Every finding on record at Matrix HHA Inc

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over the counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by document review, interview, and observation. In 2 of 3 (67%) home visits observed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. DOCUMENT 2: The agency's policy 11.10.1 titled Medication Profile, dated June 2019, required in part, The nurse will add all new/changed medication(s) to the medication profile. The medication profile will be reviewed every home visit, updated as changes occur, and reviewed by the IDG (interdisciplinary group). HOME VISIT 1: The patient's representative elected the hospice benefit on 06/14/2024. The current medication profile was dated 05/21/2026, as part of the updated plan of care. During the home visit with the Registered Nurse (RN) (Personnel Record 1) on 05/28/2026, a review of the patient's current home medications compared to the medication profile found a prescription filled on 10/14/2025 (Gas Relief 125 mg chewable tablet, one by mouth after each meal for gastritis and bloating), which was not listed on the medication profile. HOME VISIT 2: The patient's representative elected the hospice benefit on 01/17/2025. The medication profile was dated 05/2/2026, as part of the updated plan of care. During the home visit with the hospice aide (Personnel Record 2) on 05/28/2026., a review of the patient's current home medications compared to the medication profile found a prescription filled on 04/07/2026 (Nystatin 100,000 units/gram cream applied three times a day for fungal infection), which was not listed on the medication profile. An interview was conducted on 05/28/2026, with the Director of Nursing (Personnel Record 1) and Alternate Administrator (Personnel Record 8) regarding the findings of patients' medication omitted from the agency's medication profile. They stated that this issue is one of the agency's active performance improvement projects.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address the minimum information provided to facilitate patient evacuation and transportation including: if the patient is mobile or not; if the patient has life-dependent equipment, and if so, is it able to be transported (e.g. battery operated, size, condition, etc.); and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g. deaf, non-English speaking, etc.). This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure that the minimum required patient assessment information was collected and documented for assisting the patient needing evacuation or transport during an emergency. Clinical Record 4: The patient elected the hospice benefit on 4/26/2023. The initial comprehensive assessment completed by the Registered Nurse (RN) on 4/26/2023 documented that the patient was bedbound and required someone to feed him due to Parkinson's tremors. The patient was assessed as a Class III triage level at admission. The "Emergency Preparedness Information" signed and dated 4/26/2023 by the patient, the admission assessment, and the agency's patient emergency report did not include documentation of the patient's mobility, if the patient required life-saving equipment, or if the patient had special needs to be communicated to emergency officials. Clinical Record 5: The patient elected the hospice benefit on 5/3/2023. The initial comprehensive assessment completed by the Registered Nurse (RN) on 5/3/2023 documented that the patient was bedbound. The patient was assessed as a Class III triage level at admission. The "Emergency Preparedness Information" signed and dated 4/26/2023 by the patient, the admission assessment, and the agency's patient emergency report did not include documentation of the patient's mobility, if the patient required life-saving equipment, or if the patient had special needs to be communicated to emergency officials. During an interview on 6/26/2023, the Administrator and the Director of Nursing (DON) confirmed that the "Emergency Preparedness Information" form did not include the required elements.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 3 (67%) clinical records reviewed of patients receiving hospice aide services, the agency did not ensure that the RN provided specific written patient instructions for the hospice aide. The state's Board of Nursing "Delegation Principles" stated in part that when the RN delegates a task to unlicensed personnel, those instructions should include, "Situation-specific communication includes...specific activities to be performed and client-specific instruction and limitation." Clinical Record 1: The patient elected the hospice benefit on 4/21/2023. The plan of care ordered: "stage 4 sacrum, 4x4, 2 ABD pad/day... NPO/Glucerna 1.2 can bolus with 300cc water..." The aide care plan dated 4/23/2023 documented the assigned aide tasks: "provide urinary catheter care by cleaning and maintaining the catheter site and emptying the catheter bag (3x week); provide shampoo support to promote hygiene and self-esteem (3x week); provide skincare as directed, including using moisturizers and creams, or lotions to prevent or treat dryness, irritation, or infection (3x week); offer bed baths including washing patient's body, hair, and face (3x week); provide oral care to prevent infection, injury, or discomfort (3x week); universal precautions (3x week); notify RN if no BM in 3 days (3x week); place heel boots after bath (3x week)." The aide care plan was unchanged as of the Interdisciplinary Group Meetings (IDG) dated 5/11/2023, 5/25/2023, 6/8/2023, and 6/22/2023. The aide care plan did not include instructions documenting what to do if the wound dressing became wet or soiled during the visit or for the care and cleaning around the PEG tube site. Clinical Record 5: The patient elected the hospice benefit on 5/3/2023. The plan of care dated 5/3/2023 and 5/31/2023 ordered wound care to both lower extremities three times a week and PRN (Pro Re Nata) if soiled. Hospice aide services were ordered three times a week. The Aide care plan dated 5/8/2023 documented the assigned aide tasks: provide oral care to prevent infection, injury, or discomfort (1x/week)… Provide Shave support to promote hygiene and self-esteem (1x/week)…Use barrier products...to protect the patient's skin from moisture, irritation, or infection (1x/week)… Offer bed baths, including washing patient's body, hair, and face (1x/week)." The Aide care plan was unchanged as of the Interdisciplinary Group Meetings dated 5/11/2023, 5/25/2023, 6/8/2023, and 6/22/2023. The aide care plan did not include instructions documenting what to do if the wound dressing became wet or soiled during the visit. During an interview on 6/27/2023, the Director of Nursing confirmed that the aide care plans did not provide the aide with instructions on what to do in case the patient's wound dressings became wet, soiled, or fell off.

It is required that hospice nursing services, physician services, drugs, and biologicals are made routinely available on a 24-hour basis, seven (7) days per week. All covered services are available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. This standard was not met as evidenced by document review and interview. In 1 of 6 (17%) contracts reviewed, the agency did not ensure that pharmacy services were made available on a 24-hour basis, seven days a week, when reasonable and necessary to meet the patient's and family's needs. The agency policy "Medication Dispensing" (approved 3/30/2023) stated, "...provides medications 24 hours/day, 7 days/week through contracted pharmacy providers." Contract 2: The pharmacy agreement with the effective date of 2/28/2023 did not include documentation which stated that the contracted pharmacy services were available to meet the needs of the patient and family on a 24-hour basis, seven (7) days a week. During an interview and a joint review of the pharmacy contract on 6/27/2023, the Director of Nursing (DON) and the Administrator confirmed that the pharmacy agreement did not contain language that pharmacy services was available 24 hours a day, seven days a week. Before the conclusion of the site visit, the DON and the Administrator contacted the pharmacy regarding an addendum to the contract.

It is required that the Interdisciplinary Group determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. The plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure that the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home was determined by the Interdisciplinary Group (IDG). The agency policy "Medication Administration" (approved 3/30/2023) stated in part, "The IDG, as part of the review of the plan of care, will determine initially and ongoing the ability of the patient/family/caregiver to safely and competently administer drugs and biologicals to the patient in his/her home. The individualized IDG plan of care must identify if patient/family/caregiver are administering drugs and biologicals." Clinical Record 4: The patient elected the hospice benefit on 4/26/2023 and died on 4/29/2023. The patient's medication list documented the following medications ordered on 4/26/2023: Alprazolam 2mg by mouth four times a day...Carisoprodol 350mg by mouth every 6 hours as needed...Escitalopram 20mg by mouth twice a day...Lactulose 10g/15ml: take 15ml by mouth daily as needed... Morphine 15mg ER by mouth every 12 hours...Morphine 20mg/ml: 10mg under tongue every 4 hours as needed for pain...Pregabalin 50mg daily...Phenobarbital 97.2mg three times a day...Hydroxyzine Hydrochloride 50mg twice a day by mouth as needed for itching...Atenolol 100mg by mouth daily." The ability of the patient and family to safely manage medications was not addressed in the comprehensive assessment or the plan of care. Clinical Record 5: The patient elected the hospice benefit on 5/3/2023 and died on 6/18/2023. The patient's medication list documented the following medications ordered 5/3/2023: Lorazepam 2mg/ml: 0.5ml under the tongue every 4 hours as needed for anxiety; Morphine 20mg/ml: 0.25mg to 5mg under the tongue every 4 hours as needed for pain; Quetiapine 25mg by mouth nightly at bedtime; Loratadine 10mg by mouth daily; Ipratropium-Albuterol 0.5mg/2.5mg in 3ml solution by nebulizer every 6 hours as needed for chest congestion." The ability of the patient and family to safely manage medications was not addressed in the comprehensive assessment or the plan of care. During an interview on 6/27/2023, the Director of Nursing confirmed the finding and stated the Electronic Medical Record (EMR) did not designate a place for this assessment. The current clinical records were updated prior to the end of the site visit.