Every finding on record at Phoenix Hospice & Palliative Care, LLC

Observed in HR File Review. In 4 of 10 HR records reviewed, the Operations Manager confirmed that staff and a volunteer had not received education on the emergency operations plan.

Observed in Record Review. On 4 of 14 active patient records reviewed, the hospice nurse surveyor noted that goals were not measurable and specific to the patient. On RRHV #1, it was noted that goals were not measurable and specific to the patient with example of ADLs met through anticipation. In addition, spiritual and MSW goals were not individualized to the patient. On RRHV #2, it was noted that the spiritual and MSW goals were generic goals that had not been individualized to the patient. In addition, goals were not measurable and specific to the patient such as ADLs met through anticipation and Bowel and bladder incontinence managed by caregivers. On RRHV #3, it was noted that the spiritual and MSW goals were generic goals that had not been individualized. In addition, a pain goal that was not measurable and specific to the patient’s need. On RRHV #4, it was noted that goals were not measurable and specific to the patient with example of dyspnea managed at acceptable level. This was reviewed and discussed with the hospice leadership.

Observed in Record Review. In 1 of 2 discharged records reviewed, the organization did not get an physician order for discharge. On review of RRDC #2, it was noted that patient transferred to another hospice but no doctor's order was obtained prior to transfer. This finding was reviewed and discussed with Hospice Leaders.

Observed in Record Review. In 7 of 14 active patient records reviewed, the hospice nurse surveyor noted that goals were not updated to reflect the current needs of the patient. On RRHV #3, it was noted that goals had not been updated to reflect current needs such as teaching for oxygen safety on the POC 2 months after admission. On RRNHV #1, it was noted that the patient has been on service for 4 months goals have not been updated to reflect current POC with example of teaching goals of skin integrity and pain management education since admit. On RRNHV #2, it was noted that patient has had teaching goals for the past year with the example of teaching skin integrity. On RRNHV #5 it was noted that patient still had admission goals related to verbalizing when to call hospice and for having DME supplies 2 months after admission. On RRNHV #6, it was noted on assessment that patient reported she didn’t know how to do her PRN medications and if the pill box wasn’t filled then she wouldn’t know how to take those either but there is nothing regarding medication management on the POC. On RRNHV #7 it was noted that patient had changes to anxiety medications, but the POC was not updated with goals to reflect the changes to care. On RRNHV #10 it was noted that patient had new medication of calmoseptine ointment for redness of skin but this is not updated on the POC with goals and interventions for teaching of the new medication. The was reviewed and discussed with the hospice leadership.

Observed in Record Review. In 8 of 14 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On RRHV #1, the physician orders had duplicate anxiety medications of (Lorazapam oral and liquid) with no indication on how to handle the duplicate therapy. On RRHV #2, the physician orders had duplicate constipation medications (Senna, Biscodyl and Milk of Magnesia) with no indication how to handle the duplicate therapy. On RRHV #3, the physician orders had duplicate constipation medications (MiraLAX and Milk of Magnesia) with no indication how to handle the duplicate therapy. On RRNHV #1 the physician orders in the plan of care had duplicate PRN therapies for Pain (Acetaminophen, Voltaren and Morphine Sulfate) and constipation (MiraLAX and Milk of Magnesia) with no indication on how to handle the duplicate therapies. On RRNHV # 2 the physician's orders in the plan of care had both duplicate PRN therapy for constipation (Milk of Magnesia and Magnesium Citrate) and chronic pain (Acetaminophen and oxycodone) with no indication how to handle the duplicate therapies. In addition, RRNHV #3, RRNHV #7, and RRNHV #8 had duplicate therapy for pain and/or constipation that the duplicate therapy was not addressed. This was discussed with the hospice leadership.

Observed in Data Session. Upon review of QAPI, the Operations Manager confirmed that the Hospice QAPI program did not involve all their services, specifically they were missing the volunteer program.

Observed in Infection Control System Tracer. During document review, the Operations Manager confirmed that the organization had not been following their policy titled Influenza Vaccination Program by collecting flu vaccination data from employees with a goal of 90% compliance.

Observed in Document Review. During a review of the volunteer program, the Operations Manager confirmed that volunteers had not provided at least 5% of the total patient care hours of all paid hospice employees and contract staff. They stood at 0.9% for 2025.

Observed in HR File Review. In 1 of 10 HR records reviewed, the Operations Manager that initial competence assessment had not been completed for the Associate Medical Director.

Observed in Record Review. In 1 out of 4 home visits conducted, the organization failed to ensure the medical record contained information to accurately reflect the patient's care, treatment, and services. During the home observation for RRHV #4, the registered nurse noted that they were giving tramadol nightly for pain but the orders was for PRN use. In addition, the Levocetirizine had been stopped several weeks ago but the change had not been reflected on the medication list. This was reviewed and discussed with the Hospice leadership team.

Observed in Record Review. In 1 of 2 discharge records reviewed, the organization failed to provide a written discharge summary to the receiving hospice. During record review for RRDC #2, the Hospice Nurse Surveyor observed that no discharge summary was sent to the receiving hospice. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Patient Home. In 2 of 4 Home Visits conducted, the surveyor noted that there was no documentation provided to the patient regarding their policy on controlled substance disposal. On review the admission packet, it was noted the organization did not provide a copy of its written policies and procedures on the management and disposal of controlled medications in the packet. On RRHV #3 and RRHV #4, it was noted that the patient was not given a copy of the agency's policy on controlled substance disposal. This was discussed and reviewed with agency leadership.

Observed in Patient Home. In 3 of 3 home visits conducted, Problems identified during initial assessment and on the plan of care were not reassessed in the home (Board and Care): HV 1 specific reference to no assessment of 1+ edema, and pain, which was noted as 4-6 during initial assessment and 3-4 on a follow-up visit. HV 2 no reassessment of pain; HV 3 no reassessment of incontinence, food intake for a patient admitted for malnutrition. The Board and Care caregiver was not interviewed. The Pain Assessment policy states: When the patient identifies pain, the following in-depth information will be obtained whenever possible: pain intensity using rating score, location, quality/patterns of radiation and character, onset/duration/variations and patterns, alleviating and aggravating factors, present pain management regimen and effect, pain management history, effects of pain. The Ongoing Comprehensive Assessments policy states: During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. The nurse will assess the patient on each visit for: Pain, including the origin, location, duration, severity and relief measures; secondary symptoms related to the terminal illness, factors that alleviate or exacerbate physical symptoms, current treatment related to the identified symptoms and the patient's response, skin integrity, appetite/diet, nutritional status... This was verified by the Administrator/CEO who was present during the visits.

Observed in Patient Home. In 3 of 3 home visits conducted, There was no evaluation of medications the patient was being given by the Board and Care as compared to the medication profile, as evidenced by the lack of review of the medication administration record or interview with the caregiver regarding the patient's status and medications being given. The Medication Profile policy states Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. This was verified by the CEO who was present during the visit.

Observed in Record Review. The initial nursing assessment was not in the medical record 11 days after admission. The Administrator designee stated that the policy is to submit documentation within 72 hours.

Observed in Record Review. The plan of care did not include patient needs assessed during the initial nursing assessment, e.g. incontinence, patient at risk for bleeding when on an anticoagulant (Warfarin); unsteady gait/fall risk. The problem on the plan of care stated Safety. This was verified by the Administrator designee.

Observed in Record Review. In 5 of 5 patient records reviewed, The plan of care Socio-Emotional Problem goal was not measurable: Patient will have adequate system(s) /or community resource to maintain plan of care. This was verified by the Administrator designee.