Every finding on record at Physicians Choice Hospice

Based on record review, interview, and document review, the hospice agency failed to ensure medications listed on the hospice agency's medication list were the same as the medications at home for one of 14 patients (Patient (P)8) whose medications were reviewed out of a total sample of 19. This had the potential for unmet medication needs. Findings include: --- Review of P8's "Hospice Medication Profile" located under the "Patient Chart" tab in the electronic medical record (EMR) revealed an order dated 06/26/2025 for Acetaminophen (Tylenol) 325 milligrams (mg) take two tablets every six hours as needed for mild pain. An order for Lorazepam (anti-anxiety) was not on the hospice medication profile.During an observation on 07/15/2025 at P8's home visit the medications were reviewed with P8 as to what was being taken. P8 took the following medications: Tylenol eight-hour Arthritis 650 mg, two tablets every morning and night. There was also Lorazepam 2 mg/ml (milligram per milliliter) take 0.5 ml under the tongue every four hours as needed for anxiety or agitation in P8's refrigerator that could be taken if needed.During an interview on 07/15/2025 at 9:25 AM, Registered Nurse (RN)1 stated," I check the medication list at the beginning of each week, but I did not ask [P8] to show me what [he]/she was actually taking. I will have to begin doing that. The Lorazepam was my mistake. I forgot to add it to the mediation list when it was ordered."During an interview on 07/15/2025 at 4:30 PM, the Director of Clinical Services (DCS) stated, "The nurses need to ask the patient to show them exactly what they are taking to make sure this doesn't happen again."Review of the hospice agency's policy titled "Medication Reconciliation" dated June 2019 revealed, "…The medication list/profile will be updated with each new or changed medication…"

Based on record review and interview, the hospice agency failed to ensure that the required individuals (physician, registered nurse (RN), social worker, and/or chaplain) had documented signatures to indicate they attended the Interdisciplinary Group (IDG) meetings for 14 of 14 patients (Patient (P)1. P2. P3, P4, P5, P6, P7, P8, P9, P10, P11. P12, P13, and P14) reviewed out of a total sample of 19. This failure had the potential for the staff not to have knowledge of the patient's plan of care.Findings include: --- 1. Review of P1's undated "Patient Profile" located under the "Patient Profile" tab in the electronic medical record (EMR) indicated P1 was admitted to hospice services on 02/11/2025 with the terminal illness of atherosclerotic cardiovascular disease.Review of P1's "IDG Meeting Sign In" sheets dated 03/07/2025, 03/21/2025, 04/18/2025, and 05/02/2025, indicated no evidence that the physician had attended these meetings due to no signature present on the sign in sheet. There were no sign-in sheets for the dates of 05/16/2025, 06/13/2025, 06/27/2025 and 07/11/2025 which indicated the presence of a physician, RN, social worker, and/or chaplain at the IDG meetings.2. Review of P2's undated "Patient Profile" located under the "Profile" tab in the EMR indicated P2 was admitted to hospice services on 12/12/2024 with the terminal illness of Alzheimer's Disease.Review of P2's "IDG Meeting Sign In" sheets dated 02/07/2025, 03/07/2025, 03/21/2025, 04/18/2025, and 05/02/2025, indicated no evidence that the physician had attended these meetings due to no signature present on the sign in sheet. There were no sign-in sheets for the dates of 12/26/2024, 01/09/2025, 01/23/2025, 02/21/2025, 05/16/2025, 05/30/2025, 06/13/2025, 06/30/2025, and 07/11/2025 which indicated the presence of a physician, RN, social worker, and/or chaplain at the IDG meetings.3. Review of P3's undated "Patient Profile" located under the "Profile" tab in the EMR indicated P3 was admitted to hospice services on 09/10/2024 with the terminal illness of Alzheimer's Disease. Review of P3's "IDG Meeting Sign In" sheets dated 02/07/2025, 03/07/2025, 03/21/2025, 04/18/2025, and 05/02/2025 indicated no evidence that the physician had attended these meetings due to no signature present on the sign in sheet. There were no sign-in sheets for the dates of 12/26/2024, 01/09/2025, 01/23/2025, 02/21/2025, 05/16/2025, 05/30/2025, 06/13/2025, 06/30/2025, and 07/11/2025 which indicated the presence of a physician, RN, social worker, and/or chaplain at the IDG meetings.4. Review of P4's undated "Patient Profile" located under the "Profile" tab in the EMR indicated P4 was admitted under hospice services on 03/11/2025 with the terminal disease of chronic obstructive pulmonary disease.Review of P4's "IDG Meeting Sign In" sheets dated 03/21/2025, 04/18/2025, and 05/02/2025 indicated no evidence that the physician had attended these meetings due to no signature present on the sign in sheet. There were no sign-in sheets for the dates of 05/16/2025, 05/30/2025, 06/13/2025, 06/27/2025, and 07/11/2025.5. Review of P5's undated "Patient Profile" located under the "Profile" tab in the EMR indicated P5 was admitted under hospice services on 03/18/2025 with the terminal illness of chronic obstructive pulmonary disease.Review of P5's "IDG Meeting Sign In" sheets dated 03/21/2025, 04/18/2025, and 05/02/2025 indicated no evidence that the physician had attended these meetings due to no signature present on the sign in sheet. There were no sign-in sheets for the dates of 05/16/2025, 05/30/2025, 06/13/2025, 06/27/2025, and 07/11/2025 which indicated the presence of a physician, RN, social worker, and/or chaplain at the IDG meetings.6. Review of P6's undated "Patient Profile" located under the "Profile" tab in the EMR indicated P6 was admitted under hospice services on 04/03/2025 with the terminal illness of cerebrovascular accident.Review of P6's IDG Meeting Sign In" sheets dated 04/18/2025 and 05/02/2025 indicated no evidence that the physician had attended these meetings due to no signature present on the sign in sheet. There were no sign-in sheets for the dates of 05/16/2025, 05/30/2025, 06/13/2025, 06/27/2025, and 07/11/2025 which indicated the presence of a physician, RN, social worker, and/or chaplain at the IDG meetings.7. Review of P7's undated "Patient Profile" located under the "Profile" tab in the EMR indicated P7 was admitted under hospice services on 01/30/2025 with the terminal illness of atherosclerotic cardiovascular disease.Review of P7's "IDG Meeting Sign In" sheets dated 02/07/2025, 03/07/2025, 03/21/2025, 04/18/2025, and 05/02/2025 indicated no evidence that the physician had attended these meetings due to no signature present on the sign in sheet. There were no sign-in sheets dated 05/16/2025, 05/30/2025, 06/13/2025, 06/27/2025, and 07/11/2025 which indicated the presence of a physician, RN, social worker, and/or chaplain at the IDG meetings.8. Review of P8's undated "Patient Profile" located under the "Profile" tab in the EMR indicated P8 was admitted under hospice services on 06/26/2025 with the terminal illness of heart disease.There was not an "IDG Meeting Sign In" sheet dated 07/11/2025 for P8 which indicated the presence of a physician, RN, social worker, and/or chaplain attending this meeting.9. Review of P9's undated "Patient Profile" located under the "Profile" tab in the EMR indicated P9 was admitted under hospice services on 06/04/2025 with the terminal illness of coronary artery disease.There were no "IDG Meeting Sign In" sheets dated 06/13/2025, 06/27/2025, and 07/11/2025 which indicated the presence of a physician, RN, social worker, and/or chaplain at the IDG meetings.10. Review of P10's undated "Patient Profile" located under the "Profile" tab in the EMR indicated P10 was admitted under hospice services on 05/07/2025 with the terminal illness of malignant neoplasm of the liver.There were no "IDG Meeting Sign In" sheets dated 05/16/2025, 05/30/2025, 06/13/2025, 06/27/2025, and 07/11/2025 which indicated the presence of a physician, RN, social worker, and/or chaplain at the IDG meetings.11. Review of P11's undated "Patient Profile" located under the "Profile" tab in the EMR indicated P11 was admitted under hospice services on 05/27/2025 with the terminal illness of Alzheimer's Disease.There were no "IDG Meeting Sign In" sheets dated 05/30/2025, 06/13/2025, 06/27/2025, and 07/11/2025 which indicated the presence of a physician, RN, social worker, and/or chaplain at the IDG meetings.12. Review of P12's undated "Patient Profile" located under the "Profile" tab in the EMR indicated P12 was admitted under hospice services on 03/25/2025 with the terminal illness of Alzheimer's Disease.Review of P12's "IDG Meeting Sign In" sheet dated 05/02/2025 indicated no evidence that the physician had attended this meeting due to no signature present on the sign in sheet. There were no sign-in sheets dated 05/16/2025, 05/30/2025, 06/13/2025, 06/27/2025, and 07/11/2025 which indicated the presence of a physician, RN, social worker, and/or chaplain at the IDG meetings.13. Review of P13's undated "Patient Profile" located under the "Profile" tab in the EMR indicated P13 was admitted under hospice services on 05/16/2025 with the terminal illness of Alzheimer's Disease.There were no "IDG Meeting Sign In" sheets dated 05/30/2025, 06/13/2025, 06/27/2025, and 07/11/2025 which indicated the presence of a physician, RN, social worker, and/or chaplain at the IDG meetings.14. Review of P14's undated "Patient Profile" located under the "Profile" tab in the EMR indicated P14 was admitted under hospice services on 06/26/2025 with the terminal illness of Parkinson's Disease.There were no "IDG Meeting Sign In" sheets dated 06/30/2025 and 07/11/2025 which indicated the presence of a physician, RN, social worker, and/or chaplain at the IDG meetings.During an interview on 07/14/2025 at 4:30 PM, the Director of Clinical Services (DCS) stated, "All of the required people attend the IDG meetings. I just cannot find all of the sign-in sheets to prove they were there."During an interview on 07/16/2025 at 6:30 PM, the Administrator stated, "We are going to educate everyone that attends the IDG meetings that they have to sign the sign in sheet so that we can prove they were here."

Based on record review, interview, and policy review, the hospice agency failed to follow the Plan of Care for home health aide visits for two of 14 patients (Patient (P)7 and P8) whose records were reviewed for visit frequencies out of a total sample of 19. This failure had the potential for the patients not having their activities of daily living needs met.Findings include: --- 1. Review of P7's "Patient Profile" located under the "Profile" tab in the electronic medical record (EMR) revealed P7 was admitted to hospice services on 01/30/2025 with the terminal illness atherosclerotic cardiovascular disease.Review of P7's "Plan of Care" located under the "Plan of Care" tab in the EMR for the certification period of 01/30/2025 through 03/30/2025 and 03/31/2025 through 05/29/2025 revealed P7 was to receive home health aide visits five times a week. The aide made a visit on 02/03/2025 and then a missed visit note dated 02/04/2025. There was no further documentation of aide visits for 02/05/2025 through 02/07/2025. Aide visits were documented for four days, the week of 04/06/2025 and 04/14/2025. There was no further documentation of aide visits being made or refused by the patient and/or caregiver. The week of 05/26/2025, there was documentation of four aide visits being made; however, one visit was missing with no documentation of the visit being made or refused by the patient and/or caregiver.2. Review of P8's "Patient Profile" located under the Profile" tab in the EMR for the certification period of 06/26/2025 through 09/23/2025 revealed P8 was to receive home health aide visits five times a week. The week of 05/26/2025, there were four aide visits documented as being made. There was one visit not documented as being made or refused by the patient and/or caregiver.During an interview on 07/16/2025 at 4:30 PM, the Director of Clinical Services (DCS) stated, "The aide could not remember if the visits in February were made or not. The aide was on PTO [paid time off] on 04/10/2025 and 04/14/2025 and the patient did not want another aide for those visits. There should have been a missed visit note made for any visits that were not made. The visit on 05/26/2025 was a holiday and the aide was to ask the patient or caregiver if they want aide visit to be made on that day. If they do not, then a missed visit note should be made for that also."Review of the agency's policy titled "Charting Policy" dated 05/06/2025 revealed, "…Best practice is charting at the visit or within 4 [sic] days. Charting times that exceed four days will result in corrective action…"Review of the agency's policy "Professional Standards of Practice" dated June 2019 revealed, "…Hospice staff will perform care, treatment and services to each patient according to the IDG [Interdisciplinary Group] plan of care and physician orders…"

Based on record review and interview, the hospice agency failed to ensure that patient care plans incorporated measurable data elements to assess if progress toward expected outcomes of care plan goals were being met for nine of 14 patients (Patient (P)1, P2, P4, P5, P6, P7, P8, P10, and P13) out of a total sample of 19. This deficient practice had the potential for the patients to have unmet care needs. Findings include: --- 1. Review of P1's "Plan of Care" located under the "Plan of Care" tab in the electronic medical record (EMR), indicated the Chaplain started P1's care plan on 02/11/2025 that included assess, perform, and instruct patient/caregiver on spiritual, grieving, and coping methods. The Registered Nurse (RN) started P1's care plan on 02/11/2025 that included assess/manage pain and discomfort and provide symptom relief and implement and instruct on medication regimen including dosage, side effects, name, route, frequency, desired action, adverse reactions, and medication compliance/medication set-up. The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.2. Review of P2's "Plan of Care" located under the "Plan of Care" tab in the EMR, indicated the Medical Social Worker (MSW) started P2's care plan on 12/12/2024 that included patient/caregiver counseling and assess, perform, and instruct on grief management. The RN started P2's care plan on 12/12/2024 that included assess/manage pain and discomfort and provide symptom relief, and implement and instruct on medication regimen including dosage, side effects, name, route, frequency, desired action, adverse reactions, and medication compliance/medication set-up, implement and instruct on medication regimen including dosage, side effects, name, route, frequency, desired action, adverse reactions, and medication compliance/medication set-up. The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.3. Review of P4's "Plan of Care" located under the "Plan of Care" tab in the EMR, indicated the RN started P4's care plan on 03/11/2025 that included assessing vital signs and all body systems, knowledge of disease process and its associated care and treatment, medication regimen knowledge, and signs/symptoms and complications necessitating medical attention as needed. The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.4. Review of P5's "Plan of Care" located under the "Plan of Care" tab in the EMR, indicated the RN started P5's care plan on 03/18/2025 that included assess/manage pain and discomfort and provide symptom relief, and implement and instruct on medication regimen including dosage, side effects, name, route, frequency, desired action, adverse reactions, and medication compliance/medication set-up, implement and instruct on medication regimen including dosage, side effects, name, route, frequency, desired action, adverse reactions, and medication compliance/medication set-up. The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.5. Review of P6's "Plan of Care" located under the "Plan of Care" tab in the EMR, indicated the RN started P6's care plan on 04/03/2025 that included assessing vital signs and all body systems, knowledge of disease process and its associated care and treatment, medication regimen knowledge, and signs/symptoms and complications necessitating medical attention as needed. The care plan also included assess/manage pain and discomfort and provide symptom relief, and implement and instruct on medication regimen including dosage, side effects, name, route, frequency, desired action, adverse reactions, and medication compliance/medication set-up, implement and instruct on medication regimen including dosage, side effects, name, route, frequency, desired action, adverse reactions, and medication compliance/medication set-up. The MSW started P6's care plan on 04/09/2025 that included patient/caregiver counseling and assess, perform, and instruct on grief management. The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.6. Review of P7's "Plan of Care" located under the "Plan of Care" tab in the EMR, indicated the RN started P7's care plan on 01/30/2025 that included assess/manage pain and discomfort and provide symptom relief, and implement and instruct on medication regimen including dosage, side effects, name, route, frequency, desired action, adverse reactions, and medication compliance/medication set-up, implement and instruct on medication regimen including dosage, side effects, name, route, frequency, desired action, adverse reactions, and medication compliance/medication set-up. The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.7. Review of P8's "Plan of Care" located under the "Plan of Care" tab in the EMR, indicated the RN started P8's care plan on 06/26/2025 that included assessing vital signs and all body systems, knowledge of disease process and its associated care and treatment, medication regimen knowledge, and signs/symptoms and complications necessitating medical attention as needed. The care plan also included assess/manage pain and discomfort and provide symptom relief, and implement and instruct on medication regimen including dosage, side effects, name, route, frequency, desired action, adverse reactions, and medication compliance/medication set-up, implement and instruct on medication regimen including dosage, side effects, name, route, frequency, desired action, adverse reactions, and medication compliance/medication set-up. The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.8. Review of P10's "Plan of Care" located under the "Plan of Care" tab in the EMR, indicated the Chaplain started P10's care plan on 05/08/2025 that included assess, perform, and instruct patient/caregiver on spiritual, grieving, and coping methods. The MSW started P10's care plan on 05/08/2025 that included patient/caregiver counseling and assess, perform, and instruct on grief management. The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.9. Review of P13's "Plan of Care" located under the "Plan of Care" tab in the EMR, indicated the RN started P13's care plan on 05/16/2025 that included assessing vital signs and all body systems, knowledge of disease process and its associated care and treatment, medication regimen knowledge, and signs/symptoms and complications necessitating medical attention as needed. The care plan also included assess/manage pain and discomfort and provide symptom relief, and implement and instruct on medication regimen including dosage, side effects, name, route, frequency, desired action, adverse reactions, and medication compliance/medication set-up, implement and instruct on medication regimen including dosage, side effects, name, route, frequency, desired action, adverse reactions, and medication compliance/medication set-up. The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals.During an interview on 07/15/2025 at 9:54 AM, the Chaplain confirmed the goals on the care plans were not measurable as they were written.During an interview on 07/16/2025 at 5:30 PM, the Director of Clinical Services (DCS) confirmed the goals in the patients' care plans were not measurable.

Based on interview, document review, and policy review, the hospice agency failed to have volunteer hours that equaled five percent (%) of total patient hours. This failure had the potential to affect all 143 patients receiving hospice services. Findings include: --- Review of the untitled hospice agency's document revealed the agency's monthly volunteer hour percentages for the last year were:June 2024 – 2.71%July 2024 – 2.49%August 2024 – 3.63%September 2024 – 3.80%October 2024 – 2.53%November 2024 – 3.31%December 2024 – 2.38%January 2025 – 2.90%February 2025 – 3.68%March 2025 – 2.46%April 2025 – 0.20%May 2025 – 1.15%June 2025 – 1.93%This was an average volunteer hour percentage of 2.55% for June 2024 through June 2025.During an interview on 07/16/2025 at 5:45 PM, the Administrator stated, "The Volunteer Coordinator was not meeting standards of job performance in meeting the minimum of 5% of volunteer hours.” Review of the hospice agency's policy titled, "Volunteer Services" dated February 2021 revealed, "…Hospice will document and maintain a volunteer staff to provide administrative and/or direct patient care in an amount that, at a minimum, equals 5% [sic] of the total patient hours of all paid hospice employees and contract staff…"

Based on review of the Emergency Preparedness Program (EPP) policy, document review and interview, the hospice agency failed to test its' emergency response plan by participating in a community-based full-scale exercise every two years, conducting mock disaster drill, or tabletop exercise on the alternate year. This failure had the potential to delay the agency's ability to respond to the needs of the 45 current hospice patients living in the community. Findings include: Review of an undated agency policy titled, "Testing Program for Emergency Operations Plan (EOP)" revealed, "Hospice will conduct exercises to test the EOP [EPP] ... Hospice will do the following: Participate in a full-scale exercise that is community-based ... Conduct an additional exercise that may include ... a tabletop exercise ... " Review of the agency's EPP documentation and staff training records failed to show the agency had tested the emergency preparedness plan by participating in a community-based full-scale exercise or agency based mock disaster drill or tabletop exercise. During an interview on 02/02/2022 at 8:30 AM, the Director of Clinical Services (DCS) confirmed the agency had not conducted a test of the EPP or participated in a community-based exercise.

Based on document review, policy review, and interview, the hospice agency failed to include infection surveillance and data analysis in the quality assessment and performance improvement (QAPI) program. This failure had the potential to affect the hospices' ability to identify trends and take appropriate actions to prevent the spread of infection among staff and all 45 current patients. Findings include: Review of the agency policy titled, "Infection Control Committee," dated June 2019 revealed the hospice committee responsibilities include "Analyzing data from infection control surveillance system and taking appropriate actions ... Reports from the meetings will be forwarded to the QAPI committee, Administrator, and Governing Body." Review of the hospice's infection control surveillance program revealed tracking of infections by general type, for example, upper respiratory infection (URI), urinary tract infection (UTI), patient identifier, antibiotic, and date. The documentation did not include an analysis of the data. Review of the quarterly QAPI meetings presentations revealed the documentation did not include any information related to infection surveillance or data analysis. During an interview on 02/02/2022 at 8:30 AM, the Director of Clinical Services confirmed there was no documentation that the infection control program, including surveillance data and analysis, was reviewed during QAPI meetings.

Based on policy review, use of the web-based electronic medical record (EMR), document review and interview, the hospice agency failed to monitor, manage, and maintain the electronic equipment used to access patient medical information. This failure had the potential to result in unauthorized access to patient information which could affect all 45 patients receiving hospice services. Findings include: During the entrance conference interview on 01/31/2022 at 9:15 AM, the Director of Clinical Services (DCS) stated the agency used a web-based medical record documentation system called "DeVero" and identified that full time staff were provided with "iPads" that were owned by the agency. The DCS stated part time and staff working on an "as needed" basis used their own personal devices to access the web-based medical record system. Review of a list of all hospice employees revealed a total of 21 staff had not been provided with an electronic device owned by the agency to document in the medical record. Surveyor received a log-in and password to access the patient records in the web-based EMR. During review of patient information, the surveyor identified that the patient assessments, plan of care, visit notes, and personal information including address, date of birth, social security number, and insurance information could be saved to the computer desktop which allowed access when not logged into the web based EMR. Review of the undated agency policy titled, "Information Management Plan" revealed "Data encryption, passwords, and firewalls are utilized for electronic patient information ... All patient information and personal information is strictly confidential." During an interview on 02/02/2022 at 8:30 AM, the DCS confirmed the agency would not know if staff that used personal electronic devices to access the web based EMR saved patient information to their desktop, lost their computer which could contain saved patient information, or allowed other people to use the device.