Every finding on record at Legacy Hospice, LLC

Upon observation, there was no evidence the hospice has developed and maintained an emergency preparedness plan that must be reviewed, and updated at least every two years. There was evidence that the Emergency Preparedness Plan was neither updated or reviewed.

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. Upon observation, there was no evidence of a hazard and vulnerability assessment.

Upon personnel record review, 3 of 19 (Personnel #1, #2, #5 ) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel #1, #2, #5- There was no evidence of Emergency Preparedness Training.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years.

Upon patient record review 1 of 19 (Patient #5) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient#5: The patient was admitted on 1/14/23. The record indicated that the spiritual assessment was completed on 1/20/23.

Upon patient record review 1 of 19 (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient#4: There was not evidence of a spiritual assessment.

Upon patient record review, 8 of 19 (Patient #1,#3,#4,#5,#8,#9,#11,#12) 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: Medication profile indicated 2L oxygen. There was no evidence of a route. Corrected onsite. Also, the record indicated order for oxygen 2L. RN visit notes for 10/31/23, 11/8/23, and 12/14 stated patient was on 2.5L-3L oxygen. There was not evidence of an order to change the liter flow. Corrected onsite. Patient#3: The medication profile indicated patient on 3L oxygen, without evidence of a route. Corrected onsite. In addition, Miralax 17 GM daily for constipation. There was not evidence of a diluent. Corrected onsite. Also, Lidocaine Patch 5% topical patch for pain, without evidence of specific location to apply patch. Corrected onsite. Also, Nystop 100,000units/gm topical powder. No evidence of specific location to apply powder. Corrected onsite. Also, Voltaren Arthritis Pain 1% topical gel for arthritis pain. No evidence of specific location to apply gel. Corrected onsite. Patient#4: The certification of terminal illness and nurse documentation indicated that the patient is on 2L oxygen as needed. There was not evidence that oxygen was on the medication profile. Corrected onsite. Also, Biscodyl 10mg rectal suppository, 1 suppository daily PRN constipation, Miralax 17gm oral powder 1 packet daily PRN constipation, and Simethicone 125mg 2 caplets twice daily PRN constipation. There was not evidence of which laxative to use first and under what conditions to use the second laxative. Corrected on site. Patient#5: The medication profile indicated patient on 2L oxygen, without evidence of a route. Corrected onsite. Patient #8: The medication profile indicated for Miralax 17 GM daily for constipation. There was not evidence of a diluent. Corrected onsite. In addition, oxygen 3L/min continuously without evidence of a route. Corrected onsite. Patient #9: The medication profile indicated for Acetaminophen 160mg/5ml., 30ml q6h prn pain or fever, There was not evidence of parameters for the fever. Corrected onsite. Patient#11: The medication profile indicated patient on 1-6L oxygen continuous, without evidence of a route. In addition, medication profile indicated duplicated orders of Lorazepam 0.5mg 2 tablet PO every 4 hours PRN and Lorazepam 0.5mg 1 tablet PO every 4 hours PRN. Patient#12: The medication profile indicated Latanoprost 0.005% eye drops 1 drop at bedtime. There was no evidence of which eye to place drop in.

Upon patient record review, 6 of 19 (Patient #1,#2,#3,#4,#5,#6) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient#1: The patient was admitted on 10/23/23. The record indicated that the bereavement assessment was completed on 11/24/23. Patient#2: The patient was admitted on 10/20/23. The record indicated that the bereavement assessment was completed on 10/30/23. Patient#3: The patient was admitted on 10/17/23. The record indicated that the bereavement assessment was completed on 10/30/23. Patient#4: The patient was admitted on 8/4/23. The record indicated that the bereavement assessment was completed on 10/30/23. Patient#5: The patient was admitted on 1/14/23. The record indicated that the bereavement assessment was completed on 1/22//23. Record #6: The patient was admitted on 11/10/23. The record indicated that the bereavement assessment was completed on 12/1/23.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 4 of 19 (Patient #4,#5,#6,#14) 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#4: The record indicated patient has Atherosclerotic Heart Disease diagnosis and a 19% ejection fraction rate. There was no evidence of a cardiovascular care plan. Corrected onsite. Patient#5: The initial certification of terminal illness indicated multiple falls despite the use of a walker. The certification of terminal illness for the benefit period beginning 11/10/23 indicated that the patient suffered falls several weeks ago.. There was not evidence of falls/safety in the plan of care. Corrected onsite. Patient #6: The certification of terminal illness indicated that the patient has frequent falls. Social work documentation dated 12/4/23 indicated that the grandson stated that the patient falls 1-2x/day. There was not evidence that the hospice has developed an individualized written plan of care that reflects patient/family goals and interventions based on safety, especially in regards to falls. Corrected onsite. Patient#14: Record indicated Stage 2 sacrum pressure ulcer. There was no evidence of a skin integrity/wound care plan.

Upon patient record review, 7 of 19 (Patient #3, #6,#7,#10,#11,#13,#14) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient#3: The initial visit frequencies for the spiritual care counselor and the social worker were both 1 prn Patient #6: The initial visit frequencies for the spiritual care counselor and the social worker were both 1 prn. Patient #7: The initial visit frequency for the social worker was 6 prn. Patient#10: The initial visit frequency for the spiritual care counselor was 1 prn. Patient#11: The initial visit frequencies for the spiritual care counselor and the social worker were both 1 prn. Patient#13: The initial visit frequencies for the spiritual care counselor and the social worker were both 1 prn. Patient#14: The initial visit frequencies for the spiritual care counselor and the social worker were both 1 prn.

Upon patient record review, 8 of 19 (Patient #1, #3,#4,#5,#8,#9,#11,#12) 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: Record indicated order for oxygen 2L. RN visit notes for 10/31/23, 11/8/23, and 12/14 stated patient was on 2.5L-3L oxygen. There was no evidence of an order to adjust the liter flow. Corrected onsite. In addition, record indicated 2L oxygen. There was no evidence of a route. Corrected onsite. Patient#3: The record indicated patient on 3L oxygen, without evidence of a route. Corrected onsite.. Also, Miralax 17 GM daily for constipation. There was not evidence of a diluent. Corrected onsite. Also, Lidocaine Patch 5% topical patch for pain, without evidence of specific location to apply patch. Corrected onsite. Also, Nystop 100,000units/gm topical powder. No evidence of specific location to apply powder. Corrected onsite. Also, Voltaren Arthritis Pain 1% topical gel for arthritis pain. No evidence of specific location to apply gel. Corrected onsite. Patient#4: The certification of terminal illness and nurse documentation indicated that the patient is on 2L oxygen as needed. There was not evidence of an order for oxygen. Corrected onsite. Also, Biscodyl 10mg rectal suppository, 1 suppository daily PRN constipation, Miralax 17gm oral powder 1 packet daily PRN constipation, and Simethicone 125mg 2 caplets twice daily PRN constipation. There was not evidence of which laxative to use first and under what conditions to use the second laxative. Corrected on site. Patient#5: The record indicated patient on 2L oxygen, without evidence of a route. Corrected onsite. Patient #8: The record indicated for Miralax 17 GM daily for constipation. There was not evidence of a diluent. Corrected onsite. In addition, oxygen 3L/min continuously without evidence of a route. Corrected onsite. Patient #9: The record indicated that the patient had a Foley catheter. There was not evidence of an order for the foley, including the catheter size, balloon size, or under what conditions to change or flush the catheter. Corrected onsite. In addition, the record indicated for Acetaminophen 160mg/5ml., 30ml q6h prn pain or fever, There was not evidence of parameters for the fever. Corrected onsite. Patient#11: The record indicated patient on 1-6L oxygen continuous, without evidence of a route. Patient#12: The record indicated Latanoprost 0.005% eye drops 1 drop at bedtime. There was no evidence of which eye to place drop in.

Upon patient record review, 2 of 19 (Patient #1, #3) 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 equipment and supply needs. Patient#1: Record indicated DME listed as "none." There was evidence that patient had a wheelchair, walker, nebulizer and was on oxygen. Corrected onsite. Patient#3: The record indicated patient has COPD diagnosis and on 3L oxygen. There was no evidence of oxygen on plan of care. Corrected onsite.

Upon patient record review, 3 of 19 (Patient #1, #4,#5) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient#1: Record indicated that patient had Advance Care Directives (signed 11/29/23). All IDG meeting reports/updated plan of care, including 12/6/23 stated, "No Advance Care Directives." Patient#4: The social worker documentation in the plan of care indicated a goal of facilitating discussion to patient regarding advance directives. The patient had an advance directive and this was a part of the record. There was not evidence that the plan of care was revised and this goal remained on the plan of care. Corrected onsite. Patient#5: The record indicated patient had a left wrist skin tear with wound care orders. There was no evidence of a skin or wound care plan.

Upon client record review, 8 of 19 (Patient #2,#4,#5,#7,#10,#11,#12,#13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#2: The record indicated chaplain visit frequency for an evaluation then 3M2, 2M1, 1M1. Evaluation was conducted on 10/25/23. A missed visit document was in the record dated 11/1/23, and a routine visit on 11/27/23. Patient#4: For the benefit period beginning on 11/2/23, the skilled nurse visit frequency was 1W6. The record indicated visits on 11/9/23, 11/22/23, and 12/6/23. Patient#5: The visit frequency for the skilled nurse in the benefit period beginning 11/10/23 was 1 every 2W2, 1W7. The record indicated visits on 11/14/23, 11/20/23, 12/1/23, and 12/7/23 Patient #7: The skilled nurse visit for the benefit period beginning on 9/19/23 was 2x/week. For the week of 11/12/23-11/18/23, the record indicated only 1 visit. And, for the benefit period beginning 11/18/23, the skilled nurse visit frequency was 1 every 2W2, 2W1, 1W6. The record indicated that visits were conducted on 11/20/23, 11/27/23, 12/1/23, 12/7/23, and 12/14/23. Patient#10: The skilled nurse visit frequency was 6W1, 2W12. The record indicated visits on 10/2/23, 10/3/23, and 10/5/23. Also, chaplain visit frequency 1 visit every 2M2, 2M1, 4PRN. The record indicated an evaluation on 10/6/23, with 2 routine visits on 11/3/23 and 12/1/23. Patient#11: The record indicated the chaplain visit frequency 2 visits every 2M2, 3M1. The record indicated 2 visits on 11/20/23 and 12/5/23 Patient#12: The record indicated the skilled nurse frequency of 1W1, 4W1, 2W12. The record indicated visits on 12/9/23 for week 1, followed by visits on 12/10/23, 12/12/23, and 12/14/23. Patient #13: The skilled nurse visit frequency was 2x/week. For the week of 11/26/23 -12/2/23, the record indicated only 1 visit on 12/1/23.

Upon patient record review, 3 of 19 (Patient #3,#6,#8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient #3: The aide care plan indicated to provide a bed bath and a shower at every visit. Corrected onsite. Patient #6: The certification of terminal illness indicated that the patient has frequent falls. Social work documentation dated 12/4/23 indicated that the grandson stated that the patient falls 1-2x/day. There was not evidence of fall precautions on the aide plan of care. Corrected onsite. Patient #8: The aide plan of care indicated to provide a bed bath weekly and to shower at every visit. (Aide visit frequency was 2x/week). Corrected onsite.

Upon patient record review 5 of 19 (Patient #1,#3,#6,#10,#13) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient#1: The record indicated no aide visits made from SOC 10/23/23-10/29/23. Aide visit frequency was 2x/week. Patient#3: The record indicated aide visit frequency was 2x/week. From 12/3/23-12/9/23, there was evidence of only 1 visit during this week. Also, the aide plan of care indicated to provide the task of nail care and shampoo weekly. From 10/24/23 to current, the record indicated that the aide performed a shampoo at all visits and nail care at most visits. Patient #6: The aide plan of care indicated to provide the task of nail care weekly. The record indicated that the aide performed this task at all visits. In addition, the aide visit frequency was 2x/week. For the weeks of 11/19/23-11/25/23 and 11/26/23-12/2/23, the record indicated only 1 visit each of these weeks. Patient#10: The aide plan of care indicated to provide the tasks of bath or shower and nail care weekly. The record indicated that the aide performed these tasks at all visits. In addition, aide visit frequency was 2x/week. From 11/19/23-11/25/23, there was evidence of only 1 visit on 11/22/23. Patient#13: The aide visit frequency was 2x/week. There was evidence that only 1 visit was made from 11/19/23-11/25/23.

Upon patient record review 1 of 19 (Patient #3) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient#3: The record indicated an aide supervisory visit on 11/6/23. There was not evidence of another aide supervisory visit until 11/28/23 which is greater than the 14 day requirement.

Upon personnel record review, 1 of 13 (Personnel #3) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel#3: Staff member holds roles of BC and SCC. There was not evidence of a competency for BC.

Upon patient client record review, 1 of 19 (Patient #7) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #7: The benefit election indicated that the patient/representative wished to receive the Notification of non-covered items. There was not evidence that this was furnished. Corrected onsite (Attestation obtained).

Upon client record review, 1 of 19 (Patient #8) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #8: The social work visit frequency was 6 PRN. The record indicated that routine visits were conducted on 9/7/23, 9/22/23, 10/11/23, 10/23/23, and 11/7/23.

Upon personnel record review, 1 of 19 (Personnel #5) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel#5: There was not evidence of a Speech Therapist personnel file.

Upon personnel record review, 1 of 13 (Personnel #1) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel#1: There was not evidence of the Occupational Therapist personnel file.

Upon personnel record review, 1 of 13 (Personnel # 2) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel#2: There was not evidence of a personnel file for a Physical Therapist.

Upon personnel record review, 3 of 13 (Personnel #1, #2, #5 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #1, #2, #5: There was no evidence of initial criminal background checks being obtained.

Upon personnel record review, 1 of 13 (Personnel #3) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #3, : No evidence of criminal background checks being obtained in accordance with state requirements.

Based on interview and record review, the hospice failed to ensure patients received effective symptom control for 1 of 1 patient records reviewed who required a catheter (Patient #1). Findings include: HOSPICE POLICY According to the policy, "Hospice Nursing Care," dated 11/2020, in part: "The hospice nurse will: -Manage discomfort and provide symptom relief according to physician orders. -A hospice nurse will be available on a 24-hour basis to meet the physical, psychosocial, spiritual and practical needs of patients and families/caregivers admitted to the hospice program." According to the policy, "On Call Response," dated 8/2021, in part: "We are responsible to provide clinical excellance (sic) in all On Call responses to patient needs. All calls received after hours are to be effectively triaged and the need of the patient/caregiver or facility staff is to be accurately determined, responded to and documented." 1. The clinical record for Patient #1 was reviewed on 6/9/22. The patient was admitted for hospice care and services on 2/16/22, with a terminal diagnosis of secondary malignant neoplasm of the lung. Plan of care for the certification period dated 4/17 to 6/15/22 included orders for skilled nurse (SN) visits twice weekly for two weeks and three visits as needed (PRN) for symptom management; medical social worker (MSW) once monthly for one month, three times monthly for one month then once monthly for one month; chaplain visits once monthly for one month; and home health aide (HHA) visits twice weekly for two weeks. The patient resided at home. a) The hospice failed to provide adequate pain management and symptom control for Patient #1. Review of the hospice's on-call logs for May 2022 revealed a family member of Patient #1 made three calls to the hospice after hours on-call service on 5/14/22. Specifically, at 9:52 a.m., Patient #1's family member called and reported Patient #1's stomach was distended, hard, and she had no urine output in days; at 3:14 p.m., the family member called regarding the status of the catheter placement for Patient #1; and at 6:45 p.m., the family member called regarding Patient #1's pain level. Review of a SN visit note, initiated by registered nurse (RN) #2 on 5/14/22 and completed by RN #2 on 6/9/22, revealed RN #2 completed a PRN SN visit to Patient #1 at 12:20 p.m. following the initial call to the hospice after hours on-call service at 9:52 a.m. RN #2 documented he received a message that Patient #1's belly was distended and the nurse from the previous day had indicated if the patient didn't pass urine, the family should call the hospice to have a Foley catheter placed on Saturday (5/14/22). The family member reported Patient #1 had not had urine output for approximately five to seven days, however, according to RN #2, the family member stated the situation was "not emergent." RN #2 continued to document when he arrived at the patient's home at 12:20 p.m., her abdomen was "visibly distended" but Patient #1 had no verbalization or physical indication of pain with palpation (process of pressing on the surface of the body to feel the organs and tissues underneath). He documented he attempted to place a straight catheter (thin tubing inserted into the bladder to relieve urinary retention in the bladder) twice without success. He documented he placed a call to the hospice's executive director and received additional information for other regional resources who could potentially visit Patient #1 and would call the family member back when he had received an answer from those additional resources. However, the record failed to show any communication with Patient #1 or her family for several hours until hospice after hours on-call logs showed Patient #1's family member again called the after hours on-call service at 3:14 p.m. to inquire about the status of RN #2's ability to secure additional resources for the straight catheter placement to provide relief to Patient #1. Upon receipt of the message from the after hours on-call service regarding the call made by Patient #1's family member at 3:14 p.m., RN #2 documented he returned the call "immediately" and informed the family member he had been with other patients and no additional resources were available that day to provide a home visit to Patient #1 to insert the catheter. He documented he informed the family member, she could take the patient to the emergency room (ER) or wait until the next day when another nurse would be available. He further documented the family member agreed that, since the patient was not in distress, they would wait until the next day for another nurse. However, further review of the after hours on-call logs revealed the family member for Patient #1 called the after hours on-call service again at 6:45 p.m. to report Patient #1 was in pain. There was no documentation in the record of any follow up made by the hospice following the family members call at 6:45 p.m. Review of the complaint log revealed the family member for Patient #1 called the hospice on 5/17/22 to report she was upset that a catheter was not placed, was told there were no other nurses to come and attempt to place the catheter, and she was told there was no manager on duty for her to speak to on 5/14/22. The documented intervention for the complaint was an apology to the patient. During an interview on 6/10/22 at 12:29 p.m., the family member for Patient #1 stated she had been very upset about the events of 5/14/22. She stated she was not upset RN #2 was unable to place the catheter, but was upset RN #2 stated he would get someone to come and insert the catheter, left the home and did not provide adequate follow up. She stated she called the after hours on-call again at 3:14 p.m., RN #2 returned the call at approximately 4:00 p.m., told her there was no other nurse available to come to the home and stated the family member could give Patient #1 medication for pain and wait until the following day for another nurse. The family member for Patient #1 further stated she called the after hours on-call again at 6:45 p.m., stating Patient #1 was in pain and she was concerned Patient #1 could "go septic." She stated she was told by the answering service they would obtain the phone number for the local non-emergency services and would call her back to provide that phone number. However, she stated she never received a return call and, instead, paramedics arrived at her home at approximately 8:00 p.m. The family member stated Patient #1 was transported to the ER where the catheter was finally placed and Patient #1's bladder was emptied of urine, 10 hours after Patient #1's family member placed her initial call voicing concerns about Patient #1's distended abdomen and lack of urine output for approximately one week. She stated Patient #1 returned home at 12:30 a.m. on 5/15/22 with a catheter that was still in place to date. 2. During an interview on 6/10/22 at 2:42 p.m. Employee #1 stated after hours on-call visits should be conducted to patients within one hour of receipt of a call to the after hours on-call service, as that was the hospice's expectation. She stated if there were any difficulties experienced by the on-call clinician in providing needed interventions, hospice staff should reach out to the administrator on call (AOC) and should send the patient to the ER if it was the right thing to do for the patient. Employee #1 further stated that, in regards to the situation with Patient #1, the expectation would have been that if RN #2 was unable to place the catheter himself, he should have immediately called and had the patient transported to the ER for further evaluation. She stated when she spoke with RN #2 on 6/9/22, he informed her, he had also had a patient on 5/14/22 who was reported to be in respiratory distress. Employee #1 continued to state the events of 5/14/22, including the length of time between responses provided by the hospice, were not acceptable and she was "at a loss for words" to attempt to explain or justify the lack of response made by the hospice for Patient #1.

Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 418.56, INTERDISCIPLINARY GROUP, CARE PLANNING AND COORDINATION OF SERVICES was out of compliance. A complaint survey initiated on 4/11/22, revealed a pattern of failures in regard to the hospice ensuring the registered nurse case manager (RNCM) coordinated the patient's needs to the interdisciplinary group (IDG). Additionally, the hospice failed to ensure each patient's plan of care included locations of wounds and medical equipment for the palliation of the patient. Further review revealed the hospice failed to ensure the IDG assessed, directed, coordinated and supervised patient care in regards to medication administration and the use of side rails. These failures had the potential to affect all patients served by the hospice. L540- Based on interviews and record review, the hospice failed to ensure the RNCM that was a member of the IDG provided coordination of each patient's needs to the IDG for 1 of 5 patient records reviewed. L549- Based on interview and record review, the hospice failed to ensure each patient's plan of care included all information necessary to meet the needs of the patient for 1 of 3 patients reviewed who had orders for wound care. L550- Based on observation, interview and record review, the hospice failed to ensure each patient's plan of care included all medical supplies and appliances necessary to meet the needs of the patient for 1 of 2 patients reviewed who had bed side rails. L554- Based on interviews and record review, the agency failed to maintain for one of five patients an appropriate system of communication and integration to ensure the IDG maintained responsibility for directing, coordinating, communicating, and supervising all aspects of care and services provided. L555- Based on interview and record review, the hospice failed to ensure care and services were provided in accordance with the plan of care for 3 of 5 patient records reviewed. L556- Based on interview and record review, the hospice failed to ensure care and services were provided according to assessment of patient needs. This failure occurred in 2 of 2 patient records reviewed who were using side rails without documentation of nursing assessments of the patient and family needs and least restrictive interventions utilized.

Based on interviews and record review, the hospice failed to ensure the registered nurse case manager (RNCM) that was a member of the interdisciplinary group (IDG) provided coordination of each patient's needs to the IDG for 1 of 5 patient records reviewed (Patient #4). Findings include: I. AGENCY POLICY According to the agency policy titled "Interdisciplinary Group Plan of Care," dated 11/2020 (in pertinent part), "It will be the responsibility of the Case Manager to facilitate communication about changes in the patient's status between interdisciplinary group members and the patient's attending physician if any." A. The clinical record for Patient #4 was reviewed on 4/12/22. The patient was admitted for hospice care and services on 7/5/21 with a terminal diagnosis of congestive heart failure and dementia with behaviors and discharged to another agency on 2/22/22. The plan of care for the certification period 7/5/21 through 10/2/21 included orders for skilled nurse (SN) services two times weekly for one week then once weekly for 12 weeks and three visits as needed (PRN) for symptom management; certified nurse aide (CNA) services one time weekly for one week then twice weekly for 12 weeks; medical social worker (MSW) and chaplain evaluations. The patient resided at home. The plan of care for the certification period dated 10/3/21 through 12/31/21 included orders for SN services one time weekly for 13 weeks; MSW services twice monthly for three months; CNA services three times weekly for 13 weeks; and chaplain services twice a month for three months. The plan of care for the certification period dated 1/1/22 through 3/1/22 included orders for SN services twice every two weeks for two weeks then twice weekly for seven weeks then once weekly for one week and three as needed visits for symptom management; CNA services three times weekly for 13 weeks; and chaplain services twice a month for three months. Review of Patient #4 ' s medication report (a report of all medications prescribed for Patient #4 from the start of care to discharge) showed the patient was to take: -Albuterol Sulfate 2.5mg/3mL solution, 3mL inhaled four times daily starting 7/7/21 for chronic obstructive pulmonary disease (COPD) -Benzonotate 100mg, 1-2 capsules oral every 8 hours starting 12/21/21 for cough -Citalopram 10mg, 1 tablet oral daily starting 7/7/21 for anxiety -Dexamethasone 2mg, 1 tablet oral daily starting 10/26/21 for shortness of breath -Dextromethorphan 15mg, 1 capsule oral 3 times daily starting 10/26/21 for cough -Dextromethorphan 15mg/5mL syrup, 15mg oral every 4 hours starting 7/8/21 for cough -Eliquis 2.5mg, 1 tablet 2 times daily starting 7/7/21 for cerebral vascular accident (CVA) -Furosemide 20mg, 1 tablet oral PRN starting 7/7/21 for edema -Guaifenesin 100mg/5mL, 1200mg oral 2 times daily starting 7/8/21 for congestion -Haloperidol 2mg, 1-2 tablets oral PRN every 6 hours starting 2/5/22 for agitation -Haloperidol Lactate 2mg/mL, 0.5-1mL oral PRN every 6 hours starting 1/14/22 for agitation, anxiety -Loperamide 2mg, 2 tablets oral as directed starting 7/20/21 for loose stool -Lorazepam 0.5mg, 0.25-0.5mg oral every 6 hours starting 7/8/21 for agitation -Macrodantin 100mg, 1 capsule oral daily starting 2/7/22 for infection -Metoprolol 25mg, 1 tablet oral daily starting 10/26/21 for hypertension -Mometasone 50mcg/actuation, nasal as directed starting 7/7/21 -Nexium 40mg, 1 capsule 2 times daily starting 7/20/21 for reflux -Oxycodone 5mg, 2.5mg tablet PRN every 6 hours starting 2/5/22 for pain -Oxygen 1L at bedtime starting 8/12/21 for shortness of breath -Pepcid 20mg, 1 tablet at bedtime starting 7/20/21 for reflux -Quetiapine 25mg, 12.5-25mg tablet at bedtime starting 11/7/21 for agitation -Reglan 10mg, 1 tablet every 6 hours starting 8/2/21 for gastrointestinal (GI) upset -Sucralfate 1g, per instructions daily starting 7/7/21 for GI upset -Trazadone 50mg, 25mg at bedtime starting 8/15/21 for insomnia Discontinued medications included: -Amoxicillin 500mg, 500mg 3 times daily starting 8/23/21, ending 8/30/21 for cellulitis -Cefuroxime 500mg, 1 tablet every 12 hours for 5 days starting 7/7/21, ending 7/6/21 for suspected urinary tract infection (UTI) -Cephalexin 500mg, 1 tablet 4 times daily starting 11/13/21, ending 2/7/22 for right breast swelling -Cipro 500mg, 1 tablet 2 times daily starting 1/16/22, ending 2/4/22 for UTI -Cipro 500mg, 1 tablet 2 times daily starting 2/7/22, ending 2/20/22 for UTI -Moxifloxacin 400mg, 1 tablet daily for 5 days starting 7/7/21, ending 7/8/21 for suspected infection -Moxifloxacin 400mg, 1 tablet daily starting 7/8/21, ending 7/13/21 for suspected infection -Moxifloxacin 400mg, 1 tablet daily starting 8/19/21, ending 8/23/21 for sinus infection -Moxifloxacin 400mg, 1 tablet daily starting 9/1/21, ending 10/25/21 for right breast infection -Moxifloxacin 400mg, 1 tablet daily starting 11/30/21, ending 12/5/21 for UTI -Moxifloxacin 400mg, 1 tablet daily for 7 days starting 12/24/21, ending 12/30/21 for respiratory infection -Quetiapine 25mg, per instruction starting 7/7/21, ending 2/4/22 for agitation 1) The hospice failed to ensure the RNCM who was a member of the IDG coordinated care and ensured Patient #4's plan of care was followed in regards to medication administration. Review of the RN Clinical Notes and On Call Notes dated 7/6/21, 7/29/21, 7/30/21, 8/12/21, 8/14/21, 8/28/21, 8/29/21, 9/18/21, 9/19/21, 9/22/21, 9/24/21, 9/25/21, 9/29/21, 10/4/21, 10/7/21, 10/14/21, 10/18/21, 10/21/21, 10/23/21, 10/24/21, 10/25/21, 10/28/21, 11/1/21, 11/5/21, 11/6/21, 11/15/21, 11/22/21, 11/24/21, 11/25/21, 11/26/21, 12/6/21, 12/10/21, 12/25/21, 12/27/21, 12/31/21, 2/4/22, 2/6/22, 2/12/22, 2/15/22 and completed by various clinicians, revealed Patient #4's daughter called the triage and/or RNCM to inform them she administered medication not listed on the medication profile. The daughter requested medications that were not listed on the medication profile. The daughter called the triage and/or RNCM to inquire into how to administer medications. The RNCM did not ensure medication changes were reflected on the medication profile including instructions for use such as which medications could be given together and ensure the daughter administered medications as ordered by the physician. Review of the IDG documentation dated 7/14/21, 7/28/21, 8/11/21, 8/23/21, 8/25/21, 9/8/21, 10/6/21, 10/20/21, 11/3/21, 11/17/21, 12/1/21, 12/15/21, 12/29/21, 1/12/22, 1/26/22, 2/9/22 revealed the RNCM did not accurately represent the daughter administering medications not listed on the medication profile, requesting medications not ordered and inquiring how to administer medications in the IDG meetings. Although the RNCM conducted assessments and provided education/instruction to the family/caregiver, nothing changed in the home and no new interventions had been implemented to effect change in the home. Clinical record review showed despite the instability in the patient's home in regards to her medication administration, there was no time the RNCM questioned the competency of the caregiver and coordinated that with the IDG. Review of the IDG notes revealed on 7/14/21, the IDG determined the caregiver was capable of providing medication administration to Patient #4, however review of On Call notes showed Patient #4's caregiver repeatedly administered medications not ordered and requested help on how to administer Patient #4's medications. Additionally, all that was recorded as the intervention was caregiver education following each instance of the caregiver requesting help and administering medications not ordered. a. FAMILY INTERVIEW During an interview with the family/caregiver on 4/11/22 at 9:23 a.m., Patient #4's daughter said the agency wanted to sedate her mother after asking them to adjust her medications since they were not effective in controlling her agitation. She said she had to call triage and/or RNCM to get clarification on instructions for administering medications every time her mom was agitated. She said the agency sent medications to the home but did not do an assessment to determine if the medications were necessary. She said the medication profile was not accurate and reflect the current medications Patient #4 was taking. b. STAFF INTERVIEWS During an interview with the RNCM #4 on 4/14/22 at 10:11 a.m. she said RNCM #3 was not available during the survey. RNCM #4 said the family/caregiver would use medications that the patient had used in the past and were effective. When the daughter reported to the agency that she gave a certain medication, RNCM #4 stated she would obtain a physician order and add it to the medication profile. She said the profiles were updated with medication changes and taken to the patient's home on the nurses' next visit. During continued interview, RNCM #4 said the daughter spoke to her about getting miscommunication from the agency. She said it was determined in the IDG to limit the number of people getting physician orders for the patient. She said the family/caregiver would reach out to the triage staff and request medications. RNCM #4 said, she and RNCM #3 reviewed the medications numerous times with the daughter and the daughter agreed with the plan but was nervous about her mom's care and did not follow the medication profile. She said she and RNCM #3 directed the caregiver to call the hospice first before adjusting medications. RNCM #4 further stated, "She took care of her mother for so long that she thought she knew. She called consistently every weekend. She would call based on who was on call to get a different response." She said RNCM #3 and the SW met together in the patient's home to improve communication in the house. During continued interview, RNCM #4 said the medical director/primary physician was aware of the family/caregiver adjusting medications and they were unable to do anything since they could not lock up the medications since the patient could not access them. She said the IDG decided to continue with educating the family/caregiver although the medications were not being used appropriately. She said the daughter had a history with lots of medical providers and brought in past experiences. RNCM #4 stated the daughter questioned everything. During an interview on 4/11/22 at 11:22 a.m. the director of operations (DOO) stated the IDG decided the type of services the patient would receive. She stated, "It's an on-going conversation, not just at IDG. The nurses are good about calling and talking about the needs of patients and asking if we can get different services." During an interview with the regional director of clinical operations (RDCO), the director of operations (DOO) and the area vice president on 4/15/22 at 11:54 a.m., the DOO said there was discussion at every IDG meeting about Patient #4 and the daughter. She said they should have documented the discussion and decision in the IDG notes. During continued interview, the DOO said they submitted a medication list to every family member on admission. She said they felt the daughter was safe to administer medications until Patient #4 was closer to discharge. She said the last (2/15/22) IDG meeting should not have marked the daughter as safe to administer medications since they were concerned and implemented the nurse, social worker (SW) and doctor visits to help with education. She said the doctor (1/13/22) was sent to educate the daughter on giving medications as ordered. She was notified that the doctor's notes did not reflect education to the daughter about safety of administering medications as ordered and during his interview he did not recall the visit other than the daughter focusing on a fish tank and fish for which he found odd. During continued interview, the DOO said the IDG members discussed the competency of the daughter to administer medications as ordered by the physician. She said the daughter did not consistently give medications as ordered and threw away the medication list provided by the nurse. She said they gave a medication list to all patients at admission so the patients would have a copy. She said they did not have a medication administration record in the home that would be signed by the daughter after giving medications and collected by the agency to show whether the medications were given or not. During an interview with the RDCO on 4/15/22 at 12:11 p.m., she said the daughter called triage and the RNCM to report conflicting responses Patient #4 to the medications. She said the daughter would say in one call that Patient #4 was sedated from the medications then call the triage at a later time and report Patient #4 was screaming. She said she was not aware the nurse said that the concern was identified early on after a few weekends after admission of getting on-call notifications. During an interview with the RDCO on 4/15/22 at 1:25 p.m., she said she and computer support service were not able to print Patient #4's medication profile from the system after discharge. She provided a blank medication profile to show what the form contained. 2) The hospice failed to ensure the RNCM who was a member of the IDG coordinated care and ensured Patient's #4's plan of care was followed in regards to behavioral needs. Review of the RN Clinical Notes and On Call Notes dated 7/9/21, 7/27/21, 7/28/21, 7/29/21, 8/14/21, 8/15/21, 8/29/21, 9/13/21, 9/29/21, 10/4/21, 10/18/21, 10/21/21, 11/29/21, 12/25/21, 12/31/21, 11/1/21, 11/4/21, 11/5/21, 11/6/21, 11/11/21, 11/25/21, 11/28/21, 11/29/21, 12/25/21, 12/31/21, 2/4/22, 2/6/22, 2/15/22 and completed by various clinicians, revealed Patient #4's daughter called the triage and/or RNCM to report Patient #4 was agitated, anxious and/or combative and requested medication and behavioral management. The RNCM provided an assessment and skilled teaching related to management of the patient's dementia/Alzheimer's disease and associated behavioral disturbances; however the RNCM did not ensure the instruction was effective since the daughter continued to call the agency for guidance. Review of the IDG documentation dated 7/14/21, 7/28/21, 8/11/21, 8/23/21, 8/25/21, 9/8/21, 10/6/21, 10/20/21, 11/3/21, 11/17/21, 12/1/21, 12/15/21, 12/29/21, 1/12/22, 1/26/22, 2/9/22 revealed the RNCM did not accurately coordinate the patient's family/caregiver strain of providing 24 hour care to the patient; and the family/caregiver's difficulty with managing the patient's agitation/combativeness using medication and behavioral management techniques like distracting the patient. a. FAMILY INTERVIEW During an interview with the family/caregiver on 4/11/22 at 9:23 a.m., Patient #4's daughter said she reported to the agency that the medications Patient #4 was prescribed were not effective for managing agitation and combativeness but did make her mother sleepy. She was instructed by the agency that making her sleepy was acceptable and they did not feel the patient was sedated. She said she requested medications to be adjusted but the agency would not send someone to assess her mother. b. STAFF INTERVIEW During an interview with the RNCM #4 on 4/14/22 at 10:11 a.m. she said she spoke to the IDG team about the patient's agitation over the weekends and the daughter calling the on-call line. She spoke to the family about overstimulation and allowing the patient to sleep. She said the family had constant interaction with the patient and no change to daily routines. She said she felt this was the reason the patient would have increased agitation, especially on weekends. During continued interview, RNCM #4 said she talked to the family about the patient having regular feelings of anger, feelings of being overwhelmed, and anxiety as part of the disease process. She said she felt the patient was happy to live with the daughter and granddaughter but with all three at home at once, the patient became more anxious. RNCM #4 said the medical director/primary physician was aware of the daughter holding medications to treat anxiety, agitation and combativeness because the patient was confused and sleepy. During continued interview, RNCM #4 said the IDG determined the daughter required ongoing education about medication adjustments. She said the patient improved during her care at the agency. She said she felt the daughter was not expecting the caregiver role to be as demanding as it was. She said she discussed with the family/caregiver about overstimulating the patient and that was the reason the patient got agitated. She said she reminded the family to give the medications as ordered to manage the agitation. She said she reminded the daughter to sleep when the patient slept so she could get some rest. The daughter did not want her mother's sleep cycle disturbed so she would stimulate her when she dozed in her chair. She said because of the way the daughter gave the medications there was no way to know whether medications were effective or not. She said the daughter would give conflicting information about the patient's status such as the patient was sleepy after taking Ativan but prior to that she reported the patient was agitated and combative. She said it made it difficult to make medication adjustments and make a determination on the effectiveness of medications. During an interview with the RDCO, the DOO and the area vice president on 4/15/22 at 11:54 a.m., the DOO said there was discussion at every IDG meeting about the patient and daughter. She said that they should have documented the discussion and decision in the IDG notes. She said she did not know why the IDG determinations were not documented in the IDG notes. She said she remembered the daughter was not always agitated. She said she was a concerned daughter and insisted on more care. The daughter did not become disorganized in her thoughts until later. She said once the IDG recognized the concerns were not improving, they initiated the SW and nurse to go in together and had the doctor conduct a visit. She said it was not common practice to have the doctor do a face to face visit unless they recognized something was wrong.

Based on interview and record review, the hospice failed to ensure each patient's plan of care included all information necessary to meet the needs of the patient for 1 of 3 patients reviewed who had orders for wound care (Patient #1). Findings include: HOSPICE POLICY According to the policy, "The Plan of Care," dated 2/2009 (in part): "The plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient and family/caregiver's needs, goals and outcome achievement." 1. The clinical record for Patient #1 was reviewed on 4/11/22. The patient was admitted for hospice care and services on 2/13/22 with a terminal diagnosis of dysphagia. The plan of care for the certification period dated 2/13/22 through 5/13/22 included orders for skilled nurse (SN) services three times weekly for one week then twice weekly for 12 weeks and three visits as needed (PRN) for symptom management and to provide instruction and reinforcement related to urinary incontinence; certified nurse aide (CNA) services three times weekly for one week then twice weekly for 12 weeks for assistance with personal care and activities of daily living (ADLs); medical social worker (MSW) evaluation; and chaplain evaluation. The patient resided at home. a) The hospice failed to ensure all necessary information pertaining to wound care orders for Patient #1 was included in the patient's plan of care. Review of the initial comprehensive assessment, completed on 2/13/22 by registered nurse (RN) #9, revealed RN #9 documented Patient #1 had a 10 pound weight loss in the most recent six months, Patient #1 was chairfast, his mobility was very limited, nutrition was inadequate and friction and shear injuries to the skin were a potential problem. Further review revealed RN #9 documented Patient #1 had a stage 2 pressure sore on his coccyx area. However, the initial assessment failed to reveal documentation of a wound assessment and evidence, the presence of a wound was reported to the physician. Review of the hospice plan of care for the certification period dated 2/13/22 through 5/13/22 also failed to reveal documentation of the coccyx wound and wound care orders. Review of a physician's order dated 2/14/22 completed by RN #3, revealed wound care orders to include cleansing the wound with wound cleaner, patting dry, applying Medihoney or barrier cream and covering with Mepilex. The order failed to show the location of the wound. During an interview on 4/14/22, Employee #8 confirmed the wound care order for Patient #1 did not contain the location of the wound. She stated she did not know why RN #9 did not include the wound on the original plan of care or why RN #3 did not include the wound location on the physician order dated 2/14/22. RNs #3 and #9 were not available for interviews as RN #3 was on vacation and not able to be reached and RN #9 was no longer employed by the agency.

Based on observation, interview and record review, the hospice failed to ensure each patient's plan of care included all medical supplies and appliances necessary to meet the needs of the patient for 1 of 2 patients reviewed who had bed side rails (Patient #1). Findings include: HOSPICE POLICY According to the policy, "The Plan of Care," dated 2/2009 (in part): "The written plan of care will contain, but not be limited to, the following: -DME [durable medical equipment] and medical supplies necessary to meet patient needs." 1. The clinical record for Patient #1 was reviewed on 4/11/22. The patient was admitted for hospice care and services on 2/13/22 with a terminal diagnosis of dysphagia. The plan of care for the certification period dated 2/13/22 through 5/13/22 included orders for skilled nurse (SN) services three times weekly for one week then twice weekly for 12 weeks and three visits as needed (PRN) for symptom management and to provide instruction and reinforcement related to urinary incontinence; certified nurse aide (CNA) services three times weekly for one week then twice weekly for 12 weeks for assistance with personal care and activities of daily living (ADLs); medical social worker (MSW) evaluation; and chaplain evaluation. The patient resided at home. a) The hospice failed to ensure the plan of care included all medical supplies. Specifically, the plan of care failed to show documentation of bed side rails. During a home visit on 4/12/22 beginning at approximately 8:45 a.m., bilateral half side rails were observed on Patient #1's hospital bed in the raised position. Certified nurse aide (CNA) #10 was observed lowering the half rails to allow himself and the patient's non-skilled caregiver to provide assistance to Patient #1 to complete bed mobility. Review of the plan of care for the certification period dated 2/13/22 through 5/13/22 showed orders for the following durable medical equipment: wheelchair, gloves and incontinence supplies. The plan of care failed to show documentation of bed side rails. Review of a SN visit note, completed by RN #3, showed RN #3 ordered a hospital bed and half rails for Patient #1 on 2/14/22. However, the clinical record for Patient #1 failed to reveal a physician's order for the bed side rails, documentation of the additional equipment ordered on the plan of care, and evidence the physician authorized the use of side rails. During an interview on 4/12/22 at a home visit beginning at 8:45 a.m., CNA #10 stated the bed for Patient #1 had the half rails in the raised position each time he came for a visit and he lowered them when he provided care to the patient. He further stated Patient #1 needed maximal assistance to complete all mobility and did not get out of bed. During the same interview on 4/12/22 beginning at 8:45 a.m., Patient #1's non-skilled caregiver confirmed the side rails were typically in the raised position and Patient #1 sometimes moved himself a little bit in the bed but rarely used the side rails independently. During an interview on 4/13/22 at 4:16 p.m., Employee #8 provided an order for a hospital bed, half rails and an air mattress for Patient #1 dated 4/13/22. She confirmed the agency had not obtained an order for the hospital bed, mattress and half rails when the equipment was ordered on 2/14/22 and so she had the Director of Nursing (DON) obtain an order immediately. She further stated she did not know why RN #3 had not obtained an order for the equipment when the equipment was originally ordered. During an interview on 4/14/22 at 4:14 p.m., Employee #8 stated the RN case manager was the clinician who would typically write orders for DME like hospital beds and side rails. However, she stated any of the clinicians could place the order for the equipment and the ordering clinician would receive the electronic mail (email) from the DME company confirming the order. She stated if the RN case manager was not made aware of the order, they didn't always know to obtain the order from the physician. She again stated she did not know why RN #3, who was the case manager for Patient #1, had not obtained an order for the equipment when the equipment was originally ordered. RN #3 was not available for interview as RN #3 was on vacation and not able to be reached.

Based on interviews and record review, the agency failed to maintain for one of five patients an appropriate system of communication and integration to ensure the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, communicating, and supervising all aspects of care and services provided (Patient #4). (Cross reference L540) Clinical record review revealed the agency failed to ensure the IDG maintained responsibility for directing and coordinating the care and service for Patient #4. Specifically, the IDG was aware that the family administering medications to the patient reported not following the orders as the physician prescribed; and frequently administered antibiotics to treat urinary tract infection (UTI) without signs and symptoms, except her determination of noticeable changes in cognition/mental status of the patient, which the IDG believed was related to the patient's diagnosis of dementia. Record review showed the IDG discussed medication changes and provided education to the family/caregiver, however the IDG did not identify the concern related to the family/caregiver not giving medications as prescribed. The IDG discussed the number of times antibiotics were prescribed during that look back period of time, however the IDG failed to identify the concern related to the family/caregiver not completing the antibiotic treatment or starting antibiotic treatment from antibiotics that were not completed prior with symptoms the family/caregiver deemed appropriate. The IDG identified the family/caregiver and patient at times as appropriate and safe to administer medications, however the staff interviews revealed the patient was not safe to administer her own medications and relied on the family/caregiver. The IDG did not have an assessment to determine the competency of the family/caregiver to administer medications although they knew the family/caregiver was not following the medication profile. Additionally, the IDG failed to identify that the medication profile was frequently not reflective of current medication regimen as evidenced by the On Call notes. Findings include: I. Agency policy According to the agency policy titled, "Interdisciplinary Group Plan of Care," dated November 2021, included the following in pertinent parts: "The type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The exact combination of services and the level of care will be unique to each patient and family/caregiver unit and will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice." "It will be the responsibility of the Case Manager to facilitate communication about changes in the patient's status between interdisciplinary group members and the patient's attending physician if any." "The hospice personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and /or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication." "The interdisciplinary group (in collaboration with the attending physician, if any,) will conduct assessments, develop and update the plan of care, and review the effectiveness of care at a minimum of every 15 calendar days, or per state regulation. The attending physician will receive a copy of the care plan updates." "The interdisciplinary group responsibilities include but are not limited to: E. Reviewing and resolving conflict of care and ethical issues." II. Patient information A. The clinical record for Patient #4 was reviewed on 4/12/22. The patient was admitted for hospice care and services on 7/5/21 with a terminal diagnosis of congestive heart failure and dementia with behaviors. The plan of care for the certification period dated 7/5/21 through 10/2/21 included orders for skilled nurse (SN) services two times weekly for one week then once weekly for 12 weeks and three visits as needed (PRN) for symptom management; certified nurse aide (CNA) services one time weekly for one week then twice weekly for 12 weeks to provide personal care; and medical social worker (MSW) and chaplain evaluations. The patient resided at home. The plan of care for the certification period dated 10/3/21 through 12/31/21 included orders for SN services one time weekly for 13 weeks; MSW services twice monthly for three months; CNA services three times weekly for 13 weeks; and chaplain services twice a month for three months. The plan of care for the certification period dated 1/1/22 through 3/1/22 included orders for SN services twice every two weeks for two weeks then twice weekly for seven weeks then once weekly for one week and three PRN visits for symptom management; CNA services three times weekly for 13 weeks; and chaplain services twice a month for three months. 1) Clinical record review revealed the agency failed to ensure the IDG maintained responsibility for directing, coordinating and supervising the care and service for Patient #4 when the family administered medications to the patient and reported not following the orders as the physician prescribed. Review of Patient #4's medication report (a report of all medications prescribed for Patient #4 from the start of care to discharge) showed the patient was to take: -Albuterol Sulfate 2.5mg/3mL solution, 3mL inhaled four times daily starting 7/7/21 for chronic obstructive pulmonary disease (COPD) -Benzonotate 100mg, 1-2 capsules oral every 8 hours starting 12/21/21 for cough -Citalopram 10mg, 1 tablet oral daily starting 7/7/21 for anxiety -Dexamethasone 2mg, 1 tablet oral daily starting 10/26/21 for shortness of breath -Dextromethorphan 15mg, 1 capsule oral 3 times daily starting 10/26/21 for cough -Dextromethorphan 15mg/5mL syrup, 15mg oral every 4 hours starting 7/8/21 for cough -Eliquis 2.5mg, 1 tablet 2 times daily starting 7/7/21 for cerebral vascular accident (CVA) -Furosemide 20mg, 1 tablet oral PRN starting 7/7/21 for edema -Guaifenesin 100mg/5mL, 1200mg oral 2 times daily starting 7/8/21 for congestion -Haloperidol 2mg, 1-2 tablets oral PRN every 6 hours starting 2/5/22 for agitation -Haloperidol Lactate 2mg/mL, 0.5-1mL oral PRN every 6 hours starting 1/14/22 for agitation, anxiety -Loperamide 2mg, 2 tablets oral as directed starting 7/20/21 for loose stool -Lorazepam 0.5mg, 0.25-0.5mg oral every 6 hours starting 7/8/21 for agitation -Macrodantin 100mg, 1 capsule oral daily starting 2/7/22 for infection -Metoprolol 25mg, 1 tablet oral daily starting 10/26/21 for hypertension -Mometasone 50mcg/actuation, nasal as directed starting 7/7/21 -Nexium 40mg, 1 capsule 2 times daily starting 7/20/21 for reflux -Oxycodone 5mg, 2.5mg tablet PRN every 6 hours starting 2/5/22 for pain -Oxygen 1L at bedtime starting 8/12/21 for shortness of breath -Pepcid 20mg, 1 tablet at bedtime starting 7/20/21 for reflux -Quetiapine 25mg, 12.5-25mg tablet at bedtime starting 11/7/21 for agitation -Reglan 10mg, 1 tablet every 6 hours starting 8/2/21 for gastrointestinal (GI) upset -Sucralfate 1g, per instructions daily starting 7/7/21 for GI upset -Trazodone 50mg, 25mg at bedtime starting 8/15/21 for insomnia Discontinued medications included: -Amoxicillin 500mg, 500mg 3 times daily starting 8/23/21, ending 8/30/21 for cellulitis -Cefuroxime 500mg, 1 tablet every 12 hours for 5 days starting 7/6/21, ending 7/7/21 for suspected urinary tract infection (UTI) -Cephalexin 500mg, 1 tablet 4 times daily starting 11/13/21, ending 2/7/22 for right breast swelling -Cipro 500mg, 1 tablet 2 times daily starting 1/16/22, ending 2/4/22 for UTI -Cipro 500mg, 1 tablet 2 times daily starting 2/7/22, ending 2/20/22 for UTI -Moxifloxacin 400mg, 1 tablet daily for 5 days starting 7/7/21, ending 7/8/21 for suspected infection -Moxifloxacin 400mg, 1 tablet daily starting 7/8/21, ending 7/13/21 for suspected infection -Moxifloxacin 400mg, 1 tablet daily starting 8/19/21, ending 8/23/21 for sinus infection -Moxifloxacin 400mg, 1 tablet daily starting 9/1/21, ending 10/25/21 for right breast infection -Moxifloxacin 400mg, 1 tablet daily starting 11/30/21, ending 12/5/21 for UTI -Moxifloxacin 400mg, 1 tablet daily for 7 days starting 12/24/21, ending 12/30/21 for respiratory infection -Quetiapine 25mg, per instruction starting 7/7/21, ending 2/4/22 for agitation Clinical record revealed no physician orders for Lomotil, meclizine, Tums, Gaviscon, Tylenol and clonazepam within the patient's medical record. On 4/15/22 at 1:28 p.m., the surveyor requested a copy of the medication profile provided to the patient and family/caregiver from the regional director of clinical operations (RDCO), however the RDCO reported the record could not be retrieved from the computer system once the patient was discharged. The RDCO said the nurse would provide an updated copy to the patient and family/caregiver with every medication adjustment. The RDCO provided a blank medication profile to show the information that would be available to the patient and family/caregiver, they included medication name and directions for how to take, how much to take, when to take, reason to take, other information relevant to medication administration and if the medication was to be administered by the agency. Review of the IDG documentation dated 7/14/21 revealed, the persons authorized to administer medications were the patient, family/caregiver, and hospice nurse. The family/caregiver required the medication profile to be accurate including instructions for use of the medication in order to administer the medications safely. Review of the On Call Note dated 7/27/21 at 7:11 p.m. revealed the daughter reported to the on-call nurse that she gave Patient #4 an Ativan at 6:30 p.m. but the patient was very agitated o she gave the patient Seroquel and Celexa (although the only instruction on the medication list was to provide these medications at bedtime). The daughter wanted to know if it was safe to give the Ativan again at 8:00 p.m. The on-call nurse advised the daughter that she could give the Ativan at 8:00 p.m. although the orders were for Ativan to be given every six hours. There was no documentation found of a follow up to the caregiver not following the medication administration order by the IDG. Review of the On Call Note dated 7/30/21 at 9:05 p.m. revealed the daughter called the on-call nurse and reported Patient #4 had severe heartburn. The on-call nurse reviewed the medical record and noted the patient was on multiple gastro-intestinal (GI) medications but no PRN GI medications were ordered. The daughter reported the patient was taking Protonix in the morning and Nexium at night, which was not on the medication profile per the on-call nurse. The daughter reported those medications were not effective. The daughter said that the patient ate a burrito with hot sauce and was now having severe heartburn. The daughter reported that the patient had taken Nexium, Tums, Pepcid and Gaviscon. The daughter was requesting another Pepcid. The daughter reported that the patient had not taken sucralfate today, so the on-call nurse instructed daughter to give the sucralfate now and the on-call nurse would leave a message for the RN on-call (RNOC) who happened to be the director of operations (DOO). There was no documentation any of the medications administered by the caregiver had been ordered by the physician and there was no documentation found to show any of the medications above had been authorized as instructed by the on call nurse to the caregiver. Review of the On Call Note dated 7/30/21 at 9:44 p.m. revealed the daughter called and reported Patient #4 had nausea and heartburn. The daughter stated that she gave the patient 0.5 mg of Ativan, which helped, and wanted to know if it was safe to give Trazodone. The on-call nurse reported to the daughter that it was safe to give them together, however the medication list did not show whether Ativan was safe to take with other medications. The on-call nurse reviewed the medication profile and did not find Trazodone on it (However Trazodone 25 mg was ordered on 7/26/21 and added to the medication list on 8/15/21). The on-call nurse informed the daughter that there was no direction to give the Trazodone since it was not on the medication profile. The RNOC was notified to follow-up and provide advice to the daughter. Review of the On Call Note dated 7/30/21 at 10:21 p.m. revealed the daughter called and reported Patient #4 was complaining of clogged ears. The daughter reported that the patient took Meclizine when she was dizzy. The on-call nurse reviewed the medication profile and did not find an order for Meclizine. The daughter said that the patient got a prescription for Meclizine from her own private doctor. The on-call nurse informed the daughter that the call would be forwarded to the RNOC to advise. Review of the On Call Note dated 7/30/21 at 11:39 p.m. revealed the daughter called and reported Patient #4 was having heartburn. The daughter stated she gave the patient Pepcid, Nexium, Gaviscon and crackers but there was no improvement. The daughter reported the patient had ear pain. The daughter reported the patient no longer was nauseated, however the gastric secretions prompted a cough. The on-call nurse instructed the daughter to raise the head of the patient's bed to as high a level as she would tolerate to prevent gastric acid from flowing upward into her upper esophagus and laryngopharynx. The on-call checked the medication profile and documented the patient was administered what was ordered, however the Pepcid, Nexium and Gaviscon were not on the medication profile. This was forwarded to the RNOC. Review of the IDG documentation dated 8/11/21 following the issue of the caregiver administering meclizine, Tums, Trazodone, Protonix and Gaviscon on prior dates, medications not ordered, were not discussed during the IDG meeting. The IDG determined the persons authorized to administer medications were the patient and family/caregiver. There was no evidence the IDG had discussed or implemented a plan to address Patient #4's caregiver providing medications that were not ordered or her need for instruction on when to administer medications. Review of the On Call Note dated 8/14/21 revealed the daughter called and reported she had given Patient #4 citalopram (Celexa), then two hours later at 10:00 p.m. gave quetiapine (Seroquel) 25 mg and Trazodone 25 mg (The medication list did not specify what medications could or could not be taken together). The daughter said the patient was still awake and she was concerned her behavior would escalate during the night if she did not sleep. The daughter wanted to know if she could give an additional dose of Trazodone 25 mg now since she had given only 25 mg earlier. The on-call nurse reviewed the medication profile and Trazodone was not on it (However Trazodone 25 mg was ordered on 7/26/21, increased to 50 mg on 8/14/21 and added to the medication list on 8/15/21). Trazodone half a tab (25mg) was to be given at bedtime and not 50 mg. The daughter was not happy with the fact the medication profile was not updated. The on-call said they would notify RNOC to further advise. Review of the On Call Note dated 9/18/21 at 5:00 p.m. revealed the daughter called triage and requested a RNOC because the patient's pulse was ranging from 90-123, BP 124/89 and patient had a history of atrial fibrillation. The daughter was requesting to give metoprolol 25 mg, however metoprolol had been discontinued on 7/6/21 and not ordered again until 10/26/21. The daughter reported she cut the patient's tablet into quarters to administer if the patient had slight angina. The daughter reported being diligent about monitoring the BP and said the BP was labile for which she had been holding the metoprolol due to hypotension. The on-call nurse advised the daughter to continue to monitor and to call back as needed. The RNCM was monitoring and would follow up with the patient. Review of the On Call Note dated 9/19/21 at 7:57 p.m. revealed the daughter called triage regarding the patient's elevated heart rate of 133-143. The daughter reported she was concerned since the patient had been on metoprolol prior to the hospice and was being titrated by the physician between 25 to 50 mg. The patient had a history of BP dropping below 80 systolic and then got dizzy and went to the hospital. The on-call nurse reviewed the medication profile and discussed with the daughter that the pulse did not always register correctly especially if irregular. The on call nurse instructed the daughter to take a radial pulse and it was 76. The BP prior to the call was 129/78. The on-call nurse said that the patient was doing fine and instructed the daughter not to give metoprolol and that the RNCM would be updated for a clarification of the order. Review of the RN Clinical Note dated 9/20/21 revealed that during the visit the daughter reported she was not comfortable giving Lasix due to labile blood pressure (BP), although there were no instructions regarding the Lasix to be given based off of BP. The patient had two plus edema with legs elevated and the IDG was updated. Review of the IDG documentation dated 9/22/21 revealed the IDG did not address the family/caregiver cutting the metoprolol tablets into quarters to administer if the patient had slight angina. The IDG did not address the metoprolol orders for medication adjustment. The IDG did not address when the Lasix should be given or held dependent upon labile BP or for fluid management especially since the patient had heart failure, edema and atrial fibrillation. Review of the On Call Note dated 9/25/21 at 9:45 p.m. revealed the daughter called the triage about the patient's BP being 156/101 but reduced to 124/83 after she administered Trazodone to the patient. The on-call nurse discussed medications with the daughter and told her to hold the BP medication tonight. The on call nurse discussed with the RNCM about monitoring medications, nebulizer treatments and BP for possible correlations with hypo/hypertension. Review of the IDG documentation dated 10/6/21 revealed the persons authorized to administer medications were the family/caregiver and hospice nurse. The nurse reported the patient continued to have episodes of agitation with family and had relief with lorazepam but episodes lasted up to two to three days. The patient developed different areas of fluid filled bumps. The patient had bilateral lower extremity edema which decreased with taking Lasix. The physician reported the patient continued to decline in cognition and function. The patient's blood pressure was labile with bouts of hypo/hypertension. The patient became more forgetful, weaker and more unstable in gait. Patient #4 fell a few weeks ago which resulted in skin tears. She could still transfer to a commode but required assistance. She was incontinent of bowel and bladder. She had worsening dyspnea and was using daily nebulizer breathing treatments. Her appetite and intake were poor and she continued to lose weight both in appearance and measured. She was dependent on two liters of continuous oxygen. The IDG did not address the triage note that was documented to discuss with the RNCM about monitoring medications, nebulizer treatments and BP for possible correlations with hypo/hypertension. The IDG did not address the effectiveness of educating the family/caregiver on the appropriate administration of medications. Review of the On Call Note dated 10/7/21 at 7:52 p.m. revealed the daughter reported Patient #4 was coughing and needed some cough medication. The on-call nurse reviewed the medication profile and found no orders for cough medication except dextromethorphan 15 mg/ml (Delsym) syrup. The daughter said that usually she gave the capsules (dextromethorphan capsules were not ordered until 10/26/21) during the day and Delsym syrup at night but did not have enough syrup and wanted to know if she could give the capsules instead. The on-call nurse confirmed that the capsules were the same medication as the dextromethorphan and confirmed that the one capsule was equivalent to the Delsym liquid dose. A note was sent to the RNCM to be aware. Review of the On Call Note dated 10/14/21 at 4:18 a.m. revealed the daughter reported to triage that the patient had been sick since Monday. The daughter increased oxygen to three liters per minute (Patient #4 was ordered to receive 1 liter oxygen at bedtime) to maintain 90% oxygen saturation. Review of the RN Clinical Note dated 10/14/21 revealed the RNOC reported the patient was having increased shortness of breath and low oxygen saturation. The patient was on 2 liters per minute via nasal cannula with oxygen saturation of greater than 90%. The family had the flow on 3 liters per minute earlier but the patient was feeling better although it was still hard to catch her breath. The RNOC updated the IDG regarding this visit. Review of the On Call Note dated 10/21/21 at 6:52 p.m., revealed the daughter called the triage to report that Patient #4 was nauseated and wanted to know what medications to give. The on-call nurse spoke with the daughter who reported the patient was having nausea triggered by anxiety from phlegm. The on-call nurse reviewed the medication profile and advised the daughter to give a PRN dose of Ativan to see if that helped. The daughter said she would start at the lowest dose of 0.25 mg of Ativan. The daughter asked what medications could be given with Ativan. The on-call nurse said she could give the Trazodone with the Ativan but not the Seroquel. The on call nurse advised the daughter to space out giving Seroquel approximately two hours or more after the Ativan administration. The daughter verbalized understanding. The instructions for spacing out the medications approximately two hours apart and to give Trazodone with the Ativan but not the Seroquel were not found in the physician orders and the agency could not provide a copy of the medication profile that was given to the patient and family/caregiver. Review of the On Call Note dated 10/23/21 at 11:22 p.m. revealed the daughter called the triage and reported the patient having wheezing off and on tonight. The patient received dexamethasone daily at 11:00 a.m. The daughter asked if she could give medication tonight if the patient woke up wheezing. The daughter said dexamethasone helped with the wheezing. Oxygen on one liter per minute with oxygen saturation 98%. The on-call nurse reviewed the medication profile and dexamethasone was not on the medication list. The daughter stated that it had been an ongoing problem with hospice not having the correct medications on the patient's medication profile. The daughter mentioned metoprolol was another medication not on the profile that the patient was taking. The on-call nurse confirmed that the metoprolol was not on the medication profile. The daughter requested the RNCM sort out missing medications from the medication profile on Monday. The on-call nurse advised the daughter to follow the directions on the bottle of dexamethasone which read daily. The on-call nurse said they could not advise to give it 12 hours earlier. The on-call nurse advised the daughter to let the patient sleep for now and give a nebulizer treatment if the patient woke up with shortness of breath. The on call nurse advised the daughter that the RNOC was contacted to obtain a physician order to increase the dexamethasone frequency. Review of the RN Clinical Note dated 10/25/21 revealed the patient's breathing was shallow with increased effort, however the patient denied any symptoms. The right upper lobe anteriorly had ronchi and diminished in bases. The family called triage this weekend and were unable to see dexamethasone order, added it in as a PRN order for wheezing. Metoprolol was showing as discontinued so it was re-ordered. The patient had tolerated one mg of dexamethasone without experiencing extreme anxiety or confusion. One dose given on Saturday for wheezing. The family reported that the patient had a dry and barking cough. No bilateral lower extremity edema noted. No medication refills noted. Supplies delivered. Daughter and granddaughter both present during the visit. The IDG was updated by the nurse. Review of the RN Clinical Note dated 10/28/21 revealed the patient needed assistance to the bathroom. The granddaughter had just given the patient a Lomotil (no order was found in the patient's medical record). The patient had bilateral lower extremity edema with the left greater than the right. The nurse updated the IDG. Review of the IDG documentation dated 11/3/21 revealed the nurse reported the patient was taking Lasix three times a week on average. The patient started dexamethasone to help with respiratory status. The patient took a two mg dose and became extremely agitated so now takes one mg at a time and tolerated better. The patient's lungs have intermittent wheezing for which the patient used intermittent oxygen and nebulizer treatments as often as every four hours. The IDG did not address the medication profile concerns the family/caregiver repeatedly verbalized regarding the inaccurate information. The family/caregiver required the medication profile to be accurate including instructions for use of the medication in order to administer the medications safely. Review of the On Call Note dated 11/5/21 at 7:22 p.m., revealed the daughter reported the RNCM visited the previous day and an order for Seroquel was to be increased to 50 mg daily at bedtime. No order for that change was noted in the chart. The daughter stated she was not comfortable with giving 50 mg of Seroquel due to the patient being very sensitive to medication changes, so she gave 37.5 mg (1.5 tablets) the previous night and at 6:00 p.m. on 11/5/21. The daughter repeated how sleepy the patient was and fluid intake was diminished. The daughter voiced concern about the patient possibly having a urinary tract infection (UTI) since she often became combative with an infection. The daughter was expecting a call back regarding testing for UTI but never received a phone call. The daughter reported she had one more dose of moxifloxacin from when the patient had a UTI before so she gave it to the patient earlier today. The daughter reported that she knew the patient was getting an infection, a UTI or pneumonia based on her behavior. The daughter reported the patient insisted on taking a bath tonight and then started growling, grinding her teeth and punching at her. The daughter reported that the patient would not lay down and was falling asleep standing up and talking to people in her sleep. The daughter said the patient would not lay down and became combative. The daughter said she was able to give the patient's night medications but the patient would not take the lorazepam. The on-call nurse discussed the possibility of a nurse visit but the patient was sleeping in a chair at the end of the conversation. The daughter said she would call triage if the patient became combative again. The RNCM and RNOC notified the daughter of follow-up tomorrow for possible UTI and Seroquel dose change due to increased drowsiness. The daughter refused a visit that night but wanted a visit the following day. Review of the SW Clinical Note dated 11/17/21 revealed the daughter wanted to discuss blood pressure medication with the RNCM and physician. She said the RNCM discussed possibly switching it but she did not feel it had been resolved. The daughter shared frustration with the nurse change stating that she and the granddaughter were not informed until the evening prior. The patient was sad to lose her regular case manager. The daughter reported that she was looking into other hospice agency companies. Review of the IDG documentation dated 11/17/21 revealed the nurse reported the patient had recurring bilateral lower extremity edema and took Lasix as often as every other day depending on level of edema. The daughter reported she gave three tablets of Keflex and liquid Keflex was ordered due to the patient having loose stools but the daughter reported she would likely not administer it. The IDG did not address the medication profile concerns the family/caregiver repeatedly verbalized regarding the inaccurate information. The family/caregiver required the medication profile to be accurate including instructions for use of the medication in order to administer the medications safely. Review of the RN Clinical Note dated 11/19/21 revealed, the nurse addressed the patient and family concerns about miscommunication with the office and RN changes. The nurse left a small notebook on the right side of the patient's recliner to improve communication between the family and the agency. The nurse explained she would write down what was discussed during the visits and encouraged them to write things down as they think of them between visits. They could then review the book at each visit. The patient and family felt it would help with feelings of frustration. The patient had an upcoming cardiology appointment but could not remember the date so the nurse asked the family to get a copy of the assessment and findings so the doctor at the hospice could collaborate on medication management. Review of the RN Clinical Note dated 12/6/21 revealed the daughter reported the patient complained of right elbow/shoulder pain. The daughter said it was because she slept on that side and the patient agreed. The daughter gave 500 mg of Tylenol (No order was found in patient's medical record) by mouth during the visit. Review of the IDG documentation dated 12/29/21 revealed the IDG did not address the medication profile concerns the family/caregiver repeatedly verbalized regarding the inaccurate information. The family/caregiver required the medication profile to be accurate including instructions for use of the medication in order to administer the medications safely. Review of the On Call Note dated 12/31/21 at 4:36 p.m., revealed the daughter called the triage to report the patient was having an issue with irritable bowel syndrome (IBS) and the patient had large loose stools. The daughter reported the patient was restless and confused with incontinence care. The patient had been more confused lately and taking lorazepam more frequently. The daughter asked if she could give Lomotil with the lorazepam. The daughter reported the doctor said not to give Lomotil and lorazepam together. The on-call nurse reviewed the medication profile and Imodium was ordered but there was no order for Lomotil. The nurse said it was ok to give the lorazepam and two tablets of Imodium now. The nurse instructed the daughter that the Imodium could be repeated for each stool and not to exceed eight tablets in 24 hours. Clinical review showed the IDG failed to address the multiple calls made by the caregiver to the on-call nurses, the multiple verbal admissions by the caregiver of not giving medications as ordered, administering medications that were not ordered, and holding back medications that were to be administered without instructions from the agency. The IDG further failed to address the caregiver's complaints about her confusion over the medication updates and lack of updates to the medication profile. Additionally, the IDG failed to adopt a medication administration record (MAR) with clear instructions by the agency for caregiver to sign what medication was given and when. Further review showed the IDG allowed th e caregiver to provide medications which had not previously been ordered. There was no documented evidence the IDG had provided a different intervention to safeguard the welfare and safety of the patient. The agency failed to assess the caregiver to ensure she was deemed competent to adequately provide care to the patient. FAMILY INTERVIEW During an interview with the family/caregiver on 4/11/22 at 9:23 a.m., Patient #4's daughter said the agency sent medications to the home but did not do an assessment to determine if the medications were necessary. She said the medication profile was not accurate and did not reflect the current medications Patient #4 was taking. She said this was an ongoing issue which she informed the RNCM and director of operations (DOO) about, but nothing changed. STAFF INTERVIEWS During an interview on 4/11/22 at 11:22 a.m., the DOO stated the members of the IDG included the chaplain, two SWs, volunteer coordinator, bereavement coordinator, RNCMs, the DOO, the medical director and the patient coordinator. The meetings were held every other Wednesday. The IDG meetings were documented in the patient's medical record and every member was to complete an IDG note. The IDG decided the type of services the patient would receive. "It's an on-going conversation, not just at IDG. The nurses are good about calling and talking about the needs of patients and asking if we can get different services. We do a lot with the VA and they are great about coordinating care with us." During an interview with the RNCM #4 on 4/14/22 at 10:11 a.m., she said RNCM #3 was not available during the survey. RNCM #4 said the family/caregiver would use medications that the patient had used in the past and were effective. When the daughter reported to the agency that she gave a certain medication, RNCM #4 stated she would obtain a physician order and add it to the medication profile. She said the profiles were updated with medication changes and taken to the patient's home on the nurses' next visit. During continued interview, RNCM #4 said the daughter spoke to her about getting miscommunication from the agency. She said it was determined in the IDG to limit the number of people getting physician orders for the patient. She said the family/caregiver would reach out to the triage staff and request medications. RNCM #4 said, she and RNCM #3 reviewed the medications numerous times with the daughter and the daughter agreed with the plan but was nervous about her mom's care and did not follow the medication profile. She said she and RNCM #3 directed the caregiver to call the hospice first before adjusting medications. RNCM #4 further stated, "She took care of her mother for so long that she thought she knew. She called consistently every weekend. She would call based on who was on call to get a different response." She said RNCM #3 and the SW met together in the patient's home to improve communication in the house. During continued interview, RNCM #4 said the medical director/primary physician was aware of the family/caregiver adjusting medications and they were unable to do anything since they could not lock up the medications since the patient could not access them. She said the IDG decided to continue with educating the family/caregiver although the medications were not being used appropriately. She said the daughter withheld the Lasix and the swelling occurred in strange areas like the chest. She said the daughter had a history with lots of medical providers and brought in past experiences. RNCM #4 stated the daughter questioned everything. During an interview with the regional director of clinical operations (RDCO), the DOO and the area vice president on 4/15/22 at 11:54 a.m., the DOO said there was discussion at every IDG meeting about Patient #4 and the daughter. She said they should have documented the discussion and decision in the IDG notes. During continued interview, the DOO said they submit a medication list to every family member on admission. She said they felt the daughter was safe to administer medications until Patient #4 was closer to discharge. She said the last (2/15/22) IDG meeting should not have marked the daughter as safe to administer medications since they were concerned and implemented the nurse, social worker (SW) and doctor visits to help with education. She said the doctor (1/13/22) was sent to educate the daughter on giving medications as ordered. She was notified that the doctor's notes did not reflect education to the daughter about safety of administering medications as ordered and during his interview he did not recall the visit other than the daughter focusing on a fish tank and fish for which he found odd. During continued interview, the DOO said the IDG members discussed the competency of the daughter to administer medications as ordered by the physician. She said the daughter did not consistently give medications as ordered and threw away the medication list provided by the nurse. She said they gave a medication list to all patients at admission so the patients would have a copy. She said they did not have a medication administration record in the home that would be signed by the daughter after giving medications and collected by the agency to show whether the medications were given or not. During an interview with the RDCO on 4/15/22 at 12:11 p.m., she said the daughter called triage and the RNCM to report conflicting responses Patient #4 had to the medications. She said the daughter would say in one call that Patient #4 was sedated from the medications, then call the triage at a later time and report Patient #4 was screaming. She said she was not aware the nurse said that the concern was identified early on after a few weekends after admission of getting on-call notifications. During an interview with the medical director on 4/15/22 at 8:32 a.m., he said he was the patient's primary physician. He said the inconsistencies with family members reporting medications and symptoms made it difficult to make medication adjustments. He said the IDG was thorough; he was sure it was discussed but not specific comments, mostly inconsistencies in stories. He said the daughter said not getting follow up visits yet lots of visits found. He said education was provided to the family regarding the disease process and patient's decline. He did not remember specifically the patient being in danger from over dosing of medications, just inconsistencies in reports from family about symptoms and behaviors. He said it was difficult to prescribe and determine medication adjustments with inconsistent reports of symptoms and behaviors. 2) Clinical record review revealed the agency failed to ensure the IDG maintained responsibility for directing and coordinating the care and service for Patient #4 when the family/caregiver administered medications she liked but were not prescribed. Review of the On Call Note dated 7/30/21 at 9:05 p.m. revealed the daughter called the on-call nurse and reported Patient #4 had severe heartburn. The on-call nurse reviewed the medical record and noted the patient was on multiple gastro-intestinal (GI) medications but no PRN GI medications were ordered. The daughter reported the patient was taking Protonix in the morning and Nexium at night, which was not on the medication profile per the on-call nurse. The daughter reported those medications were not effective. The daughter said that the patient ate a burrito with hot sauce and was now having severe heartburn. The daughter reported that the patient had taken Nexium, Tums, Pepcid and Gaviscon. The daughter was requesting another Pepcid. The daughter reported that the patient had not taken sucralfate today, so the on-call nurse instructed daughter to give the sucralfate now and the on-call nurse would leave a message for the RN on-call (RNOC) who happened to be the director of operations (DOO). There was no documentation any of the medications administered by the caregiver had been ordered by the physician and there was no documentation found to show any of the medications above had been authorized as instructed by the on call nurse to the caregiver. Review of the RN Clinical Note dated 11/26/21 revealed the RNOC followed up on the call regarding difficulty with breathing. The daughter wanted to know if she could give benzonate with Seroquel. The nurse instructed the daughter that the triage instructed her to give lorazepam for shortness of breath/agitation. The daughter said she decided to give the leftover Cipro instead because she felt it was a respiratory infection. The nurse discussed the importance of not using antibiotics intermittently and to complete ordered treatments. The daughter voiced understanding but said that she felt the antibiotic helped. The daughter reported the dexamethasone was not given because the patient got up late and she did not want it to "wire her'' for the day. The nurse emphasized the importance of taking dexamethasone to help with the wheezing. 3.) Clinical record review revealed the agency failed to ensure the IDG maintained responsibility for directing and coordinating the care and service for Patient #4 when the family reported providing incomplete antibiotic regimen and re-starting left over medications. The following antibiotic orders were found from 7/6/21 through 2/15/22. -An order with a start date of 6/25/21 for cefuroxime axetil (Cipro) 500 mg tablet, dose one tablet by mouth every 12 hours for five days for a suspected UTI. -An order with a start date of 7/3/21 and stop date of 7/8/21 for moxifloxacin 400 mg tablet, dose one tablet daily by mouth for five days for suspected infection. -An order with a start date of 7/9/21 and stop date of 7/13/21 for moxifloxacin 400 mg tablet, dose one tablet daily by mouth for five days for suspected infection. -An order with a start date of 8/18/21 and stop date of 8/23/21 for moxifloxacin 400 mg tablet, dose 400 mg daily by mouth for sinus infection. -An order with a start date of 8/23/21 and stop date of 8/30/21 for amoxicillin dose 500 mg three times daily by mouth for cellulitis. -An order with a start date of 8/30/21 and stop date of 10/25/21 for moxifloxacin 400 mg tablet, dose 400 mg daily by mouth for right breast infection. -An order with a start date of 11/12/21 and no stop date for cephalexin (Keflex) 500 mg tablet, dose 500 mg four times daily for right breast swelling. -An order with a start date of 11/29/21 and stop date of 12/5/21 for moxifloxacin 400 mg tablet, dose one tablet daily by mouth for UTI. -An order with a start date of 12/23/21 and no stop date for moxifloxacin 400 mg tablet, dose one tablet daily by mouth for seven days for respiratory infection. -An order with a start date of 1/14/22 and stop date of 2/4/22 for Cipro 500 mg tablet, dose take one tablet by mouth twice daily for seven days for UTI. -An order with a start date of 2/6/22 and stop date of 2/20/22 for Cipro, dose give one tablet twice daily by mouth for UTI. -An order with a start date of 2/13/22 for macrodantin 100 mg capsule, dose give one capsule daily by mouth for infection prophylactically. Review of the On Call Note dated 7/6/21 revealed the Patient #4's daughter called the on-call nurse to report Patient #4 had drainage and a productive cough with "yellowish greenish stuff coming up" and when the patient coughed, it hurt. The patient had no pain medication ordered. The daughter reported giving Tylenol which helped. The patient was on an antibiotic for a UTI but the daughter felt the patient had developed a sinus infection and requested more antibiotics. The patient did not have a fever. The daughter requested to give the patient cough syrup The daughter was advised by the on-call nurse to not give it until she spoke with the RNCM. The on-call nurse explained to the daughter that she may not want to stop the coughing because it was helping to get the stuff up. The daughter reported that the patient had been sleeping quite a bit and not drinking. The on-call nurse advised the daughter to give the patient warm sweetened tea and further explained how the warm fluid would help get the drainage out and thin it. The daughter then requested a nurse visit today to assess the patient for further infection. The daughter was advised to call the office for further assistance and/or to report changes/concerns. Review of the RN Clinical Note dated 7/6/21 revealed the daughter reported to the nurse that the patient had not eaten or drank much. No agitation in the last 24 hours. The patient had an increased productive cough with yellow/green sputum. The patient was currently on a five day course of antibiotics. The daughter requested an additional five days. The doctor agreed and the order was placed with the pharmacy. Review of the RN Clinical Note dated 8/23/21 revealed during the assessment found the patient's right breast to be swollen three times the size on the left. The underside was hard and warm upon palpation. The patient reported tenderness. The daughter stated that the patient's GI system never seemed to tolerate antibiotics but wanted to try amoxicillin. Review of the 8/30/21 RN Clinical Note dated 8/30/21 revealed, the patient had good appetite and minimal diarrhea. The patient was taking amoxicillin but her right breast was swollen and hard, not warm or painful. The patient tolerated moxifloxacin well so the doctor ordered it for ten days. The IDG was updated. The IDG did not address the patient's response to medications such as the antibiotic and the effectiveness of those medications. The patient had been on antibiotics for UTI, sinus infection and cellulitis for the past two months. The IDG did not address the frequent use of antibiotics and the negative side effects such as diarrhea. Review of the RN Clinical Note dated 9/29/21, revealed an order for an ultrasound was placed due to the swelling in the ribs and breast. The left leg was greater in size than the right. The patient took Lasix that morning. The patient was starting another course of moxifloxacin. There was no documentation regarding the effectiveness of the prior course of moxifloxacin. Review of the IDG documentation dated 10/6/21, revealed the patient was currently receiving treatment of moxifloxacin for a mass on her right breast that did not appear to be infected. The ultrasound showed cellulitis. The family was interested in intravenous (IV) antibiotics to discuss with the doctor. The nurse was to assess the mass on the right chest and monitor for signs and symptoms of infection and assess agitation episodes and response to current medication regimen. The IDG did not address the physician's assessment of the bumps on the chest or IV antibiotic treatment. The IDG did not address the multiple antibiotic use. Review of the RN Clinical Note dated 11/8/21, revealed the daughter reported that the patient was doing much better since starting Cipro (No order was found in the patient's medical record). The daughter voiced concern that the antibiotics were not started last Thursday as she expected. The patient received the COVID vaccine and later Thursday developed a puffy face, then slept 14 hours and urinated twice. The daughter was concerned about a UTI, however there were no other symptoms of a UTI. The RN referenced a triage note over the weekend regarding respiratory symptoms. The patient's lungs were clear but she had a productive cough with thick mucus. The patient was currently on a ten day course of Cipro. The IDG was updated. Review of the On Call Note dated 11/12/21 at 4:43 p.m., revealed the daughter called triage to report the order received today for Keflex 500 mg by mouth four times a day for swelling in the right breast. The order did not contain how many days to take the antibiotics. Triage called the pharmacy but they were closed so a call to the RNOC was made for follow-up. Review of the RN Clinical Note dated 11/15/21, revealed the nurse reached out to the pharmacy to get liquid Keflex delivered instead of the tablets. The Keflex was ordered for cellulitis infection under the right armpit/breast. The patient denied pain, shortness of breath, or anxiety. The daughter said the patient wouldn't use the antibiotics because it caused bad diarrhea. The nurse explained that not giving it as ordered would not be effective if there was an infection. The daughter verbalized understanding. The patient had loose bowels. Abdomen was soft, non-tender, bowel sounds in all four quadrants and vital signs were stable. Review of the IDG documentation dated 11/17/21, revealed the nurse reported the family's concern the patient had a sinus infection, so Cipro was started on 11/11/21 (No order was found for Cipro in the medical record). The patient's right breast began to swell and doubled in size with bruising on 11/12/21. The doctor was notified and switched antibiotics to Keflex four times a day, starting on 11/15/21. The daughter reported she gave three tablets of Keflex due to the patient's loose stools so liquid was ordered but the daughter reported she would likely not administer. The nurse was to assess the response to the current medication regimen and assess right breast/chest and update the treatment plan as needed. Review of the RN Clinical Note dated 11/24/21, revealed cough continued with light yellow mucus in phlegm. The patient was prescribed an antibiotic however the caregiver did not give due to causing diarrhea. The nurse educated the caregiver on the importance of taking the antibiotics as ordered to prevent resistance and ineffectiveness. Review of the IDG documentation dated 12/1/21, revealed the daughter reported she held the antibiotic due to diarrhea. The daughter felt the swelling was from sleeping and water entrapment occurring. Moxifloxacin was started on 11/29/21 due to a possible UTI. The caregiver requested moxifloxacin due to it working in the past. The doctor ordered 400 mg once a day for seven days although no signs and symptoms of infection. The caregiver was reminded by the nurse of the interactions between Carafate and probiotic (There was no order found in the medical record for a probiotic). The IDG did not address the repeated antibiotic use and the effectiveness of the instructions provided to the family/caregiver on negative outcomes. The IDG did not address the instructions to the family/caregiver regarding having more than one symptom to confirm an infection like UTI. Review of the RN Clinical Note dated 12/2/21, revealed the patient was feeling better than she had on Monday 11/29/21 during a visit by the nurse. The patient reported no more pain with urination. The patient started Bactrim (listed on the plan of care physician orders that the patient was allergic to Bactrim) 400 mg for seven days for UTI. Review of the IDG documentation dated 1/26/22, revealed the IDG team discussed and determined the patient and caregiver's ability to administer medications. The patient was not able to administer medication. The persons authorized to administer medications were the family/caregiver and hospice nurse. The patient received Cipro 500 mg by mouth twice a day for UTI starting on 1/14/22. There was no evidence the IDG had discussed and addressed Patient #4's continued use of antibiotics. Review of the On Call Note dated 2/6/22, revealed the daughter called the on-call nurse to report Patient #4 had only slept a couple of hours, was confused and had intermittent agitation despite several doses of medications (not named). The daughter reported that the patient had not been drinking and the patient was not urinating so the daughter felt the patient had a UTI. The physician was notified and an order for Cipro (antibiotic) was sent to the pharmacy. The on-call nurse (who was the patient's first case manager) documented that she wanted to discuss a daily preventative (such as probiotic) to go along with the antibiotic. Review of the IDG documentation dated 2/9/22, revealed the nurse reported the patient had increased agitation/anxiety in the past week. The doctor ordered Cipro 500 mg twice a day for seven days. The nurse documented it was the third UTI treated this period. Macrodantin 100 mg daily was prescribed by the doctor prophylactically after Cipro completed. Review of the On Call Note dated 2/15/22, revealed the daughter called the on-call nurse to report Patient #4 continued to have hallucinations so her UTI was not cleared up from the Cipro. The daughter requested moxifloxacin (antibiotic). The note read that the on-call nurse wanted to speak to the case manager of the patient since the patient had "been placed on ABX (antibiotics) constantly d/t (due to) daughter's request." The daughter called back to the on-call nurse and reported the patient had pain when urinating, was combative and hallucinating. The on-call nurse told the daughter that the case manager did not feel the agitation was related to the UTI but instead to the progression of the disease, dementia and constant use of antibiotics would cause deterioration of the stomach flora. Clinical record review revealed the IDG failed to address the caregiver's multiple requests for antibiotics based on Patient #4's increased agitation and combativeness. The IDG further failed to address the daughter not administering a full course of antibiotics and then administering left over antibiotics when Patient #4 had increased agitation and combativeness. Instead of implementing new interventions, the IDG routinely ordered new antibiotics when the daughter reported Patient #4 had an infection. FAMILY INTERVIEW During an interview with the family/caregiver on 4/11/22 at 9:23 a.m., Patient #4's daughter said the agency did not assess Patient #4 when she had a UTI. She said the antibiotics first prescribed caused increased agitation with her mother. She said she used the antibiotics until her mother felt better then she would stop them. She said her mother had chronic infections. STAFF INTERVIEWS During an interview with the RNCM #4 on 4/14/22 at 10:11 a.m., she said she spoke to the IDG team about the patient's daughter not finishing antibiotic treatments and giving the patient the leftover doses at a later time when the patient had periods of increased confusion. She said the daughter was re-educated continuously by the nurses regarding the necessity of completing the prescribed doses of antibiotics and not stopping and starting. She said she brought it back to IDG for discussion. She said she discussed with the family/caregiver how dangerous it was by not finishing antibiotic therapy due to chronic conditions it could cause such as diarrhea. She said when she was ordering antibiotics for the patient she used caution such as a probiotic to help offset diarrhea. During continued interview, RNCM #4 said the daughter had a history with lots of medical providers and brought in past experiences. She said the daughter gave leftover antibiotics to Patient #4, so RNCM discussed with the daughter the need for three or more symptoms of UTI beyond a change in cognition. She said the daughter reported in the past that the patient had not urinated in 12 hours and had dark and concentrated urine before UTI treatment. She said antibiotics were ordered for comfort and not usually laboratory confirmation of infection. She said she discussed with the doctor about the constant antibiotic use, so he ordered an antibiotic for prophylactic treatment of chronic UTIs. During an interview with the RDCO, the DOO and the area vice president on 4/15/22 at 11:54 a.m., the DOO said the antibiotics for UTI treatment were prescribed if the nurse determined there were more symptoms than just altered mental status. During an interview with the medical director on 4/15/22 at 8:32 a.m., he said the nurses told the daughter to not stop and start antibiotics and not call UTI with altered mental status since the patient had a diagnosis of dementia. He believed the IDG had discussed in meetings. He said she received treatment for chronic UTI with Macrobid and Cipro, then eventually an antibiotic for anaphylactic treatment of UTI. He said the antibiotics were ordered for comfort. 4) Clinical record review revealed the agency failed to ensure the IDG maintained responsibility for directing and coordinating the care and service for Patient #4 when the family reported agitation, anxiety and/or combativeness and requested medication and behavioral management. Review of the RN Clinical Note dated 7/29/21 revealed the patient was having increased episodes of agitation, likely due to sundowning dementia. The lorazepam was changed to be scheduled every evening. Review of the RN Clinical Note dated 8/23/21 revealed the daughter reported the patient went to bed late a few nights ago and that threw off her mentation for a few days. The lorazepam helped calm her but it "doesn't make her any less angry." The nurse documented that she would monitor and adjust medications as needed. Review of the IDG documentation dated 9/22/21 revealed the nurse was to assess episodes of agitation and response to medications. The physician reported the patient had increased frequency of agitation for which the patient required increased frequency of Ativan. Review of the RN Clinical Note dated 9/29/21, revealed the patient was tearful during the visit. The daughter and granddaughter reported the patient had been very confused and agitated for the past couple of days and was refusing medications. The RN let the patient express her feelings then was able to get the patient to agree to take a lorazepam. Review of the On Call Note dated 9/29/21 at 4:22 p.m. the daughter called triage to report the patient was having confusion and agitation all day. The patient received 0.25 mg lorazepam at 11:00 a.m. and again at 3:00 p.m. Earlier in the day she was calm for an hour. The patient was due to receive scheduled citalopram at 8:00 p.m. The on-call nurse reviewed the medication profile and told the daughter that the patient was allowed 0.25 to 0.5 mg every six hours. The daughter asked if she could repeat the dose now. The on-call nurse said that the RNOC would be notified for follow up on possible increase in frequency of lorazepam. At 5:39 p.m. the on-call nurse called the daughter and the patient had quieted some but was still talking to herself. The nurse instructed the daughter to give the citalopram now and at bedtime give the nightly scheduled Trazodone and Seroquel. Review of the On Call Note dated 9/29/21 at 9:50 p.m. the daughter called triage to report the patient was having a rough night with dizziness. The daughter reported the patient was calm and starting to fall asleep. The daughter said that when she was awake she was not angry as previously reported earlier. The patient received Seroquel and Trazodone at bedtime. The daughter reported she held off on giving Trazodone until one hour past giving Seroquel due to being medicated earlier with lorazepam and clonazepam (which was not listed on medication orders for this certification period). Review of the IDG documentation dated 10/6/21, revealed the physician reported the patient continued to decline in cognition and function. She had a recent increase in agitation for which required an increased frequency of Ativan (The Ativan order had only changed from PRN to scheduled). The IDG did not address how to administer medications when Patient #4 was agitated. Review of the IDG documentation dated 12/29/21 revealed the IDG did not include the family/caregiver strain with providing 24 hour care to the patient; and the family/caregiver's difficulty with managing the patient's agitation with medication and behavioral management techniques like distracting the patient. Review of the On Call Note dated 2/4/22 revealed the daughter called the on-call nurse to report that Patient #4 was severely agitated and had not slept in four days. The daughter requested the nurse inject the patient with Ativan (benzodiazepine). The on-call nurse explained to the daughter that they would not inject the patient with Ativan. The daughter requested the patient to be restrained in her bed. The nurse explained to the daughter it was "illegal". The daughter said she understood and wanted the patient's medications to be revisited. Review of the MSW Clinical Note dated 2/15/22, revealed the MSW documented Patient #4 was not agitated during the visit, however the daughter became increasingly agitated when questioned about her reports of Patient #4's increased agitation and combativeness. The MSW documented the daughter stated "okay then I will just sedate patient until she dies" meaning she would administer the medications as outline in the plan of care and ordered by the physician. The daughter further stated this would result in the patient being sedated. The MSW explained to the daughter that Patient #4's behaviors were likely due to her disease process. Clinical record review revealed the IDG did not address the family/caregiver strain with providing 24 hour care to the patient; and the family/caregiver's difficulty with managing the patient's agitation with medication and behavioral management techniques like distracting the patient. FAMILY INTERVIEW During an interview with the family/caregiver on 4/11/22 at 9:23 a.m., Patient #4's daughter said she reported to the agency that the medications Patient #4 was prescribed were not effective for managing agitation and combativeness but did make her mother sleepy. She was instructed by the agency that making her sleepy was acceptable and they did not feel the patient was sedated. She said she requested medications to be adjusted but the agency would not send someone to assess her mother. STAFF INTERVIEWS During an interview with the RNCM #4 on 4/14/22 at 10:11 a.m. she said she spoke to the IDG team about the patient's agitation over the weekends and the daughter calling the on-call line. She spoke to the family about overstimulation and allowing the patient to sleep. She said the family had constant interaction with the patient and no change to daily routines. She said she felt this was the reason the patient would have increased agitation, especially on weekends. During continued interview, RNCM #4 said she talked to the family about the patient having regular feelings of anger, feelings of being overwhelmed, and anxiety as part of the disease process. She said she felt the patient was happy to live with the daughter and granddaughter but with all three at home at once, the patient became more anxious. RNCM #4 said the medical director/primary physician was aware of the daughter holding medications to treat anxiety, agitation and combativeness because the patient was confused and sleepy. During continued interview, RNCM #4 said the IDG determined the daughter required ongoing education about medication adjustments. She said the patient improved during her care at the agency. She said she felt the daughter was not expecting the caregiver role to be as demanding as it was. She said she discussed with the family/caregiver about overstimulating the patient and that was the reason the patient got agitated. She said she reminded the family to give the medications as ordered to manage the agitation. She said she reminded the daughter to sleep when the patient slept so she could get some rest. The daughter did not want her mother's sleep cycle disturbed so she would stimulate her when she dozed in her chair. She said because of the way the daughter gave the medications there was no way to know whether medications were effective or not. She said the daughter would give conflicting information about the patient's status such as the patient was sleepy after taking Ativan but prior to that she reported the patient was agitated and combative. She said it made it difficult to make medication adjustments and make a determination on the effectiveness of medications. During an interview with the SW on 4/14/22 at 1:32 p.m., the SW sa id she was involved in explaining to the family/caregiver about medication use and the management of agitation. She was directly involved either in person or by phone. She said she tried to document all conversations in the patient's medical record. The daughter would interrupt and say she gave medications as instructed and then say medications were not working. She said the daughter would agree to the medication adjustments, then she would say she did not give medications as instructed. She said she spoke to the daughter and explained this was confusing for the team by saying the medications were not working if she was not giving them. She said the daughter messaged the nurses a lot and called triage often. She said she spoke to the daughter on the phone and did not overhear the patient's agitation. During continued interview, the SW said the daughter was observed "badgering" the patient trying to wake her up and make her comfortable. She said the daughter was worried the patient was not sleeping at night but she was instructed that it was the disease process with dementia. She said the daughter would complain if the patient was comfortable and then complain when the patient was not comfortable. She said the education provided to the daughter was not good enough. She said the nurses wrote the medications down per the request of the daughter at every visit. She said she witnessed the daughter take it and throw it in the trash. She said that by throwing it away the daughter did not know how to administer the medications. She said the nurse reported to the SW that the daughter was non-compliant giving medications as instructed. During continued interview, the SW said she provided support to the patient and family/caregiver about the disease process. She said she discussed respite and burn out with the daughter. She said the daughter declined all efforts. She threatened to go to another hospice and so she offered to assist her in the transition. The daughter declined. She said the patient was pleasantly confused and not resistive to care as the daughter reported. She said she offered support but if the daughter was not following the plan of care then the type of support was difficult to determine. She said the IDG discussed the safety of medication administration by the daughter but believed education was appropriate and the patient was safe, however record review failed to show any discussion by the IDG. The SW said there was no way to know whether medications were effective or not since reports from the daughter changed all the time. She said the daughter reported that she gave the medications and the patient slept which was the desired outcome then the daughter would call and say she was sedated and slept too long. She said she was comfortable and that was the reason for sleeping. She said the patient would wake up and be agitated. She said when she challenged or clarified with the daughter the report would change. She said she was trying to "trip" her up just trying to understand but she would get agitated. She said she reiterated with the daughter that the medications did not work if the orders were not followed. She said the daughter frequently called the triage to get a different answer than the RNCM gave. She said the daughter purposefully called triage to find someone that did not know the story to get medication adjustments. She said one time the daughter spoke to a nurse who knew her and she changed her conversation. She said she spoke to the daughter about not holding medications that were vital. During an interview with the medical director on 4/15/22 at 8:32 a.m., he said he was the patient's primary physician. He said the inconsistencies with family members reporting medications and symptoms made it difficult to make medication adjustments. He said he did not document family issues but reviewed nurse notes about it. He said he remembered being told by nurses about agitation and not sleeping for weeks, then Patient #4 was over sedated. He said it was difficult to make medication adjustments with different stories going on with the patient. He said he had one face to face visit with the patient due to agitation but he did not see the patient agitated. During continued interview, the medical director said the IDG was thorough; he was sure it was discussed but not specific comments, mostly inconsistencies in stories. He said education was provided to the family regarding the disease process and patient's decline. During an interview with the RDCO, the DOO and the area vice president on 4/15/22 at 11:54 a.m., the DOO said there was discussion at every IDG meeting about the patient and daughter. She said that they should have documented the discussion and decision in the IDG notes. She said she did not know why the IDG determinations were not documented in the IDG notes. She said she remembered the daughter was not always agitated. She said she was a concerned daughter and insisted on more care. The daughter did not become disorganized in her thoughts until later. She said once the IDG recognized the concerns were not improving, they initiated the SW and nurse to go in together and had the doctor conduct a visit. She said it was not common practice to have the doctor do a face to face visit unless they recognized something was wrong.

Based on interview and record review, the hospice failed to ensure care and services were provided in accordance with the plan of care for 3 of 5 patient records reviewed (Patients #3, #4 and #5). Findings include: HOSPICE POLICY According to the policy, "The Plan of Care," dated 2/2009 (in part): "-Care provided to the patient will be in accordance with the plan of care. -Every effort should be made to adhere to the ordered visit frequency. Attempts should be made to reschedule a visit within the ordered time frame to avoid a missed visit. In the event the ordered visit frequency is not met, the following should occur: A. If unable to reschedule within the ordered time frame, complete a missed visit coordination note. B. If the missed visit is a hospice aide visit, the hospice aide must immediately notify the RN [registered nurse] case manager. C. During the IDG [interdisciplinary group] meeting all missed visits must be reported to the Medical Director/Hospice Physician and documented in the patient-specific IDG note." 1. The clinical record for Patient #3 was reviewed on 4/13/22. The patient was admitted for hospice care and services on 11/14/21 with a terminal diagnosis of Alzheimer's disease. The plan of care for the certification period dated 11/14/21 through 2/11/22 included orders for skilled nurse (SN) services twice weekly every two weeks for two weeks then twice weekly for 12 weeks and three visits as needed (PRN); and certified nurse aide (CNA) services twice weekly for 13 weeks.The patient resided at home. a) The hospice failed to provide CNA services to meet the patient's needs in accordance with the plan of care orders. Review of the plan of care for the certification period dated 11/14/21 through 2/11/22 revealed Patient #3 was ordered to have CNA visits twice weekly for 13 weeks. Clinical record review revealed registered nurse (RN) #3 completed the comprehensive recertification assessment on 2/17/22 and established plan of care orders for CNA services twice weekly for 13 weeks with Patient #3's physician on 2/16/22 for the certification period dated 2/12/22 through 5/12/22. Further review of the record revealed a coordination note, written by the agency's director of nursing (DON) on 2/22/22, stating CNA visits "may or may not have been completed" by CNA #6 as CNA #6 had resigned without notice and prior to completing all visit notes. Review of completed CNA visit notes for Patient #3 failed to show CNA services were provided in accordance with the plan of care. Specifically, the clinical record for Patient #3 failed to reveal CNA visits were conducted on 3/3/22, 3/7/22 and 3/28/22. Additionally, the record failed to show documentation the visits were missed, the physician was aware the visits were not completed and how the patient's needs were met. During an interview during a home visit on 4/14/22 beginning at 1:00 p.m., a family member for Patient #3 stated there had been a couple of times when agency staff could not provide services as ordered and they agency always offered a replacement staff member, which the family member stated he declined because he could provide the care to Patient #3. During the same interview on 4/14/22, CNA #11 stated she was a contracted employee and had been working with the agency since January 2022. She stated she had been providing services to Patient #3, when requested by the agency, from the end of February 2022. CNA #11 stated since she was contracted with the agency, she did not document directly into the agency's electronic medical record (EMR), but completed paper timesheets when she completed a visit and turned the timesheets into the agency office every few days. During an interview on 4/15/22 at 11:02 a.m., Employee #8 confirmed the CNA visit notes from CNA #11 were turned in to the agency office and then uploaded into Patient #3's electronic chart. Following review of completed CNA visit notes for Patient #3, Employee #8 acknowledged CNA visits were not conducted to Patient #3 on 3/3/22, 3/7/22 and 3/28/22. She stated the visits were missed, however the clinical record did not contain any documentation of the missed visits including missed visit coordination notes or documentation the physician had been made aware of the deviation to the plan of care. 2. The clinical record for Patient #4 was reviewed on 4/12/22. The patient was admitted for hospice care and services on 7/5/21 with a terminal diagnosis of congestive heart failure and dementia with behaviors and discharged to another agency on 2/22/22. The plan of care for the certification period 7/5/21 through 10/2/21 included orders for SN services two times weekly for one week then once weekly for 12 weeks and three visits as needed for symptom management; CNA services one time weekly for one week then twice weekly for 12 weeks; medical social worker (MSW) and chaplain evaluations. The patient resided at home. The plan of care for the certification period 10/3/21 through 12/31/21 included orders for SN services one time weekly for 13 weeks; MSW services twice monthly for three months; CNA services three times weekly for 13 weeks; and chaplain services twice a month for three months. The plan of care for the certification period 1/1/22 through 3/1/22 included orders for SN services twice every two weeks for two weeks then twice weekly for seven weeks then once weekly for one week and three as needed visits for symptom management; CNA services three times weekly for 13 weeks; and chaplain services twice a month for three months. a) The hospice failed to provide CNA services to meet the patient's needs in accordance with the plan of care orders. During an interview with the family/caregiver on 4/11/22 at 9:23 a.m. she reported that on her Medicare statement, it said the patient received seven CNA visits from October 2021 to February 3, 2022. She said, "We had sporadic ones (CNAs) who called, but since they were not consistent, I had already bathed my mom but they never offered to come out and do anything else." Review of the plan of care for the certification period 7/5/21 through 10/2/21 included orders for CNA services one time weekly for one week then twice weekly for 12 weeks. Clinical record review revealed registered nurse case manager (RNCM) #3 completed the comprehensive recertification assessment on 7/5/21 and established plan of care orders for CNA services one time weekly for one week then twice weekly for 13 weeks with Patient #4's physician on 7/7/21 for the certification period dated 7/5/21 through 10/2/21. Review of completed CNA visit notes for Patient #4 failed to show that CNA services were provided in accordance with the plan of care. Specifically, the clinical record for Patient #4 failed to reveal CNA visits were conducted on 7/15/21, 7/26/21, 8/12/219/9/21 and 9/13/21. Additionally, the record failed to show documentation the visits were missed, the physician was aware the visits were not completed and how the patient's needs were met. Review of the plan of care for the certification period 10/3/21 through 12/31/21 included orders for CNA services three times weekly for 13 weeks. Clinical record review revealed RNCM #3 completed the comprehensive recertification assessment on 9/18/21 and established plan of care orders for CNA services three times weekly for 13 weeks with Patient #4's physician on 9/23/21 for the certification period dated 10/3/21 through 12/31/21. Review of completed CNA visit notes for Patient #4 failed to show that CNA services were provided in accordance with the plan of care. Specifically, the clinical record for Patient #4 failed to reveal CNA visits were conducted on 10/12/21, 10/27/21, 10/29/21, and 11/5/21. Additionally, the record failed to show documentation the visits were missed, the physician was aware the visits were not completed and how the patient's needs were met. Review of the plan of care for the certification period 1/1/22 through 3/1/22 included orders for CNA services three times weekly for 13 weeks.. Clinical record review revealed RNCM #3 completed the comprehensive recertification assessment on 12/29/21 and established plan of care orders for CNA services twice weekly for 13 weeks with Patient #4's physician on 12/29/21 for the certification period dated 1/1/22 through 3/1/22. Review of completed CNA visit notes for Patient #4 failed to show that CNA services were provided in accordance with the plan of care. Specifically, the clinical record for Patient #4 failed to reveal CNA visits were conducted on 2/5/22 (the CNA did not show up according to the nurse note dated 2/6/22) and 2/8/21. Additionally, the record failed to show documentation the visits were missed, the physician was aware the visits were not completed and how the patient's needs were met. During an interview with the RNCM #4 on 4/14/22 at 10:11 a.m. she said the patients and family/caregivers reported CNA missed visits to the RNCM during visits at the home. She said Patient #4's family/caregivers usually did the care before the CNA got to the home. RNCM #4 said it was difficult to find another CNA to go into Patient #4's home because the family/caregivers were particular in who they allowed into their home. RNCM #4 said it was difficult to get a CNA schedule that worked for the family/caregiver. An interview with CNA #6 and RNCM #3 were unable to occur as CNA #6 was on leave and RNCM #3 had resigned from the agency. 3. The clinical record for Patient #5 was reviewed on 4/12/22. The patient was admitted for hospice care and services on 2/12/22 with a terminal diagnosis of cirrhosis of the liver. The plan of care for the certification period 2/12/22 through 3/29/22 included orders for SN services once a week for one week, two times weekly for 13 weeks and four visits as needed for symptom management; CNA services twice weekly for 12 weeks then once a week for one week; MSW and chaplain evaluations. The patient resided at home. Clinical record review revealed RNCM #3 completed the comprehensive recertification assessment on 2/12/22 and established plan of care orders for CNA services twice weekly for 12 weeks then once a week for one week with Patient #5's physician on 2/18/22 for the certification period dated 2/12/22 through 3/29/22. Review of completed CNA visit notes for Patient #5 failed to show that CNA services were provided in accordance with the plan of care. Specifically, the clinical record for Patient #5 failed to reveal a CNA visit was conducted on 2/21/22. Additionally, the record failed to show documentation the visit was missed, the physician was aware the visit was not completed and how the patient's needs were met. 4. During an interview with the regional director of clinical operations (RDCO) and executive director (ED) on 4/13/22 at 4:27 p.m. the RDCO said the reasons for missed visits were documented on the missed visit note in the electronic health record. She said she was not able to find the documentation for the reason for the missed visits and/or the documentation was incomplete and did not indicate the reason for the missed visits for Patients #3 and #4. During continued interview, the ED said the family was at appointments like the hairdresser or getting her nails done frequently. The ED said that the family would directly contact the CNA to make alternate arrangements, however at times the daughter would take the patient to appointments and not notify the staff. The staff would show up to the visit and the patient would not be at home. The ED said it was not usual for the patients to not be at home since it was hospice services being provided to patients. During continued interview, the RDCO said the staff were to offer alternative visits and document the missed visit note. The RDCO said some of the missed visits did not have documentation to support alternative visits that were offered. During continued interview, the RDCO and ED said that the patient did not report concerns about the frequency of the CNA services. The RDCO and ED said that the case managers were notified of all missed visits and identified trends of missed visits to adjust the frequency of visits as needed. The IDG was notified of all missed visits and plans on how to meet patient needs were discussed during the IDG meeting. The medical director and Patient #4's primary physician attended the IDG meetings so he was notified of the missed visits.

Based on interview and record review, the hospice failed to ensure care and services were provided according to assessment of patient needs. This failure occurred in 2 of 2 patient records reviewed who were using side rails without documentation of nursing assessments of the patient and family needs and least restrictive interventions utilized (Patients #1 and #3). (Cross-reference L550) Findings include: 1. The clinical record for Patient #3 was reviewed on 4/13/22. The patient was admitted for hospice care and services on 11/14/21 with a terminal diagnosis of Alzheimer's disease. The plan of care for the certification period dated 11/14/21 through 2/11/22 included orders for skilled nurse (SN) services three times weekly for one week, twice weekly for 10 weeks, then once weekly for two weeks and three visits as needed (PRN) for symptom management; certified nurse aide (CNA) services once weekly for 11 weeks; medical social worker (MSW) evaluation; and chaplain evaluation. The subsequent plan of care for the certification period dated 2/12/22 through 5/12/22 included orders for SN services twice weekly every two weeks for two weeks then twice weekly for 12 weeks and three visits PRN; and CNA services twice weekly for 13 weeks. The patient resided at home. a) The hospice failed to ensure the use of side rails was based on an individual assessment of patient and family needs, and ongoing assessments to ensure the patient received the least restrictive intervention or the removal of the device when appropriate. During a home visit on 4/14/22 beginning at approximately 1:00 p.m., bilateral half side rails were observed on Patient #3's hospital bed in the raised position. The agency director of nursing (DON) was observed standing on the left side of the patient's bed and conducted a physical head to toe assessment and CNA #11, standing on the right side of the bed, was observed washing the patient's face and completing peri-care on the front of the patient's body while she laid on her back. The DON and CNA #11 then removed the patient's soiled gown and replaced it with a clean one. The DON and CNA #11 then assisted Patient #3 to roll onto her left side to allow for visual inspection of the patient's coccyx area by the DON and peri-care by CNA #11. The DON was observed allowing the patient to hold onto his right hand with both of her hands while he placed his left hand on the patient's right hip to assist her rolling to the left. CNA #11 provided assistance with both her hands on the patient's upper back and buttocks area to assist her rolling to the left. Although Patient #3 attempted to grasp onto the raised side rail on the left side of the bed, she was not encouraged to utilize the side rail to assist with bed mobility or to maintain the position on her left side. Once Patient #3 was clean and a new brief donned, the DON and CNA #11 assisted the patient to roll back to her back. They then utilized the bed sheet to lift the patient toward the head of the bed. CNA #11 was then observed completing the remaining cares (hair care and mouth care) with the side rails still in the raised position. Review of the plan of care for the certification period dated 2/12/22 through 5/12/22 failed to show documentation the patient had been evaluated for or required the use of side rails. Specifically, the section titled "Current Supplies and DME [durable medical equipment]" showed no documentation of side rails, and failed to show documentation the patient had been assessed for least restrictive measures applied, patient safety or a need for specific physician order for the use of side rails. Review of the comprehensive assessment, completed on 2/17/22 by registered nurse (RN) #3, revealed RN #3 documented she completed environment and safety, head to toe physical and equipment assessments. However, the comprehensive assessment showed no documentation that the patient had been evaluated for or required the use of side rails. Specifically, the section on the assessment titled "Environment/Safety", showed Patient #3 had no fall prevention or additional environment/safety issues; and the section titled "Braden Risk Assessment" showed Patient #3 was confined to her bed and required moderate to maximum assistance for repositioning and movement. However, the comprehensive assessment failed to show documentation that the patient had been assessed and the physician had ordered the use of side rails. Additionally, there was no evidence the RN had provided Patient #3 with education on the risks of side rail use during the comprehensive assessment. Review of a SN visit notes, completed by RN #3, showed RN #3 documented half rails in the section titled "Equipment and Supplies" of visit notes for visits conducted on 2/17/22, 2/21/22, 2/24/22, 3/3/22, 3/7/22, 3/14/22, 3/21/22, 3/24/22, 3/31/22, 4/4/22 and 4/5/22. There was no evidence the RN had provided Patient #1 with education on the risks of side rail use or assessed the need of the side rails and obtained physician orders during any of the 11 visits conducted at which the RN documented the presence of side rails. During an interview during the home visit on 4/14/22 beginning at approximately 1:00 p.m., the family member for Patient #3 stated when the bed had originally arrived at the home, the side rails were present. He stated they were usually always in the raised position and Patient #3 was sometimes observed to use them to roll herself from side to side for comfort. The family member stated he did not provide any assistance to roll her from side to side and typically only used the sheets to slide her up in the bed. 2. The clinical record for Patient #1 was reviewed on 4/11/22. The patient was admitted for hospice care and services on 2/13/22 with a terminal diagnosis of dysphagia. The plan of care for the certification period dated 2/13/22 through 5/13/22 included orders for SN services three times weekly for one week then twice weekly for 12 weeks and three visits PRN for symptom management and to provide instruction and reinforcement related to urinary incontinence; CNA services three times weekly for one week then twice weekly for 12 weeks for assistance with personal care and activities of daily living (ADLs); MSW evaluation; and chaplain evaluation. The patient resided at home. a) The hospice failed to ensure the use of side rails was based on an individual assessment of patient and family needs, and ongoing assessments to ensure the patient received the least restrictive intervention or the removal of the device when appropriate. During a home visit on 4/12/22 beginning at approximately 8:45 a.m., bilateral half side rails were observed on Patient #1's hospital bed in the raised position. CNA #10 was observed lowering the half rails to allow himself and the patient's non-skilled caregiver to provide assistance to Patient #1 to complete bed mobility. Review of the plan of care for the certification period dated 2/13/22 through 5/13/22 failed to show documentation the patient had been evaluated for or required the use of side rails. Specifically, the section titled "Current Supplies and DME" showed no documentation of side rails, and failed to show documentation the patient had been assessed for least restrictive measures applied, patient safety or a need for specific physician order for the use of side rails. Review of the initial comprehensive assessment, completed on 2/13/22 by RN #9, revealed RN #9 documented she completed environment and safety, head to toe physical and equipment assessments. However, the comprehensive assessment showed no documentation of DME including a hospital bed and side rails and that the patient had been evaluated for or required the use of side rails. Specifically, the section on the assessment titled "Environment/Safety", showed Patient #1 had no fall prevention or additional environment/safety issues; and the section titled "Braden Risk Assessment" showed Patient #1's mobility was very limited and he could make occasional slight changes in position, was not able to make frequent or significant changes independently, and occasionally slid down in the bed. However, the comprehensive assessment failed to show documentation that the patient had been assessed and the physician had ordered the use of side rails as the section titled "Equipment and Supplies" showed all equipment and supplies were assessed but "N/A" was documented under the question "indicate existing equipment present in the home." There was no evidence the RN had provided Patient #1 with education on the risks of side rail use during the initial assessment. Review of SN visit notes, completed by RN #3, showed RN #3 ordered a hospital bed and half rails for Patient #1 on 2/14/22 and documented half rails in the section titled "Equipment and Supplies" of visit notes for visits conducted on 2/17/22, 2/21/22, 2/24/22, 2/28/22, 3/18/22, 3/22/22, 3/25/22, 3/28/22 and 4/5/22. There was no evidence the RN had provided Patient #1 with education on the risks of side rail use or assessed the need of the side rails and obtained physician orders during any of the nine visits conducted at which the RN documented the presence of side rails. During an interview on 4/12/22 at a home visit beginning at 8:45 a.m., CNA #10 stated the bed for Patient #1 had the half rails in the raised position each time he came for a visit and he lowered them when he provided care to the patient. He further stated Patient #1 needed maximal assistance to complete all mobility and did not get out of bed. During the same interview on 4/12/22 beginning at 8:45 a.m., Patient #1's non-skilled caregiver confirmed the side rails were typically in the raised position and Patient #1 sometimes moved himself a little bit in the bed but rarely used the side rails independently. 3. During an interview on 4/14/22 at 3:32 p.m., Employee #8 stated she was unable to find any documentation of assessment or education for the use of the bed rails for Patients #1 and #3. She stated she believed the use of side rails for Patient #1 was for mobility to offload his buttocks area because he had a coccyx wound and Patient #3 typically used the side rails for rolling side to side. Employee #8 further stated the hospice had not completed any assessments prior to having the side rails on the hospital beds and no assessments had been completed at any SN visits thereafter. RN #3 was not available for interview as RN #3 was on vacation and not able to be reached.