Every finding on record at Hope & Mercy Hospice Care Inc

Based on interview and record review, the agency failed to follow its policy and procedure to develop and maintain a system of communication and integration for two of four sampled patients (Patients 1 and 2), when the patients’ home clinical record binders did not contain their current care plans (a guide that lists their medical and emotional needs, including treatments, medications, and personal wishes, to ensure their comfort and care) including the most current Medication Profile (MP-a current list of all medications prescribed for a specific patient).This failure had the potential to result in ineffective care coordination, unmanaged symptoms, and medication errors (mistakes with medicines that can cause harm or stop proper treatment), which could place Patient 1 and 2’s safety, comfort, and overall well-being at serious risk in his end-of-life care. Findings: A review of Patient 1’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of January 27, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice (medical care for people who are expected to live six months or less) services) of March 18, 2025 to June 15, 2025.  Patient 1 had primary diagnosis of Parkinson`s disease without dyskinesia (movement disorder that causes tremors, stiffness, and slow movements, but without the involuntary, jerky movements). During a visit at Patient 1's home, on April 9, 2025, at 10:00 AM, with License Vocational Nurse 1 (LVN 1), in the presence of Patient 1 and Patient 1’s husband, a review of Patient 1’s home clinical record binder and the surrounding area of the home was conducted. Patient 1’s current care plan, including the most recent MP, were not found in the binder or anywhere in the house. Both LVN 1 and Patient 1‘s husband confirmed these essential documents were not available. 2. A review of Patient 2’s face sheet indicated a start of care date of February 28, 2025 with a certification period of February 28, 2025 to May 28, 2025.  Patient 2 had primary diagnoses that included senile degeneration of brain (gradual decline in brain function due to aging) and Parkinsonism. During a visit at Patient 2's home, on April 9, 2025, at 12:05 PM, with LVN 1, in the presence of Patient 2 and Patient 2’s daughter and son in law, a review of Patient 2’s home clinical record binder and the surrounding area was conducted. Patient 2’s current care plan including the most recent MP were not found in the binder or anywhere in the house. Both LVN 1 and Patient 2‘s daughter confirmed that these essential documents were not available. During an interview and record review on April 10, 2025, at 12:45 PM, with the Administrator (Admin), the Admin stated, “It is the responsibility of the visiting nurse and case manager to ensure that the current care plan including the most recent Medication Profile (MP), and other essential documents are left at the patient’s location and are easily accessible.” The Admin further stated the current care plan including the most recent MP were crucial for maintaining effective care coordination, proper medication management, timely clinical responses and to facilitate continuity of care. During a concurrent interview and record review on April 10, 2025, at 1:15 PM, with the Admin, the Admin reviewed the agency’s policy and procedure (P&P) titled “Contents of the Clinical Records”, revised April 2020, which indicated, “PURPOSE. To outline the requirements for and components of a clinical record. POLICY. A clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe patient problems/needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. PROCEDURE: … M. Record and findings of initial, comprehensive and updated comprehensive assessments. N. Every dose of medication administered by organization personnel, patient response and any adverse drug reaction….  S. Care planning activity {initial and updated POCs) based on the patient's problem and needs …”. The Admin stated the agency did not follow the policy.

Based on observation, interview, and record review, the agency failed to ensure nursing staff provided required care and services, including conducting a complete medication reconciliation (process of identifying the most accurate list of all medications that the patient is taking) during the initial and recertification assessments for one of four sampled patients (Patient 2), when two of Patient 2’s medications were not reflected on the Medication Profile (MP—a current list of all prescribed  medications for the patient).This failure had the potential to cause inconsistencies in medication management, ineffective drug therapy, adverse side effects, and noncompliance, placing Patient 2’s health and safety at risk.Findings:A review of Patient 2’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of February 28, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of February 28, 2025, to May 28, 2025.  Patient 2 had primary diagnoses of senile degeneration of brain (gradual decline in brain function due to aging) and Parkinsonism (conditions that cause movement-related symptoms like tremors, stiffness, and slowed movements).During a visit at Patient 2's home, on April 9, 2025, at 12:10 PM, with a Licensed Vocational Nurse 1 (LVN 1), in the presence of Patient 2 and Patient 2’s daughter, Patient 2’s medications, which were available at home, were compared with Patient 2’s most current MP.  During a concurrent observation and interview on April 9, 2025, at 12:20 PM, with LVN 1, LVN 1 checked a bottle of Levothyroxine Sodium (a prescription medicine that treat people with low thyroid [hormone that control how your body uses energy]) 75 mcg (microgram-a unit of measure) one tablet by mouth once daily. LVN 1 reviewed Patient 2’s MP and acknowledged there was no order of Levothyroxine Sodium 75 mcg on Patient 2’s MP.During an interview on April 9, 2025, at 12:25 PM, with Patient 2’s daughter, Patient 2’s daughter stated, “She [Patient 2] had been taking Levothyroxine Sodium for more than 30 years even before starting hospice (care that helps people with a terminal illness feel comfortable and supported in their final stages of life). Her doctor is aware of it.”During further observation and interview on April 9, 2025, at 12:30 PM, with LVN 1, LVN 1 provided treatment to Patient 2. LVN 1 administered triple antibiotic ointment (topical medicine used to prevent infection in minor cuts, scrapes, and burns) onto Patient 2’s left forearm, then covered it with gauze. Upon reviewing Patient 2’s MP, LVN 1 acknowledged there was no order for the application of triple antibiotic ointment on Patient 2’s MP.During further interview on April 9, 2025, at 12:40 PM, with LVN 1, LVN 1 stated it was her responsibility to conduct medication reconciliation during visits to make sure the MP remains accurate and up to date for both medications and treatments.During a follow-up interview on April 10, 2025, at 11:30 AM, with the Administrator (Admin), the Admin stated, “It was the visiting nurse and case manager’s responsibility to update Medication Profile when there's any new order or changes. Nurses should have been reviewing, updating medication profile on their visits and the printed MP should have been updated accordingly.”During a concurrent interview and record review on April 10, 2025, at 12:30 PM, the Admin reviewed the agency’s policy and procedure (P&P) titled “Medication Profile,” revised April 2020, which indicated, “PURPOSE To define the use of the medication profile in evaluating a patient's current medication regimen. POLICY Patients receiving medications administered by hospice 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. PROCEDURE… 2. The admitting nurse will initiate a medication profile to document the current medication regiment… 5. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. …”. The Admin stated the agency did not follow the policy. During further interview and concurrent record review on April 10, 2025, at 1:30 PM, the Admin reviewed the agency’s P&P titled “JOB DESCRIPTION. Staff Nurse,” which indicated “… Essential Functions: 9. Performs specific nursing procedures as needed (e.g., treatments, management of symptoms) following doctor's orders…” and reviewed the agency’s P&P titled “JOB DESCRIPTION. Licensed Practical Vocational Nurse (LPN/LVN)”, indicated “… RESPONSIBILITIES: … 3. Provides nursing service , treatments and diagnostic and preventive procedures as assigned…. 7. Maintains accurate and complete records of observations, treatments and care of patient…”. The Admin stated the agency did not follow the policy.

Observed in Record Review. In 1 of 1 patient records reviewed, for patients who were discharged for extended prognosis, the agency failed to follow CMS regulations for providing proper discharge notice. In RR#1 the NOMC was signed on date of discharge. It did not provide the name and contact number of the QIO. Additionally the agency used the outdated CMS Form-10095 instead of the current CMS Form 10123. This was validated with the office manager and the DPCS/Administrator. The agency partially corrected this issue on site. The office manager downloaded the correct form, made necessary edits to include the agency information and information for the QIO to use with any further discharges.

Observed in Record Review. In 2 of 5 patient records reviewed, the plan of care failed to address all of the patient/family needs as identified in the comprehensive assessment. In HV#1 the MSW Social worker documented discussed IHSS. Patient states that she currently has IHSS but is unsure of the hours. Social worker educated patient on how to advocate for more hours in the future. The MSW further assessed that funeral arrangements were made but the daughter did not have details available at time of initial assessment. The MSW noted the need for assistance with IHSS in the plan of care but did not establish any visit frequency or other interventions to address this need. Instead she left it to the daughter to call hospice and provide the details on her ability to get additional hours and to provide details about the funeral arrangements at a later date. Three months after that initial assessment there were no mortuary plans documented in the patient profile. No further visits or phone contact were documented. Similarly in RR#2 on the initial assessment visit the MSW assisted the family in applying for IHHS support and also discussed the needs for making final arrangements but plans were for the social worker to revisit at recertification three months later. The need to assist with final arrangements was not addressed on the plan of care. The need for follow up on the IHHS application was identified in the plan of care but there were no follow up for 2 months at which time the MSW documented that the family still needed assistance and she would assist them to have the physician complete the medical part of the application within the following 45 days. The patient revoked services before any further interventions were documented. This was validated with the DPCS/Administrator.

Observed in Patient Home. In 1 of 1 home visits conducted, in which aide services were observed the aide failed to follow the plan of care. In HV#2 the aide plan of care instructed the aide to raise side rails. The aide turned her back on the patient several times to get additional supplies and she left the room while leaving patient side rails down.

Observed in HR File Review. In 1 of 6 HR files reviewed, the agency failed to document training in accordance with OSHA requirements. In HR#1 for the medical director the agency did not have documentation in the HR record of annual training on Bloodborne pathogens and Infection Control. This was validated with the office manager.