Every finding on record at Mercy Home Care and Hospice-Clinton

Observed in Record Review. In 1 of 4 patient records reviewed, the hospice plan of care did not address all of the needs identified in the comprehensive assessment. In HO RR#4 pain was identified as an issue in the comprehensive assessment but was not addressed on the plan of care. This was validated with the clinical manager.

Observed in Record Review. In 1 of 4 patient records reviewed, the hospice record included duplicate medication orders. In HO RR#2 there was a duplicate order for Albuterol an inhaler without differentiation. This was validated with the clinical manager.

Observed in Record Review. In 2 of 13 patient records reviewed, the comprehensive assessment was not completed no later than 5 calendar days after the election of hospice care. In HSPV #1, the hospice surveyor noted the first attempt to contact the patient to schedule MSW evaluation was on the fifth day of service and no answer was obtained. The evaluation was then completed on the 9th day of service. This was confirmed with the Hospice Quality Coordinator. In HSPV #2, the hospice surveyor noted the chaplain evaluation was not completed until 20 days after the start of care. There was no documentation as to refusal of service or reason for the delay in the assessment. This was confirmed with the Hospice Quality Coordinator.

Observed in Record Review. In 3 of 13 patient records reviewed, the comprehensive assessment did not include the severity of symptoms. In HSPV #3, HSP RR #5 and HSP RR #9, the hospice surveyor noted the comprehensive assessment identified the patient had shortness of breath; however, the assessment did not include the severity of the symptom. This was confirmed with the Hospice Quality Coordinator.

Observed in Record Review. In 4 of 13 patient records reviewed, the comprehensive assessment did not include an initial bereavement assessment. In HSPV #3, HSP RR #5, HSP RR #6 and HSP RR #8, the hospice surveyor noted the bereavement risk assessment was not completed as the patient declined medical social services. In discussion with the Hospice Quality Coordinator, the bereavement risk assessment was not performed by any other discipline. This was confirmed with the Hospice Quality Coordinator.

Observed in Record Review. In 5 of 13 patient records reviewed, the written plan of care was not based on the patient's goals and the time frames, settings and services required to meet those goals. In HSP RR #2 and HSP RR #3 the hospice surveyor noted medical social worker goals were not timed. In addition, the following goals were not measurable: Patient/CG has decreased fear/anxiety regarding death/dying process. Patient's stress/anxiety reduced to level of comfort. This was confirmed with the Hospice Quality Coordinator. In HSP RR #4, the hospice surveyor noted the plan of care massage therapy goals did not include time frames In addition, the following massage therapy goals were not measurable: Patient verbalizes/demonstrates decrease in associated pain. Patient verbalizes/demonstrates improved range of motion. This was confirmed with the Hospice Quality Coordinator. In HSP RR #5, the hospice surveyor noted the plan of care oxygen goal did not include a time frame. This was confirmed with the Hospice Quality Coordinator. In HSPV #3, the hospice surveyor noted the plan of care included the following non-measurable massage therapy goal: patient will demonstrate improved comfort through massage therapy. In addition, the goals were not timed. This was confirmed with the Hospice Quality Coordinator. In HSP RR #7, the surveyor noted the goals on the plan of care did not include time frames. In addition, the massage therapy goal was non-measurable: patient will have improved comfort through massage therapy services. This was confirmed with the Hospice Quality Coordinator.

Observed in Record Review. In 7 of 13 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In HSPV #1, the hospice surveyor noted the patient was identified as having hallucinations and was taking UTI prophylaxis; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Hospice Quality Coordinator. In HSPV #3, the hospice surveyor noted the patient was identified as having edema, shortness of breath and at nutritional risk; however, the plan of care did not include interventions to address these identified needs. In addition, the patient was taking an anticoagulant; however, the plan of care did not include bleeding precautions. This was confirmed with the Hospice Quality Coordinator. In HSP RR #4, the hospice surveyor noted the patient was taking an anticoagulant; however, the plan of care did not include bleeding precautions. In addition, the patient was identified as having dysphagia and at nutritional risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Hospice Quality Coordinator. In HSP RR #5, the hospice surveyor noted the patient was taking an anticoagulant; however, the plan of care did not include bleeding precautions. In addition, the patient was identified as having shortness of breath and at nutritional risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Hospice Quality Coordinator. In HSP RR #8 and HSP RR #9, the hospice surveyor noted the patient was identified as having nutritional risk; however, the plan of care did not include interventions to address this identified need. This was confirmed with the Hospice Quality Coordinator. In HSP RR #10, the hospice surveyor noted the patient was identified as having diarrhea, at nutritional risk and skin breakdown risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Hospice Quality Coordinator.

Observed in Record Review. In 5 of 13 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.In HSPV #1, HSPV #2,HSP RR #2, HSP RR #4 and HSP RR #7, the surveyor noted the plan of care did not include goals and interventions for the chaplain who had a visit frequency on the plan of care. This was confirmed with the Hospice Quality Coordinator.

Observed in Record Review. In 10 of 13 patient records reviewed, the plan of care did not include drugs and treatment necessary to meet the needs of the patient. In HSPV #2, HSPV #3, HSP RR #1, HSP RR #2, HSP RR #3, HSP RR #4 and HSP RR #7, the surveyor noted the plan of care included massage therapy; however, the intervention did not specify the type, location or duration of the massage. This was confirmed with the Hospice Quality Coordinator. In HSP RR #1, the hospice surveyor noted the patient had a secondary diagnosis of Diabetes Mellitus Type 2 and the nurse documented the caregiver checked the patient's blood sugar; however, the plan of care did not include interventions to address this identified need. In HSP RR #2, the hospice surveyor noted the plan of care included BIOFREEZE; however, the order did not specify the location of application. This was confirmed with the Hospice Quality Coordinator. In HSP RR #3, the hospice surveyor noted the patient had a stage 2 pressure ulcer on admission comprehensive assessment; however, the plan of care did not include wound care interventions. This was confirmed with the Hospice Quality Coordinator. In HSP RR #7, the hospice surveyor noted the patient had an intervention for foley catheter insertion change monthly and prn on the plan of care; however, the intervention did not provide an indication for prn. This was confirmed with the Hospice Quality Coordinator. In HSP RR #8, the hospice surveyor noted the patient had a stage 2 pressure ulcer; however, the plan of care did not include interventions for wound care. This was confirmed with the Hospice Quality Coordinator. In HSP RR #5, the hospice surveyor noted the patient had a secondary diagnosis of Diabetes Mellitus 2 and was on insulin; however, the initial plan of care did not include interventions to address this identified need such as blood sugar monitoring. This was confirmed with the Hospice Quality Coordinator. In HSP RR #6, the hospice surveyor noted the patient had a g-tube on admission comprehensive assessment; however, the plan of care did not include g-tube site care. In addition, it was noted the patient was applying an ice pack on admission; however, the plan of care did not include the location, duration and frequency of the application of ice. This was confirmed with the Hospice Quality Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, all disciplines that provided care, treatment or services to the patient did not collaborate in the care of the patient and coordinate effects to support the goals outlined in the plan of care. In HSP RR #3, the hospice surveyor noted the chaplain at the admission evaluation documented the patient's pain level was 7.5; however, there was no documentation the registered nurse or physician were notified of the pain level. This was confirmed with the Hospice Quality Coordinator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization did not clean and perform disinfection of medical supplies and devices. In HSPV #3, the hospice surveyor noted the aide did not clean the gait belt after patient use prior to placing in bag as required by organization policy. This was confirmed with the Hospice Quality Coordinator.

Observed in Record Review. In 2 of 11 patient records reviewed, the registered nurse did not prepare written patient care instructions for the hospice aide.In HSPV #3 and HSP RR #4, the hospice surveyor noted the patient was on anticoagulants; however, the aide plan of care did not include bleeding precautions. This was confirmed with the Hospice Quality Coordinator.

Observed in Record Review. In 1 of 11 patient records reviewed where the patient received aide services, the hospice aide did not provide services are ordered in the aide plan of care.In HSPV #3, the hospice surveyor noted the aide plan of care indicated shower; however, the aide provided a sponge bath on three aide visits. There was no documentation of RN notification. This was confirmed with the Hospice Quality Coordinator.

Observed in Record Review. In 9 of 13 patient records reviewed, the medical director or physician designee did not consider the primary terminal diagnosis, related diagnoses, current subjective and objective medical findings, current medication and treatment orders and information about the medical management of the patient's conditions unrelated to the terminal illness. In HSPV #2, the surveyor noted the narrative statement in the physician certificate of terminal illness did not include current subjective and objective medical findings. The narrative statement indicated Case discussed during IDG. Medications and frequencies reviewed. Agree with current plan of care with the following updates: Resides at eagle point nursing facility with diagnosis of heart failure. Lungs diminished but clear on room air. Foley catheter in place. Appetite poor. Drug regimen review completed with no medication changes at this time. Plan of care discussed with hospice team members and agreed upon. This was confirmed with the Hospice Quality Coordinator. In HSP RR #1 and HSP RR #6, the surveyor noted the medical director signed the certificate of terminal illness; however, the physician narrative section was blank. This was confirmed with the Hospice Quality Coordinator. In HSP RR #2, the surveyor noted the narrative statement in the physician certificate of terminal illness did not include current subjective and objective medical findings. The narrative statement indicated Case discussed during IDG. Medications and visit frequencies reviewed. Agree with current plan of care with the following updates: Resides at home with COPD. Patient still wishes she could do more of her own housework. She gets very anxious when leaving home even for a short car ride. MSW and chaplain visit regularly to provide support. Drug regimen review discussed with no further change indicated. There are no symptoms that are being addressed at this time. This was confirmed with the Hospice Quality Coordinator. In HSP RR #3, the hospice surveyor noted the narrative statement in the physician certificate of terminal illness did not include current subjective and objective medical findings. The narrative statement indicated Case discussed with IDG. Medication and visit frequencies reviewed. Agree with current plan of care with the following updates: patient resides at Alverno with heart failure. Having increased episodes of lethargy, poor appetite, small wound to buttock. Drug regimen review discussed with no changes indicated. There are no symptoms being addressed at this time. This was confirmed with the Hospice Quality Coordinator. In HSP RR #4, the hospice surveyor noted the narrative statement in the physician certificate of terminal illness did not include current subjective and objective medical findings. The narrative statement indicated Case discussed with IDG. Medications and visit frequencies reviewed. Agree with current plan of care with the following updates: Resides at Alverno with diagnosis of Alzheimers disease. Increased episodes of sleeping. Decreased appetite. Drug regimen review completed with hospice team members with no changes at this time. Plan of care discussed with hospice team and agreed upon. In HSP RR #5, the hospice surveyor noted the narrative statement in the physician certificate of terminal illness did not include current subjective and objective medical findings. The narrative statement indicated Case discussed during IDG. Medications and visit frequency reviewed. Agree with current plan of care with the following updates: Resides at home in Fulton with diagnosis of Post COVID syndrome. Also has diagnosis of dementia and CAD. Lungs diminished on oxygen at 2 liters per nasal cannula. Skin intact. Drug regimen review completed with hospice team member with no changes at this time. Plan of care discussed with hospice team members and agreed upon. This was confirmed with the Hospice Quality Coordinator. In HSP RR #7, the hospice surveyor noted the narrative statement in the physician certificate of terminal illness did not include current subjective and objective medical findings. The narrative statement indicated Case discussed during IDG. Medications and visit frequencies reviewed. Agree with current plan of care with the following updates: Resides at Park Vista with diagnosis of CAD. Several falls over the past month. Pain symptoms to be addressed by hospice team members. Potassium level 2.9. Discussed potassium supplement but per family patient does not wish any further treatments at this time. Drug regimen review completed by hospice team members with no changes at this time. Analgesic are duplicate. Plan of care discussed with hospice team members and agreed upon. This was confirmed with the Hospice Quality Coordinator. In HSP RR #10, the hospice surveyor noted the narrative statement in the physician certificate of terminal illness did not include current subjective and objective medical findings. The narrative statement indicated CASE DISCUSSED DURING IDG. MEDICATIONS AND VISIT FREQUENCIES REVIEWED. AGREE WITH CURRENT PLAN OF CARE WITH THE FOLLOWING UPDATES: RESIDES AT PARK VISTA IN CAMANCHE WITH DIAGNOSIS OF PARKINSON'S DISEASE. RECENT HOSPITALIZATION AND PATIENT DECLINED FURTHER WORKUP. ALERT AND ORIENTED. SKIN INTACT. LUNGS DIMINISHED. APPETITE POOR. DRUG REGIMEN REVIEW COMPLETED WITH HOSPICE TEAM MEMBERS WITH NO CHANGES AT THIS TIME. C2 PER FACILITY PROTOCOL. DUPLICATE OF ANTIBIOTICS. PLAN OF CARE DISCUSSED WITH HOSPICE TEAM MEMBERS AND AGREED UPON.

Observed in Individual Tracer. In 2 of 3 home visits conducted, the patient record did not contain an accurate medication list. In HSPV #1, the surveyor noted the medication profile indicated Nitrofurantoin 25 mg; however, the actual dose was 50 mg. This was confirmed with the Hospice Quality Coordinator. In HSPV #2, the surveyor noted the medication profiled included duplicate prn medications for constipation to include Dulcolax, Colace and milk of magnesia; however, the medication instructions did not specify which medication to take first. This was confirmed with the Hospice Quality Coordinator. Observed in Record Review. In 1 of 13 patient records reviewed, the patient record did not contain all clinical information. In HSP RR #8, the hospice surveyor noted the comprehensive assessment documentation indicated wound care provided and patient tolerated well; however, the note did not contain documentation as to the care provided. This was confirmed with the Hospice Quality Coordinator. Observed in Record Review. In 1 of 13 patient records reviewed, the patient record did not contain correct clinical information. In HSPV #3, the hospice surveyor noted the nurse inaccurately documented in the narrative note on the admission comprehensive assessment the patient's primary diagnosis was breast cancer; however, the actual diagnosis was penile cancer. In addition, the IDG documentation in the second month of service indicated the patient declined aide and massage therapy services; however, the patient was receiving these services. This was confirmed with the Hospice Quality Coordinator.

Observed in Record Review. In 2 of 2 closed records reviewed where the patient transferred to the hospital, the hospice did not provide the receiving facility with a copy of the hospice discharge summary. In HSP RR #8 and HSP RR #9, the hospice surveyor noted the patient's revoked hospice due to transfer to hospital; however, the hospice did not sent a copy of the discharge summary to the hospital. This was confirmed with the Business Manager.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the hospice did not provide education on the patient's individualized emergency plan. In HSPV #1, the surveyor noted the individualized emergency plan was blank in the hospice admission packet. This was confirmed with the Hospice Quality Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, the hospice plan of care did not identify which provider was responsible for performing the respective functions in the plan of care. In HSPV #2, the hospice surveyor noted the plan of care indicated the facility nurse was to change the foley catheter with the hospice nurse performing as needed; however, another intervention indicated the hospice skilled nurse was responsible to change the foley catheter. This was confirmed with the Hospice Quality Coordinator.

Based on clinical record review, hospice policy review, home visit observation, patient interviews, and hospice staff interviews, the hospice failed to ensure the hospice plan of care included all necessary medications to meet the needs of the patient for 1 of 1 sampled patients with a home visit observation(Patient #1). The concern was identified in the Clinton (parent) office location. Failure to ensure the plan of care included physician orders for all necessary medications placed patients at risk to receive inappropriate treatment of symptoms. Findings include: Review of the hospice's policy, titled Interdisciplinary Team Care Plan: Hospice, dated 1/18/2021, identified the Plan of Care (POC) will include drugs and treatments. Review of hospice's policy, titled Medication Reconciliation: Home Care and Hospice Administrative, dated 3/22/21, upon first contact a hospice representative will request that all medications are set out for review by the clinician at the admission visit. The Registered Nurse (RN) will contact the patient's physician to verify medications, dose, frequency, or route if discrepancy. The RN will review client's current medication list with actual medications in the home at each visit and document that medications were reconciled. Patient #1 had a hospice admission date of 3/29/22 and received hospice services while residing in a private home residence. a. The Plan of Care (POC), dated 3/29/22 to 6/26/22, included orders for Albuterol Sulfate HFA inhaler 90 micrograms (mcg) per actuation with instructions to take 2 puffs as needed four times per day as needed for shortness of breath. During hospice home visit observation with Staff D, Registered Nurse (RN), on 5/4/22 at 12:34 PM, the nurse reviewed the patient's medications with the patient. The patient reported not using Albuterol inhaler for over one year and the surveyor observed Combivent Respimat inhaler 20 mcg per 100 mcg and the patient reported using 1 puff four times per day for the past year. b. The Interdisciplinary Group (IDG) meeting notes, dated 3/30/22 and 4/13/22, lacked orders for the Combivent Respimat inhaler used to meet the patient's needs. c. The Plan of Care (POC), dated 3/29/22 to 6/26/22, included orders for Metoprolol Succinate extended release (ER) 25 milligrams (mg) 0.5 mg daily for hypertension. During the same hospice home visit observation with Staff D, the nurse reviewed the patient's medications with the patient. The surveyor observed the bottle in use contained 25 mg tablets and instructed the patient to take 1/2 tablet daily (for a dosage of 12.5 mg daily). d. The Interdisciplinary Group (IDG) meeting notes, dated 3/30/22 and 4/13/22, lacked orders for the Metoprolol succinate ER 12.5 mg daily. e. The Plan of Care (POC), dated 3/29/22 to 6/26/22, included orders for Pantoprazole 20 mg daily. During the same hospice home visit observation with Staff D, the nurse reviewed the patient's medications with the patient. The surveyor observed the bottle in use by the patient contained Omeprazole 20 mg daily with instructions to take 2 capsules daily, with a fill date of 3/13/22. The patient reported the primary care provider changed the medication from Pantoprozole to Omeprazole on 3/13/22 and the patient was taking 2 capsules daily as directed on the bottle. f. The Interdisciplinary Group (IDG) meeting notes, dated 3/30/22 and 4/13/22, lacked orders for the Omeprazole used by the patient. g. The Plan of Care (POC), dated 3/29/22 to 6/26/22, included orders for Striverdi Respimat 2.5 mcg per actuation 2 puffs daily. During the same hospice home visit observation with Staff D, the nurse reviewed the patient's medications with the patient. The surveyor observed the inhaler in use was Stiolto Respimat. The patient was unsure when the change occurred, but couldn't recall ever taking the Striverdi Respimat. h. The Interdisciplinary Group (IDG) meeting notes, dated 3/30/22 and 4/13/22, lacked orders for the Stiolto Respimat inhaler used by the patient. During the same hospice home visit observation with Staff D, the nurse reviewed the patient's medications with the patient. The surveyor observed a bottle Isosorbide mononitrate 30 mg with instructions to take 1/2 tablet daily for heart with a fill date of 2/7/22. The patient reported taking the medication since sometime in February. i. The Interdisciplinary Group (IDG) meeting notes, dated 3/30/22 and 4/13/22, lacked orders for the Isosorbide mononitrate. Interview on 5/4/22 at 1:40 PM with Staff D, RN, reported he/she reviewed the patient's medication list with the patient's caregiver on admission. The RN reported she went over the list with the caregiver, however, did not physically look at the patient's medications to confirm accuracy. The nurse failed to follow hospice policy to ensure all medications in use were accurate on the POC. The above findings were reviewed with Administrator, Clinical Manager, and Staff A, Risk and Accreditation Specialist. Hospice staff provided no additional findings prior to the end of the survey.

Based on hospice policy review, clinical record review, complaint log review, patient, caregiver, and hospice staff interview, the agency failed to ensure the hospice provided medical supplies and drugs related to the palliation and management of the terminal illness and related conditions in the hospice plan of care (L687). Failure to ensure the hospice provided medical supplies and drugs related to palliation and management of the terminal illness and related conditions in the hospice plan of care, increased the risk of the patient's receiving inadequate care. The cumulative effects of these systemic practices resulted in the failure to the agency to ensure the hospice promoted and supported safe and effective delivery of care to its 26 patients.

Based on clinical record review, hospice policy review, complaint log review and hospice patient, caregiver, and staff interviews, the hospice failed to provide medical supplies, drugs, and biologicals related to the palliation and management of the terminal illness and related conditions while under hospice care for 2 of 5 sampled patients (Patients #1 and #3). The concerns were identified in the Clinton (parent) office. Failure to ensure the hospice provided medical supplies, drugs, and biologicals related to the palliation and management of the terminal illness and related conditions while under hospice care, increased the risk of inadequate patient care. Findings include: According to the hospice policy titled, Interdisciplinary Team Care Plan: Hospice, dated 1/18/21, an individualized written Plan of Care (POC) developed by Hospice Interdisciplinary Team (IDT) in collaboration with attending physician (if any), patient, and primary caregiver will be established and maintained to provide hospice care and services necessary for the palliation and management of the terminal illness and related conditions furnished to patients and caregivers. The POC will include all services necessary for palliation and management of terminal illness and related conditions and frequency of services to meet the patient/caregiver needs, and drugs, treatments, and medical supplies. According to the hospice policy, titled Medication Administration and Management, dated 3/23/21, medications are administered and managed in the home setting under the direction of a physician. 1. Patient #3 had a hospice admission date of 4/4/22, received services from the Clinton (parent) office and transferred to another hospice on 4/14/22 while residing in a private home. The POC, dated 4/4/22 to 7/2/22, identified a diagnosis of colon cancer and included IDG orders for skilled nursing, social work, hospice aide, spiritual care, and massage therapy services. During review of the hospice complaint log on 5/3/22, a complaint was received on 4/12/22, by a family member. The complaint report stated the family was not happy with the services the patient was getting. The patient had pain and restlessness since 4/7/22 and nothing has been done to relieve the patient's symptoms. The family was not happy with having to wait for medication changes from the attending physician and wanted to know why the medical director is not the one making changes. Staff D, Registered Nurse (RN) educated the family member stating the patient had multiple medication changes since 4/8/22 and the medical director will not make changes when there is a designated attending physician involved. The nurse informed the family the medical director did make changes on 4/8/22 when the attending physician was not in the office. Family requested the nurse write changes down due to the family not hearing the medication changes were made until 4/11/22 when they contacted the hospice in the morning to notify the patient was still having pain and restlessness. Discussion occurred regarding possibility of changing the nurse in the home and family brought up changing agencies Staff D, RN educated the family to contact the attending physician to obtain a referral. Follow up comments on the complaint form included on 4/14/22 the agency was unable to satisfy the family and family opted to pursue a different hospice agency. The patient transferred to another hospice on 4/13/22. Clinical record review and associated interviews revealed the following: a. The initial comprehensive assessment completed at admission, dated 4/4/22 and ending at 5:20 PM, documented the patient was admitted to hospice after Emergency Room visit for dyspnea and needing hospice for comfort measures. The RN documented patient's pain was rated a "0" and the patient's urine output as "quantity sufficient." Interview on 5/3/22 at 1:12 PM with the patient's primary caregiver, reported family's understanding on admission was the patient would receive pain medications. Interview with Staff E, RN on 5/3/21 at 1:41 PM, reported the nurse attempted to get morphine ordered on admission for shortness of breath, however, the admission was late and no pharmacies were open to obtain the medications. b. The skilled nurse visit note, dated 4/5/22 and completed at 1:14 PM, documented chest and abdominal pain rated a "6" out of 10 (0 having no pain and 10 being the worst pain) and the nurse identified a goal to reduce pain to promote comfort. The nurse documented the patient had stress incontinence of bowel and bladder and used diapers and underpads. c. A verbal order, dated 4/5/22 at 3:40 PM, for morphine 5 mg every 4 hours as needed for pain was obtained from the attending provider. d. A coordination note, dated 4/5/22 at 3:44 PM, documented a prescription was sent to the pharmacy for the morphine. e. A coordination note, dated 4/6/22 at 8:49 AM, documented the RN noted the scripts for the medications were not sent to the pharmacy by the attending physician. The RN contacted the attending physician's office and was notified the attending physician did not send the scripts and the attending physician would be in the office that morning to send the scripts in to the pharmacy. f. A chaplain visit note, dated 4/6/22 and ending at 3:08 PM, documented the patient was noticeably weaker and struggling to catch breath. The patient experienced a delay in initiation of comfort meds until 2 days after the patient's admission to agency. g. A skilled nurse visit note, dated, 4/7/22 and ending at 5:19 PM, documented the RN visited the patient due to pain per family's request. The patient rated current pain a "5", but rated pain an "8" overall in past 24 hours. The RN administered morphine during the visit. The nurse documented the patient had stress incontinence of bowel and bladder and used diapers and underpads. Interview on 5/3/22 at 12:21 PM with family member reported family called the hospice on 4/8/22 at 8:00 AM when the office opened. Family spoke with Staff C, RN Hospice Lead and was told no visit would be made since the patient had an "as needed" visit the day before. The family notified the nurse the patient was only able to void 50 milliliters (ml) when attempting to urinate and requested a catheter be placed. The Hospice Lead informed family would notify the primary nurse for the patient. Interview on 5/4/22 at 11:10 AM with Staff C, RN reported the family did call in and spoke with her. The clinical record lacked documentation of the call. The RN stated the call was not documented as the primary nurse and the RN were in huddle and message given to the primary nurse at that time. Staff C, RN stated huddle occurred at 8:30 AM on 4/8/22. h. A coordination note, dated 4/8/22 at 9:44 AM, documented the RN received a call to contact the primary caregiver. The caregiver stated the patient is restless and would like a catheter or commode and the patient was trying to get up without assistance. The nurse ordered a commode from the home medical supplier and attempted to contact the attending physician, but was unable to leave a message for the attending physician due to a staff meeting and would attempt later that day. Interview on 5/3/21 at 12:21 PM with family member, reported on 4/8/22 it was taking 2-3 family members to get the patient up to the bathroom. The family called the office again at 12:00 PM and spoke with receptionist, who apologized for the family not receiving a return call yet. i. A coordination note, dated 4/8/22 at 1:40 PM, documented the RN attempted attending physician again. The phone went to an answering service who were unable to help call provider's office and hospital trying to reach the attending physician. The family stated the patient is restless and wanting to get up and they think a catheter would help. The nurse will contact the medical director for orders. Interview with family member, on 5/3/22 at 12:21 PM, reported two family members had been making calls to office. The family member reported the primary caregiver had been instructed to call the office number, not the nurse's personal cell phone to get faster assistance. The family member reported that they had called both numbers. The family member reported the nurse ordered a commode to be delivered and did not feel the patient needed a catheter, since the patient was still voiding. Interview on 5/4/22 at 11:03 AM with the Clinical Manager, reported the commode was delivered to the patient at 2:47 PM. j. A coordination note, dated 4/8/22 at 3:44 PM, documented the RN couldn't reach the attending physician and contacted Medical Director and received orders increase morphine to 10 mg every 2 hours PRN. The nurse notified the primary caregiver of the order. Interview on 5/4/22 at 8:06 AM with the attending physician's office, revealed the attending physician's office closes on Fridays at noon and the attending physician also doesn't work on Mondays. The attending physician's office did not have any documentation of phone calls received or messages left by the hospice agency on 4/8/22. k. The hospice on call log, documented the on call RN received a phone call on 4/10/22 at 12:09 AM, for restless pain and a home visit was made. l. The skilled nurse visit note, dated 4/10/22 and ending at 1:31 AM, documented the home visit was made due to family member reporting pain meds were given around the clock and pain continued and the patient was restless and trying to get out of bed and the patient was stating need to urinate. A foley catheter was placed by the nurse and the patient's restlessness was relieved. The nurse charted the patient's pain as "0". No changes were made to the patient's pain regimen. m. The skilled nurse visit note, dated 4/11/22 ending at 4:54 PM, documented the patient denied pain. Family reported the patient's pain increased at night and the patient rated pain a "7". The nurse documented an attempt to contact the attending physician. The family requested long acting morphine pills and was upset the attending physician just increased frequency and family stated concerns about the patient remaining in intractable pain. The nurse documented the family was upset the catheter was not placed on 4/8/22 as urine output 10-15 cc. The nurse informed the family she was not notified of the decreased output. n. A verbal order, dated 4/11/22 at 3:36 PM was received by the attending physician to increase the morphine to 10 mg every hour as needed for pain. o. A coordination note, dated 4/12/22 at 8:39 AM, documented by the RN as a late entry for the date of 4/8/22. The note documented when the nurse asked the primary caregiver why a catheter was being requested, the primary caregiver was unsure as other family members were with the patient and the primary caregiver was at own home trying to get some rest. The nurse asked that primary caregiver if the patient was urinating and the primary caregiver stated he/she was not with the patient at the moment, but was urinating the night prior. p. A coordination note, dated 4/12/22 at 9:03 AM, documented a message was left for the attending physician regarding family requesting long acting morphine or fentanyl patch for the patient. Family informed that message had been left for the attending physician. The nurse asked the family how the frequency of medication change was going after the new order yesterday and the family replied must have lost that information in the the conversation. q. A coordination note, dated 4/12/22 at 9:05 AM, Staff C, RN Hospice Lead, documented the family contacted the agency informing not satisfied with services as patient had been in pain since Thursday night (4/7/22) and nothing has been done. The RN stated per skilled nurse visit yesterday patient had no pain during visit and noted multiple medication changes occurred from Friday to Monday. Call placed to attending physician to ask for Fentanyl and increased in morphine. Family called this morning stating patient was still restless. Nurse spoke with family and educated the morphine was increased to every hour and the family did not hear the orders to increase the frequency during yesterday's visit. Family questioned why the medical director is not the one ordering the medications and the nurse educated family the medical director will not touch medications if the patient has an attending physician. Family upset with that answer. The nurse informed the family on 4/8/22 when the attending physician was not around, the medical director did make changes. Family was not calling the on call number due to them feeling like they will lose a visit. There was a call on Friday stating the patient was having trouble getting out of bed and going to the bathroom and family wanting a bedside commode or catheter. The nurse called and ordered a bedside commode. Family was not happy with not getting a visit. Family called Saturday and visit made and catheter placed. Family reported discomfort relieved, but the family today stating pain and restlessness since Thursday and nothing has been done. Family stated may want a referral to another hospice. Family educated they would need to get a hold of the attending physician and the hospice would discharge the patient. The family asked why the hospice won't make the referral. Staff C, RN Hospice Lead, educated family that the hospice is a small agency and runs things differently than a larger one. A different nurse was offered and family was informed the nurse may still need to see the patient after hours since there are only three nurses. Family was educated to use the on call number if any questions as the nurse on call tries to answer question over the phone before coming out to see the patient. Family stated had not used that number due to the way they were treated on Friday 4/8/22. r. A coordination note, dated 4/12/22 at 12:36 PM, documented by Staff C, RN Hospice Lead received a phone call from another hospice and the hospice would be admitting the patient on 4/13/22 at noon. The new hospice was sending over a list of information needed to be transferred over. s. A skilled nurse visit note, dated 4/13/22, for discharge for data collection only was completed stating the patient was transferred to another hospice. The hospice failed to provide the morphine and foley catheter, related to the palliation and management of the terminal illness and related conditions. On 5/9/22 at 11:00 AM, the Hospice Administrator, Clinical Manager, and Staff A, Risk and Accreditation Specialist, were notified of the above findings and that an Immediate Jeopardy was identified related to the findings. The Immediate Jeopardy was abated on 5/11/22 at 9:35 AM. 2. Patient #1 had a hospice admission date of 3/29/22 and received services from the Clinton (parent) office while residing in a private home residence. The POC, dated 3/29/22 to 6/26/22, identified a diagnoses of lung cancer and congestive heart failure and included IDG orders for skilled nursing, social work, and massage therapy services. Clinical record review and associated interviews revealed the following: a. A coordination note, dated 4/26/22, documented Staff C, RN, received a phone call from the patient's telehealth nurse. The telehealth nurse informed the hospice the patient is wanting oxygen as has been using spouse's oxygen when the spouse is not using it. b. A verbal order, dated 4/27/22 at 12:41 PM, ordered to start oxygen 2 liters per nasal cannula as needed for shortness of breath. During home visit observation on 5/4/22 at 12:34 PM with Staff D, RN, the surveyor questioned the nurse on where the oxygen was. The nurse reported last Wednesday, the nurse contacted the home medical supplier regarding the order, however, when the nurse contacted the spouse to set up home visit today the spouse informed the nurse the oxygen was never delivered and set up. The nurse arranged for the oxygen to be delivered on 5/4/22. The clinical record lacked documentation of the nurse communicating with the home medical supplier. Phone interview with Patient #1 on 5/9/22 at 11:23 AM reported the oxygen was delivered on 5/4/22 around 2:30 PM. The hospice failed to provide the oxygen related to the palliation and management of the terminal illness and related conditions of the patient while under hospice care. The above findings were reviewed with the Hospice Administrator, Clinical Manager, and Staff A Risk and Accreditation Specialist. The hospice provided no additional information prior to the end of the survey.

Based on clinical record review, agency policy review, review of the contract between the nursing home and hospice, review of the hospice complaint file and hospice staff interview, the hospice failed to oversee the professional management of the patient's care when residing in a skilled nursing facility (L762). Failure to assume responsibility for the professional management of the patient's hospice services in accordance with the hospice Plan of Care and with the hospice Conditions of Participation increased the risk of inadequate care. The cumulative effects of these systemic practices resulted in the failure of the agency to assure the organizational framework of the agency promoted and supported the safe and effective delivery of patient care to its 15 patients residing in a nursing home.

Based on clinical record review, agency policy review, review of the contract between the nursing home and hospice, review of the hospice complaint file and hospice staff interview, the hospice failed to oversee the professional management of the patient's care when residing in a skilled nursing facility (nursing home) for 1 of 2 sampled patients (Patient #4). The hospice reported providing services to 15 patients residing in a nursing home at the time of the survey. Failure to assume responsibility for the professional management of the patient's hospice services in accordance with the hospice Plan of Care and with the hospice Conditions of Participation increased the risk of inadequate care. The survey identified the deficient practice occurring at the Illinois multiple location. Findings include: According to the hospice policy, titled Medication Reconciliation; Home Care and Hospice Administrative and dated 3/22/21, a medication reconciliation will be completed with every home care visit and any exceptions noted in the patient's chart. According to the hospice policy, titled Medication Administration and Management; Home Care and Hospice Administrative and dated 3/23/21, upon every visit, the RN or therapist will assess current medications, evaluate patient compliance, potential side effects, adverse reactions and patient response to medication therapy. The medication list will be updated with any changes. According to hospice policy, titled Interdisciplinary Team Care Plan: Hospice and dated 1/18/2021, an individualized written Plan of Care developed by the Interdisciplinary Group (IDG) in collaboration with the attending physician, patient and primary caregivers will be established and maintained to provide hospice care and services necessary for the palliation and management of the terminal illness and related conditions furnished to patients and caregivers. The Plan of Care will include all services necessary for the palliation and management of the terminal illness and related conditions, including drugs and treatments necessary. Review of the hospice's complaint file revealed a complaint was filed with the hospice on 3/17/22 by the Director of Nursing of a local nursing home. The complaint allegation cited concerns with the hospice's failure to ensure comfort medications related to the terminal illness were available for use for Patient #4 as the patient was dying and the nursing home felt the hospice nurse was blaming the nursing home and treating the nursing home staff rudely. (See specifics below) Review of the contract between the above mentioned nursing home and the hospice, dated as initiated on 10/24/2016, identified the hospice was responsible for professional management of the patient/family and determining appropriate course of hospice care. The hospice was responsible for providing all drugs and pharmaceuticals related to the management of the terminal illness as specified in the Hospice Plan of Care. Patient #4, had a start of care date of 12/3/21, terminal diagnosis of Alzheimer's disease and received hospice services from the Illinois multiple location while residing in a residential home setting. The patient was transferred to the above mentioned nursing home for respite services on 3/7/22 and remained in respite status through 3/11/22. The interim physician order, dated 3/4/22, approved the respite care. The order documented the social worker attached the patient's hospice medication list to the order. The surveyor requested review of the documents sent and the hospice was unable to provide the document or show evidence the document had actually been sent. While in respite, the skilled nurse visited the patient on 3/8/22 and 3/11/22. The skilled nurse visit note, dated 3/11/22, documented no significant findings- Pulse 68 BP 124/68 Pox 94%. Appetite good. Eating 25-50% 2-3 meals/day. Lung sounds diminished, clear. No cough. Hands/feet cyanotic. Non-verbal. At the end of the respite care, the patient remained in the nursing home receiving routine level of care. The skilled nurse visit note, dated 3/15/22 at 12:39 PM, documented the following findings: Pox 94% Pulse 104 BP 112/62 abnormal breath sounds; coughing; pocketing/spitting out food- hands/feet cyanotic- Certified Nursing Assistant (CNA) reported the patient was experiencing difficulty eating/swallowing "for days"- the hospice RN called the patient's spouse to report the patient's rapid decline. Non-verbal. The communication note, dated 3/16/22 at 1:05 PM, documented the nursing home social worker called the hospice to report Patient #4 was unresponsive. The next documentation- Death Visit Note, dated 3/16/22 showed travel to the visit began at 1:42 PM. The visit documentation did not begin until 3:16 PM, ended at 3:51 PM and stated "died 2:55 PM-wife at bedside cooing appropriately- reportedly died peacefully". The nursing home filed a complaint with hospice on 3/17/22- alleging the patient declined rapidly- the hospice nurse, Staff D, was rude to nursing home staff because there were no comfort medications ordered and no comfort medications to give to the patient at the time of the patient's transitioning/imminent death. The nursing home Director of Nursing (DON) reported the nursing home had no hospice signed orders for comfort medications in the nursing home chart. The hospice nurse was upset, blaming the nursing home staff for failing to get the order for comfort medications and having none in the facility to give to Patient #4. The hospice nurse sent the patient's spouse to get Lorazepam tablets and the Morphine Concentrate from home (that was used when the patient was residing in the residential setting) to bring to the nursing home to give the patient but the patient died before the spouse returned with the medications. The complaint indicated the hospice nurse was present in the nursing home prior to and at the time of the patient's death. The hospice investigation of complaint/staff interviews indicated the medication list was sent to the nursing home (but hospice unable to provide proof to surveyor) and verified the hospice nurse was present in the nursing home prior to and at the time of the patient's death. Because the patient died during the visit, the nurse completed a Death Visit Note which then eliminated any documentation of what occurred from the time of the hospice nurse's arrival shortly after 1:42 PM until after the patient had already died. During agency staff interview on 5/3/2022 at 3:30 PM, Staff C, RN Hospice Lead, reported the hospice's process for getting comfort medications to the nursing home was: the hospice provides the hospice medication list to the nursing home; the nursing home then obtains orders for medications from attending physician, including medications related to terminal illness; the attending then sends orders to the pharmacy used by the nursing home; the pharmacy calls the hospice to verify which medications the hospice considers related to the terminal illness and the hospice is billed for and pays for the medications. During agency staff interview on 5/3/2022 at 3:40 PM, the hospice Clinical Manager verified Staff D, the hospice nurse, was present in the nursing home prior to the patient's death and didn't follow process correctly, thereby omitting any documentation between her arrival and patient's death. The hospice IDG Plan of Care Update, dated 3/2/2022 while the patient lived at home, included the following medications: Lorazepam 0.5 mg tablet orally every 6 hours as needed for anxiety, dated as originally ordered on 12/8/2; and Morphine Concentrate 100 mg/5 ml 0.25 ml (5 mg) sublingual (under the tongue) every 4 hours as needed for pain rated at 4 out of 10 or higher, originally ordered on 12/8/21. The Plan lacked physician orders for any other comfort medications. The patient's clinical record lacked any IDG updates to the Plan of Care or any physician interim orders for medication changes immediately prior to the patient's admission to the nursing home for respite care on 3/7/22. The clinical record lacked any IDG updates to the Plan of Care or any physician interim orders for medication changes when the patient changed from respite care to routine level of care in the nursing home setting on 3/12/22. Skilled nurse visit notes, dated 3/8/22 and 3/11/22, both documented the patient was unable to verbalize pain; therefore, the morphine as needed orders from the 3/2/22 update could not be executed according to physician direction. The skilled nurse visit note, dated 3/15/22, documented the patient was experiencing swallowing difficulties for several days before and was noted by the RN during the visit; therefore, oral Lorazepam tablets would have been inappropriate for administration. The nursing home Medication/Treatment Administration Record, dated 3/8/22 through 3/15/22, included physician orders for Acetaminophen 650 mg tablets every 4 hours for pain. The Medication/Treatment Administration Record lacked inclusion of Morphine Concentrate as ordered on the hospice Plan of Care for pain and lacked Lorazepam tablets orally as ordered on the hospice Plan of Care for anxiety. Both medications were added to the nursing home Medication/Treatment Administration Record on 3/16/22 at 2:45 PM, 10 minutes before the patient died. The hospice Plan of Care lacked orders for liquid Lorazepam for sublingual use at the time of transitioning (smaller amount given under the tongue or in cheek instead of needing to be swallowed resulting in a quicker response time/less liquid to be given and given when patient is unable to swallow). The Hospice Plan of Care included orders for liquid morphine, however the physician orders were for use as needed every 4 hours for pain report of 4 or greater on 1-10 scale and the patient could not verbalize pain. The hospice nurse did not ensure comfort medications were ordered by the physician and appropriate for end of life care on the hospice Plan of Care. The hospice nurse did not ensure the nursing home orders reconciled with the hospice orders. The hospice nurse visited the patient on 3/8, 3/11 and 3/15/22 in the nursing home without identifying the lack of comfort medication orders or availability of the medications in the nursing home for hospice use. The hospice nurse identified a rapid decline on 3/15/22 and did not check to see if comfort medications were in order/educate staff of the use of the medications due to rapid decline. The nurse failed to document any of this in the patient's hospice clinical record- instead documenting only patient's time of death, who was present at bedside and indicated the death was reportedly peaceful. Due to the hospice's failure, the patient's spouse could not be present with the patient at the time of death as he/she was gone obtaining the home Lorazepam and morphine to bring to the nursing home as a last resort. The hospice did not maintain professional management of Patient #4's care while the patient resided in the skilled nursing facility. The above findings were reviewed with the Hospice Administrator, Clinical Manager, and Staff A Risk and Accreditation Specialist. The hospice provided no additional information prior to the end of the survey.

Based on hospice clinical record review, review of the nursing home/hospice contract, nursing home clinical record review and facility staff interview, the hospice failed to maintain all required hospice documents/information at the long term care facilities where hospice patients reside for 1 of 2 sampled patients (Patient #4). The survey identified the deficient practice occurred at the Illinois multiple location. Failure to communicate hospice information to long term care staff placed patients at risk for not receiving effective, coordinated necessary care and services. Findings include: Patient #4 had a hospice admission date of 12/3/2021, received hospice services from the Illinois multiple location while residing in a nursing home beginning on 3/7/2022 through 3/11/2022 for respite services and from 3/11/2022 through the time of death on 3/16/2022 while receiving routine level of care. On 5/5/2022 at 8:44 AM, the nursing home Director of Nursing sent the surveyor hospice documents kept in the nursing home clinical record via secure email. The documents lacked inclusion of the hospice benefit election form. During facility staff interview on 5/9/2022 at 1:48 PM, the facility Director of Nursing reported she had sent all of the documents related to hospice from the nursing home closed clinical record. Review of the hospice/nursing home contract, dated as initiated on 10/24/16, identified the hospice was responsible for providing the nursing home with, at a minimum, the most recent Hospice Plan of Care, Hospice benefit election form and any advance directives; physician certification and recertifications of the terminal illness; names and contact information for hospice personnel; instructions on how to access the hospice's 24 hour on-call system; medication information and hospice physician and attending physician orders, if any. The above findings were reviewed with the Hospice Administrator, Clinical Manager, and Staff A Risk and Accreditation Specialist. The hospice provided no additional information prior to the end of the survey.