Every finding on record at Hillside Hospice LLC

Upon patient record review, 4 of 14 (Patient #1,#2,#3,#5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: Nursing documentation on 6/14/23 and 6/27/23 that the patient was using Tylenol for pain control. There is no evidence that Tylenol is on the medication administration record. Corrected on site. Patient 2: Nursing documentation on 6/22/23 that the patient's pain medication regimen changed from Morphine 0.5 ml by mouth every four hours as needed to Morphine 0.5 ml by mouth every two hours as needed. There is no evidence that the frequency of use was updated on the medication profile. Corrected on site. Patient 3:Upon admission, the patient's medication administration record with entry of MiraLAX powder 17 grams daily as needed. There was no evidence on the medication administration record of the type and amount of diluent needed for MiraLAX administration. Corrected on site Patient 5:The patient medical record contains documentation on 6/28/23 of patient utilizing oxygen at 4 liters per minute via NC. There is no evidence of Oxygen liter flow on the medication administration record. Corrected on site.

Upon patient record review, 2 of 14 (Patient #3,#4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3: The patients medical record contained nursing documentation upon admission of primary diagnosis of kidney disease with comorbidity of diabetes mellitus requiring insulin administration with recurring wound and nutritional issues. There was no evidence of care plan problems with goals and interventions related to management of renal disease and diabetes mellitus. Corrected on site. Patient 4: The patients medical record contained nursing documentation upon admission of primary diagnosis of endometrial cancer. There was no evidence of care plan problems with goals and interventions related to the management of the primary diagnosis of cancer. Corrected on site.

Upon patient record review, 4 of 14 (Patient #1,#2,#3,#5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: Nursing documentation on 6/14 23 and 6/27/23 that the patient was using Tylenol for pain control. There is no evidence of an order for Tylenol. Corrected on site. Patient 2: Nursing documentation on 6/22/23 that the patient's pain medication regimen changed from Morphine 0.5 ml every four hours to Morphine 0.5 ml every two hours. The order for Morphine includes the frequency as every four hours with the instructions for use note that the frequency of administration is every two hours. Nursing documentation on 6/27/23 includes that the patient is receiving oxygen via nasal cannula at 8 LPM with continued shortness of breath and the nurse ordered a mask as an alternate delivery route. The medication administration record included oxygen to be delivered at 6-7 LPM via nasal cannula. There is no evidence that oxygen delivered at 8 LPM and delivery route of mask are ordered. Corrected on site. Patient 3: Orders for MiraLAX powder 17 grams daily as needed there was no evidence of the type and amount of diluent. Corrected on site Patient 5: The patient medical record contains documentation on 6/28/23 of patient utilizing oxygen at 4 liters per minute via NC. The order for oxygen does not include a liter flow. Corrected on site.

Upon client record review, 1 of 14 (Patient #14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 14: The patient's medical record contains nursing documentation on 8/24/22 that the skilled nurse changed the suprapubic catheter as ordered by the physician. The admission order states a 20 French catheter with the balloon inflation of 30cc should be inserted. On 8/24/22 and 9/2/22 the skilled nurse noted that a 20 French catheter with the balloon inflation of 5 cc was inserted on 8/24/23.

Based on a review of agency documents and interviews it was determined the agency failed to ensure to protect the patient and patient caregivers right to voice grievances and have those grievances investigated and a resolution reached with notification of the resolution made to the complainant for one (1) of one (1) clinical records in the survey sample (clinical record #1). --- The findings: The agency's complaint log was reviewed in the agency on 04/03/2023. The complaint log did not contain documentation of this complaint or any complaints since 2020. On 04/03/2023 at 5 PM, the Administrator stated, ";we only had 2 complaints for 2022 and they are in my head". The Administrator stated, (patients name redacted) patient #1 was one of the complaints. On 04/03/2023, the agency's ";Patient Information Booklet" was reviewed and read in part as follows: "All complaints are documented in a complaint log by the Director of Hospice Services no more than 5 (five) business days from the date the complaint was first received. Appropriate personnel conduct a documented investigation of all written or verbal complaints received by the hospice. Complaints are tracked regularly reviewed to identify patterns or trends and performance improvement opportunities". A copy of the agency's complaint policy was provided on 04/04/2023 at 1:00 PM to the Medical Facilities Inspector. The policy was titled, "Patient Complaint/Grievance Reporting". This policy read the same as the agencys admission packet as mentioned above. The above noted findings regarding the incomplete process for handling the complaint and their resolution for a patient was reviewed with the Administrator on 04/03/2023 and 04/04/2023.

Based on a review of clinical records and staff interviews, it was determined the agency failed to have a medication profile in the patient's comprehensive assessment for one (1) of five (5) patients in the survey sample (Clinical record# 1). --- The findings: Five clinical records were reviewed in the agency on April 03-04, 2023, with electronic read only access. The clinical record for patient #1 was reviewed for the recertification period of 03/24/2022 to 03/30/2022 (the patient expired on 03/30/2022). Patient's #1's plan of care contained a primary diagnosis of hypertensive heart disease and chronic kidney disease with heart failure. The clinical record documented education to the caregivers regarding instructions of liquid Morphine dosages as follows: · 3/25/2022-Caregivers instructed on proper dosing for Morphine 0.5 ml every 2 hours, and 0.25 ml every hour as needed. · 03/26/2022-Reinforced caregivers proper dosing for Morphine 0.5 ml every 2 hours, and 0.25 ml every hour as needed. Patient is sitting in recliner with head down. RN was able to give Morphine and instructed family on technique to ensure morphine is absorbed. · 03/27/2022-Reinforced caregivers proper dosing for Morphine 0.5 ml every 2 hours, and 0.25 ml every hour as needed. · 03/28/2022-Instructed family to give Morphine 0.25 ml as needed as patient is unresponsive and does not appear to be in any pain. Morphine 15 ml refilled. · 03/29/2022-Family instructed again on Morphine dosing. Family continues to give Morphine ever hour for what they say is respiratory distress. Instructed family to give 0.25 ml of Morphine as needed. · 03/30/2022-Daughter gave 0.5 ml immediately after explaining that should give 0.25 ml. · 03/30/2022-Absence of vital signs confirmed. 45 ml of morphine disposed. During the clinical record review, it was noted, the patients medication list was not available for review. The record failed to contain documentation of the patients medication list and verbal orders. Staff interviews: On 04/04/2023 at 10 AM, the Medical Facilities Inspector (MFI) asked the Administrator where the medication profile and verbal orders was. The Administrator stated, ";I do not know" and provided the MFI with the medication list from the patients pharmacy. The pharmacy list included: Gentle Laxative suppository 10 mg and Lorazepam concentrate 2mg/ml ordered on 03/24/2022; Morphine 15 ml and Hyosyne 0.125/ml ordered on 03/25/2022; Morphine 15 ml ordered on 03/28/2022; Morphine 30 ml ordered 03/29/2022; Lorazepam concentrate 2mg/ml ordered on 03/30/2022. On 04/04/2023 at 10:40 AM, the MFI asked the Administrator to call the Medical Director and place on speaker phone. The Medical Director stated, ";I am unaware of a missing medication list" During the interview the Medical Director confirmed that the doses of Morphine for patient #1 would have been 0.5 ml every 2 hours and 0.25 ml as needed for distress/pain/shortness of breath until pain is resolved then 0.25 ml as needed. The above noted findings regarding no documentation of the patients medication list and verbal orders for patient #1 was reviewed with the Administrator on 04/03/2023 and 04/04/2023.

Based on a review of the clinical records and staff interview it was determined the agency staff failed to ensure that oxygen and treatments were listed as a medication on the plan of care for five (5) of five (5) patients on oxygen therapy and/or wound treatment in the survey sample (Clinical records# 1-5). --- The findings: Five clinical records were reviewed in the agency on April 03-04, 2023, with electronic read only access. The clinical record for patient #1, with a documented start of care date of 03/24/2022 contained documentation the patient was on oxygen at 2 lpm nc (liters per minute via nasal cannula). The clinical record failed to contain a medication list. The clinical record for patient #2, with a documented start of care date of 12/28/2021 contained documentation the patient was on oxygen at 2 lpm nc and to apply Medi honey (ointment with antibacterial and anti-inflammatory properties) to left buttock. The clinical record contained a medication list but failed to contain oxygen and Medi honey. The clinical record for patient #3, with a documented start of care date of 06/04/2021 contained documentation the patient was using oxygen more frequently. The clinical record contained a medication list but failed to contain oxygen. The clinical record for patient #4, with a documented start of care date of 07/06/2022 contained documentation of Calmoseptine (moisture barrier) to be applied to the sacrum. The clinical record contained a medication list but failed to contain Calmoseptine. The clinical record for patient #5, with a documented start of care date of 12/03/2020 contained documentation of Medi honey to be applied to the forehead and Calmoseptine with each diaper change. The clinical record contained a medication list but failed to Medi honey and Calmoseptine. On 04/04/2023 the Administrator confirmed and acknowledged the above noted findings during the record reviews and again at the exit conference.