Every finding on record at Medi Home Health Agency, Inc.

Based on staff (EMP) interview, hospice document review, and review of medical records (MR), it was determined the hospice failed to maintain an accurate medication profile in one (1) of fourteen (14) MR’s reviewed in the survey sample.  MR9. --- Findings:An interview was conducted with EMP11 on July 30, 2025, at approximately 12:30 PM.  EMP11 indicated the MR9 experienced frequent anxiety and agitation.  EMP11 indicated the patient was taking lorazepam as needed for anxiety and required a medication to be administered prior to each bath given by the hospice aide to decrease agitation.The medication profile for MR9 was reviewed. The medication profile did not contain lorazepam as needed or any medications with instructions to be given prior to bathing.  An interview was conducted with EMP2 on July 30, 2025, at approximately 1:00 PM. EMP2 indicated the patient was ordered an “E-Kit” (a medication kit containing emergency comfort medications) on admission that contained lorazepam and Haldol (medications that can be used for agitation and anxiety), and these may be the medications that MR9 was taking.  EMP2 indicated that if the patient was taking these medications from the E-Kit they should be included on the medication profile and acknowledged these medications were not on MR9's medication profile. The hospice’s policy, “Comprehensive Assessment” last revised May 2025, reads in part, “…The comprehensive assessment includes, but is not limited to: Prescribed medications, over the counter, herbal remedies and alternative treatments that could affect drug therapy…”

Based on staff (EMP) interview, hospice document review, and review of medical records (MR), it was determined the hospice failed to develop an individualized plan of care for each patient that reflected patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments in three (3) of fourteen (14) records reviewed in the survey sample. MR5, MR9, and MR10. --- Findings:The hospice's policy, "Symptom Management" last revised June 2025 was reviewed and reads in part, "...Symptom management includes ongoing interdisciplinary assessment...Symptom assessment is completed during the initial and comprehensive assessment; at every home visit by all clinical disciplines...during IDG (Interdisciplinary group) review and plan of care updates. The Edmonton Symptom Assessment System - revised (ESAS-r) is used to quantify symptom burden and guide interventions. Nursing Staff must complete the ESAS-r tool at every visit...Nursing staff document ESAS-r scores, clinical impressions, interventions initiated, and patient/caregiver response in the clinical record. Based on assessment findings, the plan of care must reflect measurable goals for symptom control...Plan of Care and Response to Change. Interventions must be clearly documented in the plan of care and updated: when goals are not met; when new symptoms emerge; after reassessment or change in condition...For uncontrolled symptoms: the nurse must notify the attending physician and/or medical director...whether the response to interventions provided and reassessment i.e. pain reassessed, and plan of care revisions are necessary if the current interventions are not effective...Responsibilities, IDG members collaborate to evaluate symptoms, determine interventions, and adjust care plans. Hospice nurse: leads clinical assessment, documents all symptoms and ESAS-r scores, and ensures timely communication with the physician..."A document provided by the facility, “Guidelines for Using the Edmonton Symptom Assessment System, “was reviewed and reads in part, “The Edmonton System Assessment System (ESAS) captures the increasing intensity of symptoms related to end stage diagnoses…It is on an 11-point scale from 0 to 10 that assesses the level of burden for each symptom. These values should be patient reported when available but may also be gleaned from the skilled nurse’s assessment…The person who provides the information should be clearly documented in the nurse’s note…. It is important to note with higher scores, the worse the symptom burden is for the patient. Symptom Description – Depression…Unable to assess if the patient is cognitively impaired…Wellbeing - Unable to assess if the patient is cognitively impaired…Depression and wellbeing may be completed as “unable to assess” if a patient is unable to self-report.  Both symptoms are difficult to complete based on assessment alone or caregiver reporting..."MR10 contained documentation that the patient was confused and unable to self-report symptoms.  The ESAS was completed by the nurse on July 15, 2025, with a depression score of 8, anxiety score of 9, and wellbeing score of 8; on July 18, 2025, with a depression score of 8, anxiety score of 8, and wellbeing score of 8; on July 25, 2025, with a depression score of 8, anxiety score of 8, and wellbeing score of 8.  MR10 failed to contain documentation that the hospice or attending physician was notified of the patient’s high level of anxiety from July 15, 2025 – July 25, 2025.  MR10 failed to contain evidence that the patient's plan of care was modified to include any interventions to reduce the patient’s anxiety.  The medical record failed to contain evidence that the patient’s anxiety was reassessed in a timely manner.  The nurse did not see the patient for three days after noting the level 8 anxiety on July 15, 2025. Additionally, the hospice nurse failed to use the ESAS tool according to the hospice’s instructions.  Depression and wellbeing were scored despite the hospice’s written procedure not to score these areas if the patient was unable to self-report.  There was no documentation in the three (3) above noted ESAS assessments for MR10 of who provided the information on behalf of the patient despite the hospice’s procedure to do so. Inaccurate use of the ESAS assessment, failure to report the patient's elevated symptom burden, and failure to reassess the patient's anxiety in a timely manner resulted in the IDG not having current, accurate information in order to modify MR10's plan of care. MR9 was reviewed and revealed that the patient was admitted to hospice services on July 14, 2025, with a terminal diagnosis of senile degeneration of the brain. On July 15, 2025, the hospice nurse documented the following ESAS scores: Anxiety – 8; Wellbeing – 9; Depression 8.  On July 22, 2025, documented: Anxiety – 9; Wellbeing 9; Depression 9. On July 24, 2025, documented: Anxiety 8; Depression – 8; Wellbeing – 8. The medical record contained no evidence that any interventions were put into place related to the patient’s anxiety on any of the above noted visits.An interview was conducted with EMP11 on July 30, 2025, at approximately 12:30 PM.  EMP11 indicated that if a patient in a facility expressed a high level of anxiety and a new intervention was put in place, the facility would call the hospice if the intervention was not effective.  EMP11 indicated there was no expectation of a timeframe in which to reassess unmanaged symptoms such as anxiety as documented in MR9.  EMP11 indicated that MR9 was anxious and agitated frequently, but EMP11 was educated by the hospice to score all patients "high" related to symptoms so the patients would qualify for hospice services regardless of whether or not the patient was experiencing "high" or severe symptoms. The hospice's policy, "Comprehensive Assessment" last revised May 2025 was reviewed and reads in part, "...Plan of Care Development. The IDG uses information from the comprehensive assessment to create a personalized plan of care with clear, measurable, and quantifiable interventions and goals to address the person-centered and individualized needs of the patient and/or caregiver..."MR5 revealed the patient was admitted on February 6, 2025, with a terminal diagnosis of senile degeneration of the brain.  The patient was identified as a high fall risk, and the following goal was entered onto the care plan dated February 6, 2025: “Patient will remain free from injuries related to falls as evidenced by facility staff utilizing ongoing fall precautions.”  The patient had a documented fall without injury on May 29, 2025, and a fall on June 16, 2025, resulting in a skin tear and bruising to the face and shoulder.  MR5’s care plan related to falls had not been updated since admission and contained no new interventions to prevent injury from falls after either of the falls documented.The IDG met on July 18, 2025, to discuss the comprehensive assessment for MR9 and develop an updated care plan.  During the discussion, the team documented the patient’s history of multiple falls. Neither MR9’s initial care plan dated July 14, 2025, nor the updated care plan dated July 18, 2025, contained interventions for fall prevention.An interview was conducted with EMP7 on July 30, 2025, at approximately 1:00 PM who indicated after MR5's first fall, no new interventions were put into place for MR5 as there were no injuries noted.  After the patient’s second fall, fall mats were ordered for the patient.  During a home visit on July 29, 2025, at 9:35 AM, the surveyor did not observe any fall mats in MR5's room. EMP confirmed that they checked the room for fall mats on July 29, 2025, and no fall mats were present.  EMP indicated that fall mats were reordered by the nurse on July 29, 2025, and should have been delivered the afternoon or evening of July 29, 2025.The current care plan for MR5 was again reviewed on July 30, 2025.  The care plan did not contain any documentation that fall mats were ordered for the patient or instructions for their use.

Based on staff (EMP) interviews, hospice document review, and review of medical records (MR), it was determined the hospice failed to make bereavement services available to one (1) of two (2) records reviewed for bereavement services in the survey sample.  MR14. --- Findings:Review of MR14 revealed the patient died in hospice care on May 28, 2025.  The initial bereavement assessment completed by the social worker indicated the patient’s significant other as the patient’s bereaved person and was this person was identified as a “low” bereavement risk. The medical record contained no documentation that bereavement services were provided or offered to MR14’s significant other.An interview was conducted with EMP2 on July 30, 2025, at approximately 2:00 PM who indicated the hospice’s chaplain/bereavement counselor was on vacation and MR14’s significant other was not contacted or offered bereavement services.The hospice’s policy, “Bereavement Services” last revised April 2025 was reviewed and reads in part, “…Bereavement care begins at admission with an initial assessment and continues through at least thirteen (13) months following the patient’s death, with interventions tailored to individual risk levels and needs…Risk-based support levels. Interventions are provided per bereaved request and can include: Low Risk – sympathy card, staff presence immediately following death, participation in memorial services, and initial phone call and mailings…”

Based on staff (EMP) interview and agency document review, it was determined the hospice failed to ensure a registered nurse (RN) made an annual on-site visit to the location where a patient was receiving care to observe and assess each aide while he or she was performing care in one (1) of two (2) hospice aide personnel files reviewed. EMP12. --- Findings:The personnel file for EMP12 was reviewed and revealed a date of hire of February 28, 2017.  The last documented on-site supervisory visit by an RN was documented as September 12, 2023.An interview was conducted with EMP1 on July 29, 2025, at approximately 3:30 PM.  EMP1 indicated EMP13 worked on as needed basis and did not work consistent hours.  EMP1 confirmed that a supervisory visit should be conducted yearly regardless of full/part-time/as needed status. EMP1 indicated an on-site supervisory visit with the RN would be scheduled this week for EMP12.The hospice’s policy, “Hospice Aide Services, Assignment and Supervision” last revised January 2025 reads in part, “…Supervision of hospice aides…Annual on-site visits include observation of the aide’s performance during care delivery…”

Based on staff (EMP) interview and hospice document review, it was determined the hospice failed to ensure volunteers provided day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff for the last twelve (12) months. --- Findings:Hospice documents related to volunteer hours were reviewed and revealed the following:Percentage of care hours provided by volunteers from May 01, 2025 – July 29, 2025 – 2.7%;From February 01, 2025 – April 30, 2025 – 0.38%;From November 01, 2024 – January 31, 2025 – 0.77%;From August 01, 2024 – October 31, 2025 – 0.69%.An interview was conducted with EMP2 on July 29, 2025, at approximately 2:00 PM confirmed the hospice had not met the five (5) percent volunteer hours for the last twelve-month period. EMP2 indicated the hospice only has one (1) volunteer currently and has not had a consistent volunteer coordinator.  There is now a volunteer coordinator in place and recruitment for volunteers is underway.The hospice’s policy, “Volunteer Services” last revised September 2024, was reviewed and reads in part, “…Annual compilation of the volunteer coordinator monthly data shows volunteer services meets or exceeds five percent (5%) of total patient care hours of all hospice employees and contract staff.

Based on staff (EMP) interview, hospice document review, and review of medical records (MR), it was determined the hospice failed to ensure a discharge summary was completed for each patient discharged from hospice services in two (2) of two (2) records reviewed of live discharges from the hospice.  MR2 and MR12. --- Findings:Review of MR2 revealed the patient was discharged on April 18, 2025, due to no longer meeting hospice criteria.  The medical record failed to contain evidence MR2’s attending physician received a copy of the patient’s discharge summary.Review of MR12 revealed the patient was discharged on April 1, 2025.  The medical record failed to contain evidence that MR12’s attending physician received a copy of the patient’s discharge summary.The facility’s policy, “Discharge from Hospice Care” last revised April 2025 was reviewed and reads in part, “…A copy of the patient’s discharge summary is provided to the attending physician…”An interview was conducted with EMP2 on July 30, 2025, at approximately 1:00 PM. EMP2 confirmed the absence documentation that the hospice forwarded a copy of the discharge summary to the attending physician in MR2 and MR12.

Based on staff (EMP) interview, hospice document review, and review of medical records (MR), it was determined the hospice failed to ensure a discharge summary was completed for each patient discharged from hospice services in two (2) of two (2) records reviewed of live discharges from the hospice.  MR2 and MR12. --- Findings:Review of MR2 revealed the patient was discharged on April 18, 2025, due to no longer meeting hospice criteria.  The medical record failed to contain a discharge summary for the patient.Review of MR12 revealed the patient was discharged on April 1, 2025.  The medical record failed to contain documentation that a discharge summary was completed.The facility’s policy, “Discharge from Hospice Care” last revised April 2025 was reviewed and reads in part, “…A copy of the patient’s discharge summary is provided to the attending physician and includes: along with the patient’s clinical record, when requested and includes: reason and date of discharge; instructions and referral information given to the patient and family; patient identifying information; hospice diagnosis; significant health history; discharge orders, instructions, medication profile, and allergies (if discharge not due to patient death); summary of services provided and ongoing needs that cannot be met, patient status at discharge, presence of advance directives and end-of-life decisions, any third-party revocation or termination, summary of patient’s stay including treatments, symptom management, current plan of care and latest physician orders, any other documentation that assists in post-discharge planning continuity of care or is requested by the attending physician or receiving facility…”An interview was conducted with EMP2 on July 30, 2025, at approximately 1:00 PM. EMP2 confirmed the absence of the discharge summaries in MR2 and MR12.