancies in the acquisition, storage, dispensing, administration, disposal, or return of controlled drugs are investigated immediately by the pharmacist and hospice administrator ... a written report of the discrepancy is completed ...." 5. A document titled "Medication Administration and Management," indicated " ...The patient's physician and Agency Nursing Management will be notified regarding any medication errors as soon as possible ... Any medication error ... will be documented on the [Incident Report] and submitted to Agency Nursing Management immediately ...." 6. A document titled "Responsibilities of the Administrator," indicated " ...The Agency Administrator will assume overall responsibility and authority for administrative and leadership functions, supervision of the established organizational plan and responsibility for ongoing communication with the Governing Body, as well as with the entire Agency staff ... The Administrator will be responsible for implementing and supervising the administrative policies and operations of the Agency and for administratively supervising the provision of all services to Agency patients on a day-to-day basis ... The Agency defines the responsibilities of the Administrator to include, but not be limited to ... Ensuring staff education, evaluations, and availability of applicable regulations to all Agency staff ... Ensuring completion, maintenance, and submission of required reports ... Directing staff in the performance of their duties including admission, discharge, transfer, revocation, and provision of services to patients ... Ensuring standards of ethical business and clinical practice are maintained ...." 7. During an agency office tour on 10/22/21 at 10:00 AM, a tall, two door, off-white cabinet was observed and found to have multiple medications with deceased patients' names on the medication packages. A gray, Dyno brand, laser label maker was observed to be placed on the side of cabinet in the open office area. The medications found were, but not limited to, lorazepam (treat anxiety disorders), morphine sulfate extended release (treats severe ongoing pain), diazepam (treats anxiety and muscle spasms), Oxycodone (treats moderate to severe pain), Ondansetron (prevents nausea and vomiting), Dilaudid (relieves moderate to severe pain), Norco (treats pain), ABHR gel (lorazepam, diphenhydramine, haloperidol, and metoclopramide; treats nausea and vomiting), fentanyl (treats severe pain). 8. The clinical record of Patient #5 was reviewed on 10/22/21 at 1:15 PM. The record contained a document titled "Visit Note Report," dated 9/24/21, completed by Registered Nurse I, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Lorazepam 0.5 mg ... 12 tabs [tablets] ...." The record failed to indicate how the narcotics were disposed. 9. The clinical record of Patient #6 was reviewed on 10/22/21 at 1:25 PM. The record contained a document titled "Visit Note Report," dated 10/13/21, completed by Registered Nurse J, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... RNCM [Registered Nurse Case Manager] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Registered Nurse J] ...." The record failed to indicate the type, strength, quantity of the narcotics disposed and how they were disposed. 10. The clinical record of Patient #7 was reviewed on 10/22/21 at 1:30 PM. The record also contained a document titled "Visit Note Report," dated 10/9/21, completed by Registered Nurse J, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... RNCM [Registered Nurse Case Manager] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Registered Nurse J] ...." The record failed to indicate the type, strength, quantity of the narcotics disposed and how they were disposed. 11. The clinical record of Patient #8 was reviewed on 10/22/21 at 1:35 PM. A document titled "Visit Note Report," dated 6/4/21, completed by Registered Nurse K, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine 18 [eighteen] ml ... Fentanyl 100 mcg #2 [sic] patches ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Patient #8's husband] ...." The record failed to indicate the type, strength, quantity of the narcotics disposed and how they were disposed. 12. The clinical record of Patient #9 was reviewed on 10/22/21 at 1:40 PM. The record contained a document titled "Visit Note Report," dated 9/16/21, completed by Registered Nurse J, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... RNCM [Registered Nurse Case Manager] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... OxyContin [brand name for Oxycodone] 30 [thirty] mg 5 tabs [tablets] ... Oxycodone 20 [twenty] mg 1 [one] tab ...." The record failed to indicate how the narcotics were disposed. 13. The clinical record of Patient #11 was reviewed on 10/22/21 at 1:55 PM. The record contained a document titled "Visit Note Report," dated 5/9/21, completed by Registered Nurse M, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Was family educated on safe disposal of controlled drugs and medications? ... Disposed of per facility protocol ...." The record failed to indicate the type, strength, quantity of the narcotics disposed and how they were disposed. 14. The chart of Patient #12 was reviewed on 10/22/21 at 6:00 PM. A document titled "Visit Note Report," dated 7/23/21, completed by Registered Nurse O, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Was family/caregiver[s] instructed on safe disposal of controlled drugs and medications? ... Disposed of per facility protocol ...." The record failed to indicate the type, strength, quantity of the narcotics disposed and how they were disposed. 15. The chart of Patient #13 was reviewed on 10/22/21 at 6:05 PM. A document titled "Visit Note Report," dated 6/18/21, completed by Registered Nurse G, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine Concentrate [treats severe ongoing pain] 30 [thirty] ml [milliliter] and Ativan [treats anxiety disorders] 0.5 [one half] mg [milligram] 16 [sixteen] tabs [tablets] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... Pt [patient] wife and [Registered Nurse G] ...." The record failed to indicate the type and strength of the narcotics disposed and how they were disposed. 16. The chart of Patient #14 was reviewed on 10/22/21 at 6:10 PM. A document titled "Visit Note Report," dated 8/30/21, completed by Licensed Practical Nurse P, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Was family/caregiver[s] instructed on safe disposal of controlled drugs and medications? ... Disposed of per facility protocol ...." The record failed to indicate the type, strength, quantity of the narcotics disposed and how they were disposed. 17. The chart of Patient #15 was reviewed on 10/22/21 at 6:15 PM. A document titled "Visit Note Report," dated 6/3/21, completed by Registered Nurse I, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine [treats severe ongoing pain] 28 [twenty-eight] ml [milliliter] and Lorazepam [treats anxiety disorders] 1 [one] mg [milligram] 15 [fifteen] tabs [tablets] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Patient #15's husband] ...." The record failed to indicate how the narcotics were destroyed in the home. 18. The chart of Patient #16 was reviewed on 10/22/21 at 7:45 PM. A document titled "Visit Note Report," dated 6/18/21, completed by Registered Nurse G, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine Concentrate [treats severe ongoing pain] 27 [twenty-seven] ml [milliliter] and Ativan [treats anxiety disorders]18 [eighteen] tabs [tablets] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... wife and hospice nurse ...." The record failed to indicate the type and strength of the narcotics disposed and how they were disposed. 19. The chart of Patient #17 was reviewed on 10/22/21 at 6:20 PM. A document titled "Visit Note Report," dated 6/17/21, completed by Registered Nurse K, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine Concentrate [treats severe ongoing pain] 27 [twenty-seven] ml [milliliter] and Ativan [treats anxiety disorders] 0.5 [one-half] mg [milligram] 18 [eighteen] = [sic] 26 [twenty-six] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Patient #17's granddaughter] ...." The record failed to indicate the type and strength of the narcotics disposed and how they were disposed. 20. The chart of Patient #18 was reviewed on 10/22/21 at 6:25 PM. A document titled "Visit Note Report," dated 7/6/21, completed by Registered Nurse Q, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine [treats severe ongoing pain] 20 [twenty] ml [milliliter]/ml and Ativan [treats anxiety disorders] 0.5 [one-half] mg [milligram] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Patient #18's daughter in law] ...." The record failed to indicate the quantity of the narcotics disposed. 21. The chart of Patient #19 was reviewed on 10/22/21 at 6:30 PM. A document titled "Visit Note Report," dated 9/16/21, completed by License Practical Nurse R, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine Sulfate [treats severe ongoing pain] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Patient #19's son] ...." The record failed to indicate the type, strength, quantity of the narcotics disposed and how they were disposed. 22. The chart of Patient #21 was reviewed on 10/22/21 at 6:45 PM. A document titled "Visit Note Report," dated 8/10/21, completed by Registered Nurse I, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine [treats severe ongoing pain] 20 [twenty] mg [milligram]/ml [milliliter] and Lorazepam [treats anxiety disorders] 0.5 [one half] mg ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Patient #21's daughter] ...." The record failed to indicate the quantity of the narcotics destroyed. 23. The chart of Patient #22 was reviewed on 10/22/21 at 6:50 PM. A document titled "Visit Note Report," dated 6/30/21, completed by Registered Nurse S, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine [treats severe ongoing pain] 15 [fifteen] ml [milliliter] and Lorazepam [treats anxiety disorders] 0.5 [one half] mg [milligram] 24 [twenty-four] tabs [tablets] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Patient #22's daughter] ...." The record failed to indicate how the narcotics were destroyed and their strength. 24. The chart of Patient #23 was reviewed on 10/22/21 at 6:55 PM. A document titled "Visit Note Report," dated 9/2/21, completed by Registered Nurse G, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine Concentrate [treats severe ongoing pain] 25 [twenty-five] ml [milliliter] and Ativan [treats anxiety disorders] 0.5 [one half] mg [milligram] 45 [forty-five] tabs [tablets] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... Wife ...." The record failed to indicate the type and strength of the narcotics disposed and how they were disposed. 25. The chart of Patient #24 was reviewed on 10/22/21 at 7:00 PM. A document titled "Visit Note Report," dated 7/15/21, completed by Registered Nurse L, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Comfort Kit ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Patient #24's niece] ...." The record failed to indicate the type, strength, and quantity of the narcotics disposed. 26. The chart of Patient #25 was reviewed on 10/22/21 at 7:10 PM. A document titled "Visit Note Report," dated 8/2/21, completed by Registered Nurse S, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine [treats severe ongoing pain] 15 [fifteen] ml [milliliter] and Lorazepam [treats anxiety disorders] 0.5 [one half] mg [milligram] 6 [six] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Patient #25's daughter] ...." The record failed to indicate how the narcotics were destroyed. 27. The chart of Patient #26 was reviewed on 10/22/21 at 7:15 PM. A document titled "Visit Note Report," dated 5/30/21, completed by Registered Nurse G, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine Concentrate [treats severe ongoing pain] 24 [twenty-four] ml [milliliter], Ativan [treats anxiety disorders] 0.5 [one half] mg [milligram] 23 [twenty-three] tabs [tablets], Fentanyl [treats severe pain] 25 [twenty-five] mcg [micrograms] X1 [quantity of one] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... Disposed with family ...." The record failed to indicate how the narcotics were disposed. 28. The clinical record of Patient #27 was reviewed on 10/22/21 at 7:20 PM. The record contained a document titled "Visit Note Report," dated 10/11/21, completed by Registered Nurse F, which indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Was family educated on safe disposal of controlled drugs and medications? ... Disposed of per facility protocol ...." The record failed to indicate the type, strength, quantity of the narcotics disposed and how they were disposed. 29. The chart of Patient #28 was reviewed on 10/22/21 at 7:25 PM. A document titled "Visit Note Report," dated 6/17/21, completed by Registered Nurse K, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine ER [extended release; treats severe ongoing pain] 30 [thirty] 59 [fifty-nine] ... Morphine 15 [fifteen] mg 86 [eighty-six] ... Ativan [treats anxiety disorders] 0.5 [one-half] mg [milligram] 6 [six] ... Ativan 1 [one] mg 7 [seven] ... Oxycodone [treats severe pain] 5 [five] mg 120 [one hundred twenty] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... [Patient #28's son] ...." The record failed to indicate the type and strength of the narcotics disposed and how they were disposed. 30. The chart of Patient #29 was reviewed on 10/22/21 at 7:30 PM. A document titled "Visit Note Report," dated 9/19/21, completed by Registered Nurse L, indicated, " ...Visit Type ... SN [skilled nurse] Hospice Death At Home ... Medications ... Indicate narcotic/medication disposal ... type ... strength ... quantity ... how disposed ... Morphine [treats severe pain] and Ativan [treats anxiety] ... Full name and relationship to patient of person[s] legally authorized to dispose of controlled drugs and medications ... " [sic] ...." The record failed to indicate the type, strength, and quantity of the narcotics disposed. 31. During an interview on 10/22/21 at 1:35 PM, when asked if they had ever seen medications from the metal cabinet in Former Patient Care Manger B's office, Registered Nurse I indicated, "We do have an emergency supply in the manager's office. There is no sign out sheet. There are partially used mediations in there, but I've never used the partial ones." 32. During an interview on 10/22/21 at 2:15 PM, when asked why medications had not been destroyed in the patients' homes, Former Administrator A, Former Patient Care Manager B, and Area Manager D indicated, "I do not know."