Every finding on record at Prestigious Health Services Inc

Observed in Record Review. In 1 of 10 patient records reviewed, The surveyor noted on (RRAR#6) that an order for Azithromycin and Promethazine was obtained from the physician by the LVN. Also, the LVN noted indicated that the patient had sustained an unwitnessed fall prior to her visit and that the patient's oxygen saturation levels has dropped to 83% and he had a cough. There was no evidence in the record to indicate that the registered nurse reassessed the patient when there was a change in condition, or since. The RN had not seen the patient since admission to assess the change in condition and update the comprehensive assessment. This was confirmed with the director.

Observed in Record Review. In 1 of 10 patient records reviewed, The surveyor noted on (RRAR#6) that an order for Azithromycin and Promethazine was obtained from the physician by the LVN. Also, the LVN note indicated that the patient had sustained an unwitnessed fall prior to her visit and that the patient's oxygen saturation levels has dropped to 83% and he had a cough. There was no evidence in the record to indicate that the registered nurse was informed of the change. Also, there was no documentation of the communication between the LVN and the physician other than the verbal order. This was confirmed with the director.

Observed in Record Review. In 1 of 10 patient records reviewed, The surveyor noted (RRAR#6) that the initial certification of terminal illness was blank. There was no evidence in the record that the Medical Director had reviewed the clinical information or signed the initial certificate of terminal illness, since the patient was admitted over a week ago. This was confirmed with the director.

Observed in Individual Tracer. In 3 of 14 patient records reviewed, The surveyor noted (RRHV#1) that the comprehensive assessment indicated that the patient was experiencing hallucinations and agitation; however, the assessment did not describe the severity of the agitation and frequency of hallucinations. In (RRAR#8) the assessment and care plan indicated that the patient was experiencing behavioral disturbances of agitation and self-harm with biting her own arms; however, there was no description of the frequency or severity of the episodes or the extent of the self-injury. Also, in (RRAR#11), the assessment did not describe the frequency and severity of the patient's agitation, crying episodes and hallucinations. This was confirmed with the director.

Observed in Individual Tracer. In 7 of 14 patient records reviewed, The surveyor noted (RRHV#1) that the plan of care goals were all timed for the end of the certification period and did not include short term outcomes for managing pain and falls risk. The surveyor noted that the goals in (RRHV#2), (RRHV#4), (RRARR#5), (RRAR#7), (RRAR#9) and (RRAR#10) all had time frames for outcome as the last date of the certification periods and did not include any short term outcomes for symptom management. This was confirmed with the director of nursing.

Observed in Individual Tracer. In 8 of 14 patient records reviewed, The surveyor noted (RRHV#2) that the order for oxygen was incomplete and did not include parameters for dosing the range that was ordered. The order read Oxygen 2-5 LPM as needed NC and did not include an indication for use. Also, in (RRAR#6), the order for oxygen read O2 2-5 lpm as needed and did not include a route, indication or dosing parameters. In (RRAR#7), (RRAR#8), (RRAR#9), (RRAR#11) did not include dosing parameters indication for use and (RRAR#10) and (RRAR#12) did not include a route of administration for oxygen. This was confirmed with the director.

Observed in Record Review. In 4 of 14 patient records reviewed, The surveyor noted (RRHV#2) that the patient was admitted in June; however, the plan of care and IDG meeting notes did not provide information about the patient's progress towards goals related to pain, falls risk, constipation and agitation. The care plan updates only included changing the target dates to the end of the next certification period. The surveyor noted in (RRAR#6) that the problems identified in March remained on the care plan and the target dates were changed; however the interventions were not updated. For example, the problem of immobility was opened in March; a physical therapy evaluation was completed in June with a therapy assessment that indicated a one month plan; however, the care plan as never updated and there was no evidence in the IDG notes of the patient's progress. In (RRAR#9) there was no evidence of progress toward goals for managing pain. The medication orders were changed, but there was no evidence of the progress in relieving the pain since July. In (RRAR#14), the patient had experienced a fall prior to admission with swelling of the right wrist. The care plan included interventions to apply ice 4 x a day for 2 days. The care plan was not updated and there was no evidence in the IDG notes that the swelling was resolved or if further treatment was necessary. All the goals remained with movement of the outcome dates to the end of the current certification period. This was con firmed with the director.

Observed in Individual Tracer. In 1 of 4 home visits conducted, The surveyor noted (RRHV#1) that the aide wore gloves to prepare the patient for a shower. He then proceeded to assisted the patient's roommate with a wheelchair and laundry. The aide failed to change gloves between patients and proceeded to take the hospice patient to the shower room, wearing the same gloves. This was confirmed with the director.

Observed in Record Review. The surveyor noted (RRAR#12) that a licensed vocational nursing (LVN) visit was completed the night before the Registered nurse conducted the comprehensive assessment. The LVN visit note indicated that she conducted an assessment of the patient's vital signs and provided personal care. There was no order for the visit and the registered nurse had not yet initiated the assessment visit and/or developed a plan of care for the patient. This was confirmed with administrator.

Observed in Tracer Activities. During a review of the volunteer program with the volunteer coordinator and interview with the Hospice administrator, the Hospice pharmacy surveyor noted that the organization did not have any active volunteers in the last 18 months and had not documented efforts to recruit them since the COVID 19 national emergency was lifted in May of 2023.

Observed in Tracer Activities. During a review of the volunteer program with the volunteer coordinator and interview with the Hospice administrator, the Hospice pharmacy surveyor noted that since the organization did not have any active volunteers in the last 18 months, total cost savings achieved through the use of volunteers was not able to be documented as required.

Observed in Tracer Activities. Since the organization had no active volunteers in the last 18 months listed, the organization could not validate that the volunteers had provided at least 5% of the total patient care hours of all paid hospice employees and contract staff as required. This omission was validated with the volunteer coordinator and the administrator at the time of the survey.

Observed in Record Review. In 1 of 16 patient records reviewed, The surveyor noted (RRAR#6) that the plan of care included an order for physical therapy evaluation and 1 x a week for 4 weeks. The evaluation was completed in June; however there were no therapy visit notes in the file for the subsequent visits. This was confirmed with the director.

Observed in HR File Review. In 1 of 8 employee files reviewed for staff requiring a license, the Hospice pharmacy surveyor noted that a current license for a certified home health aide was not validated using a primary source upon hire. However, this individual did have a current license at this time in May of 2022. The requirement to validate this staff person's license using a primary source was confirmed with the administrator at the time of the survey. Observed in HR File Review. In 2 of 8 employees requiring a license to provide csre, the Hospice pharmacy surveyor noted that a current license for the Hospice administrator and an LVN were not validated using a primary source at the time the licenses were required to be renewed. , The administrator did frequently provide direct patient care.The administrator's nursing license expired in September of 2023 and this license was not verified using a primary source until early in 2024. The LVN's license expired on Oct 31, 2023, but was not validated with a primary source until 5/29/24. This requirement was validated with the administrator at the time of the survey. thisnurse did provide direct patient care. provided direct patient care's using a primary source was confired with the administrator at the time of the survey.

Based on observation, interview and record review, the hospice agency (HA) failed to ensure the Conditions of Participations regarding Initial and Comprehensive Assessments of Patients was met as follow: The HA failed to follow its policy and ensure the patient's medication profiles were reviewed and updated according to professional standards of practice for four out of seven sampled patients (Patient 1, 2, 3 and 7) as identified in the plan of care. Patient 1 was provided and received the medications prescribed for Patient 7 for four days. For Patient 2, has incorrect blood pressure parameter from the physician's order. For Patient 3, calmoseptine (used to treat and prevent minor skin irritations) ointment was being used but has no physicians order, and has duplicate orders for docusate sodium (medication used in the management and treatment of constipation). (Refer to L530). The cumulative effect of these systemic practices resulted in the Hospice agency's inability to ensure the provision of quality health. --- .

Based on interview and record review, The Hospice agency (HA) failed to develop and implement a comprehensive and resident-centered fall care plan regarding Patient 4's who fell twice with the interdisciplinary team. This deficient practice had a potential for patient increased risk for further falls that would cause serious harm or injury. --- d. A review of Patient 4's admission record indicated Patient 4 is a 96-year-old male admitted to the hospice agency on 9/9/2022, with the primary diagnosis of senile degeneration of the brain, not elsewhere classified ( an old-fashioned term for dementia- a group of conditions that affect the ability to think, concentrate, or remember) and unspecified mood affective disorder (general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function). A review of the " Plan of Care (POC) Summary" dated 9/11/2022, indicated the SN visit frequency for Patient 4 was twice to three times a week and three PRN (PRN "latin for pro-re nata meaning as needed) visits for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary group (IDG). On 10/18/2022, at 11:15 a.m., during a joint home visit with the registered Nurse 2 (RN 2), Patient 4 was observed sitting on his wheelchair with no chair alarm and no bilateral footrests in the main room with other residents. Patient 4 is mostly non-verbal due to hard of hearing and had a skin tear on the right forearm covered with a dry dressing. RN 2 continued to do her home visit. During a concurrent observation and interview on 10/18/22 at 11:15 a.m., with RN 2, RN 2 stated that patient 4 had an unwitnessed fall yesterday 10/17/2022 morning. RN 2 stated that she found out exactly what happened and did an assessment. RN 2 further stated that the assisted living facility performed a neurocheck (an assessment of an individual's neurological functions, motor and sensory response, and level of consciousness), implemented fall and safety protocol and sent a full report to the hospice agency. A review of the HAs document titled ";Communication log" indicated that on 10/4 at 4:04 p.m., Patient 4 fell off his wheelchair with no injuries. A review of the HAs document titled ";POC/IDG Review" dated 10/7/2022, indicated ";Environment/Safety Issue: Goal: Patient will have no fall and /or injury during this certification period. Intervention: Assess safety concerns every visit and address. Teach patient/family risks for fall (e.g. side effects of medications, confusion, weakness. Teach family fall prevention measures: check on patient frequently, assess need to use potty, eat/drink, assess for signs and symptoms and/or discomfort. Teach fall precautions keeping hospital bed in a low position when patient is lefty alone, keeping bed and chair alarm/sensor, camera monitor in place, providing constant supervision, removing environmental hazards, providing frequent reorientation when confused. Assess environment for threats to safety. Provide low bed and fall mats. There was no written documentation specifically for medication plan of care for Patient 4 who is taking the antipsychotic, antianxiety and narcotics and the side effects for these medications. A review of the HAs policy no. 2-031.1 titled ";Ongoing Comprehensive Assessments" by the CA Joint Commission Hospice/Revised October 2015, indicated during each home visit, the Case Manager (CM) 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: B. Secondary symptoms related to terminal illness such as nausea, vomiting and respiratory distress and the patients response to medications and other interventions. C. Factors that alleviate or exacerbate physical symptoms D. Current treatment related to the identified symptoms and the patients response.

Based on observation, interview and record review, the hospice agency failed to maintain a current and accurate medication profile for four of seven patients (Patient 1, Patient 2, Patient 3, and Patient 7). This failure placed the patients at risk for medication errors and adverse drug reactions which could be life threatening. --- Based on observation, interview and record review, the hospice staff failed to review all medications the patients were taking and update the medication profiles with the currently used medications for 4 of 7 sampled patients (Patients 1, 2, 3, and 4). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. Findings: d. A review of Patient 4's admission record indicated Patient 4 is a 96-year-old male admitted to the hospice agency on 9/9/2022, with the primary diagnosis of senile degeneration of the brain, not elsewhere classified ( an old-fashioned term for dementia- a group of conditions that affect the ability to think, concentrate, or remember) and unspecified mood affective disorder (general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function). A review of the " Plan of Care (POC) Summary" dated 9/11/2022, indicated the SN visit frequency for Patient 4 was twice to three times a week and three as needed(PRN "latin for pro-re nata meaning as needed) visits for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary group (IDG). On 10/18/2022, at 11:15 a.m., during a joint home visit with the registered Nurse 2 (RN 2), at the Assisted Living Facility (ALF), Patient 4 was observed sitting on his wheelchair in the main room with other residents. Patient 4 is mostly non-verbal due to hard of hearing and had a skin tear on the right forearm covered with a dry dressing. RN 2 continued to do her home visit. After the home visit observed RN 2 went to the " Wellness Center" and asked the Licensed Vocational Nurse (LVN) of the ALF to print out the medications for Patient 4. Observed RN 2 comparing the HAs medication profile to the ALF medication profile printed out by the LVN. On concurrent interview with RN 2, stated that she reviews medication once a month and as needed if there are new medications. RN 2 further stated that she ";highlights" the medication list and gives instructions to the ALF LVN. RN 2 was not seen to compare medication bubble packs and or medication bottles. RN also stated that Patient 4s medications were supplied by the hospice contracted pharmacy. A review of Patient 4s document titled ";Medication Profile" indicated the following medication discrepancies: 1. An order for Ipratropium-Albuterol inhalation solution 0.5/2.5 milligrams per 3 milliliter 1 dose as needed every 4 hours for difficulty breathing/congestion was not found in the medication box. RN 2 stated the ALF does not allow the administration of the medication per ALF policy due to Covid-19. RN 2 confirmed it was not discontinued because it was included in the comfort pack. 2. An order for Lorazepam 0.5 milligram every 12 hours as needed for anxiety and agitation, was not seen in the medication box. LVN stated it is locked at the Director of Nursing (DON) office. 3. An order for Senna 8.6 milligrams 1 tablet at bedtime for constipation was not seen in the medication box. LVN stated the HA needs to refill it. 4. Nitroglycerin Sublingual (under the tongue) 0.4 milligrams 1 tablet every 5 minutes as needed for chest pain for 3 doses. Was not found inside the medication box. LVN stated it may be in the DONs office also. 5. Lasix 20 milligram tablet for edema 1 tablet everyday for 10 days was ordered. There was no verification for start and stop date on the medication profile. RN 2 did not know when it was started and could not figure out the stop date. 6. Patient 4s Medications were delivered from 3 different pharmacies (Omnicare Pharmacy, Phar-Merica and The Medicine Shoppe (contracted hospice pharmacy). During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on 10/18/2022 stated that the hospice agency delivers the medications to all their patients. A review of the HAs policy no. 3-002.1 titled ";Medication Profile" by the CA Joint Commission Hospice/Revised October 2015 indicated for accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patients medications upon the patients entry to the organization. A comparison of the medications ordered for the patient while under the organizations care will be made to those on the list. The admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, route, frequency and a diagnosis, condition, or indication for use for each medication ordered. A drug regimen review will be performed at the time of initial and comprehensive assessment. The review will assist in evaluating effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicative therapy and noncompliance issues, omissions and unclear information. a. A review of Patient 1's Patient Profile indicated a start of care (SOC) date 5/19/2022 with a primary diagnosis of malignant neoplasm (cancerous tumor) of connective and soft tissue (fat, muscle, nerves, blood and lymph vessels and tissues around joints that support and connect all organs and structures of the body) and secondary diagnoses of chronic atrial fibrillation (an irregular and often very rapid heart rhythm [arrhythmia] that can lead to blood clots in the heart) and secondary malignant neoplasm of lung, retroperitoneum (the space behind the abdominal cavity) and peritoneum (the serous membrane that forms the abdominal cavity). A review of Patient 1s Plan of Care (POC)/ Interdisciplinary Group (IDG) Review, dated 5/19/2022, indicated a Hospice Aide (HA) was to visit three times per week and a Skilled Nurse (SN) was to visit three times per week with an additional 3 visits as needed (PRN). The POC/IDG indicated that medications and care plans were reviewed and implemented as directed. A review of Patient 1s Comprehensive Assessment, dated 5/19/2022, indicated RN 2 admitted Patient 1 to Hospice care from Patient 1s home/residence. The assessment indicated that RN 2 provided the patient and family teaching on Patient 1s medications (administration, side effects/contraindications, comfort pack, use and risk of opioids and prescription services). A review of Patient 1s Continuous Care Visit note dated 5/19/2022, indicated at 5:30 pm, the ADM/DPCS provided Family Member (FM 1) with teaching on comfort medications (morphine, Ativan, and Imodium). A review of Patient 1s LVN Visit Note dated 5/23/2022 and 5/25/2022, indicated Comfort Pack and Medications were checked. A review of Patient 1s Physician Orders indicated order on 5/27/2022 for admission to Skilled Nursing Facility for respite level of care and order on 5/31/2022 for discharge from respite to routine level of care. A review of LVN Visit Note dated 5/27/2022 indicated Patient 1 was transferred from home to a Skilled Nursing Facility (SNF) for respite care. The visit note indicated that medication list was handed to SNF nurse. A review of Patient 1s LVN Visit Note dated 5/30/2022, indicated Comfort Pack and Medications were checked. A further review of Patient 1s Patient Profile indicated Patient 1s place of service effective 5/31/2022 was in an Assisted Living Facility (AL). A review of Patient 1s LVN Visit Note date 5/31/2022, indicated LVN 1 went over medication orders with the AL Medication Technician and confirmed that the durable medical equipment (DME, such as hospital bed, portable oxygen equipment, bedside commode, suction set up) arrived at AL facility. During a concurrent interview and record review on 10/17/2022 at 1:20 pm with the Administrator (ADM)/Director of Patient Care Services (DPCS), Patient 1s HospiceMD (an accessible and secure web-based application used to manage, access and update patient electronic health records) Audit Log and Fax Order/History was reviewed. The Audit log indicated that on 5/19/2022 at 10:17 am, the ADM/DPCS entered Patient 1s last name incorrectly and on 5/19/2022 at 10:30 am the ADM/DPCS entered the correct the spelling of Patient 1s last name. The Fax Order/History indicated that a fax was sent to the Pharmacy at 10:28 am. The ADM/DPCS stated that she had initially entered Patient 1s name incorrectly, made a phone order/read back order to the pharmacy, and then corrected the spelling of Patient 1s last name. The ADM/DPCS stated she did not call back the pharmacy to verify or confirm the corrected spelling of Patient 1s last name. During an interview on 10/17/2022 at 1:40 pm, the ADM/DPCS stated that FM 1 signed for the medications when the Pharmacy delivered to the home. The ADM/DPCS stated she visited the Patient 1 on 5/19/2022 and went over the medications with FM 1. The ADM/DPCS stated she did not remember the name on the medication and that her priority at the time was the instruction. The ADM/DPSC stated she should have performed the five rights of medication administration and checked for the right patient, the right drug, the right dose, the right route, and the right time. During a concurrent interview and record review on 10/17/2022 at 1:45 pm, the Pharmacy delivery log was reviewed and indicated FM 1 signed and received medications on 5/27/2022 and 5/31/2022. The ADM/DPCS stated on 5/27/2022, Patient 1 was admitted to a SNF for respite level of care. The ADM/DPCS stated she notifed the Pharmacy to deliver five days worth of medications to the SNF. The ADM/DPCS stated that the Hospice agency is responsible for providing the medications delivered to their patient in the SNF. The ADM/DPCS stated she received a call on 5/31/2022 from LVN 1 during Patient 1s admission to the AL and was notified that the physical medications that were delivered with the patient from the SNF did not match the medications on Patient 1s Medication Profile. The ADM/DPCS instructed LVN 1 to give the medication to FM 1 who was also present at the AL. The ADM/DPCS stated she was not aware of a medication discrepancy until 06/01/2022 after Patient 1 was transferred AL facility. The ADM/DPCS stated she confirmed the medication error, that Patient 1 was administered medication that did not belong to him, on 6/7/2022 during a meeting with SNF and FM 1. During an interview on 10/18/2022 at 12:37 pm, Licensed Vocational Nurse (LVN 1) stated that during SN visits, head-to-toe assessment and vitals were performed. LVN 1 stated that patient medication reviews were performed twice a month. LVN 1 stated during medication review, each medication on the profile from HospiceMD would be matched with the physical bottle on hand. LVN 1 stated that each bottle was checked for the five rights of medication, which included name, medication, dose, time med is to be given. LVN 1 stated she did not remember if Patient 1s medication review was scheduled or performed when the Patient 1 was staying at home. During an interview on 10/18/2022 at 12:45 pm, LVN 1 stated she was at the Skilled Nursing Facility on 5/27/2022, when Patient 1 was admitted for respite care. LVN 1 stated that Patient 1 was agitated and trying to get out of bed, so she handed Patient 1s Medication Profile to the Admitting SNF nurse and went to help the SNF Certified Nursing Assistant (CNA) with the patient. LVN 1 stated she helped the SNF CNA take Patient 1 to the bathroom and changed Patient 1s bed sheets. LVN 1 stated she looked for the Admitting SNF nurse at the nursing station to give report but was unable to find her. LVN 1 stated that she gave a report about Patient 1 to another SNF nurse at the nursing station but did not go over the medication list because she handed it to the admitting SNF nurse. LVN 1 stated she did not realize she gave the Admitting SNF nurse Patient 7s medication profile. LVN 1 stated she remembered that she printed Patient 7s medication profile and then Patient 1s medication profile. LVN 1 stated when she took the documents, Patient 1s medication profile was on top and she did not realize that Patient 7s medication profile was included with Patient 1s documentation. LVN 1 stated she thought that the documents she handed the SNF nurse belonged to Patient 1. During an interview on 10/18/2022 at 12:50 pm, LVN 1 stated that Patient 1 was admitted to the AL on 5/31/2022. LVN 1 stated she performed medication review with the AL Medication Technician and identified that there were more physical medications that were transferred to the AL from the SNF. LVN 1 stated she notified the ADM/DPCS and was instructed to return the medications to FM 1. LVN 1 stated FM 1 asked her why more medications were given to Patient 1 and ended up taking the medications home. LVN 1 stated she notified the ADM/DPCS of FM 1 concerns. b. A review of Patient 2's Patient Profile indicated an SOC date 6/28/2022 with a primary diagnosis of cerebral infarction due to embolism of left middle cerebral artery (stroke) and secondary diagnoses of aphasia (language disorder caused by damage in a specific area of the brain that controls language expression and comprehension) and hemiplegia (paralysis of one side of the body) affecting the right dominant side. A review of Patient 2's POC/IDG Review, dated 10/7/2022, indicated a Hospice Aide (HA) was to visit three times per week and a Skilled Nurse (SN) was to visit three times per week with an additional 3 visits as needed (PRN). A review of Patient 2's Medication Profile indicated a medication order dated 6/28/2022, for Amlodipine 5 milligram (mg), one tablet orally once a day for hypertension. The medication order indicated a note: hold for systolic blood pressure (SBP) less than 120 millimeters of mercury (mmHg). On 10/18/2022 at 10:00 am, a home visit was conducted at Patient 2's Skilled Nursing Facility (SNF) with Licensed Vocational Nurse (LVN 2). LVN 2 performed medication review with the SNF nurse and the following was observed: Patient 2s medication bubble pack for Amlodipine 5 mg tablet, by mouth once daily with note to hold for SBP less than 110 mmHg. Patient 2 had two bubble packs for Lorazepam, 0.5 mg tablet, take one tablet by mouth every two hours as needed for anxiety/dyspnea. During an interview on 10/18/2022 at 10:15 am, LVN 2 stated that when a patient is admitted, LVN 2 makes sure the durable medical equipment (DME) is received and if the medications are in HospiceMD (an accessible and secure web-based application used to manage, access and update patient electronic health records), LVN 2 will go over it with the family member or caregiver. LVN 2 stated she would make sure the medications on the HospiceMD list matched the SNF list and the physical medication bottle or bubble pack. LVN 2 stated she checks the medication list and the physical bottle and bubble pack with the SNF nurse to make sure the labels and orders have the right patient, the right drug, the right dose, the right route, the right time, and the expiration date. LVN 2 stated the SBP parameter to hold the medication on the HospiceMD list and the SNF list did not match and would have to call their pharmacy to have it corrected. LVN 2 stated lorazepam was not on Patient 2s medication profile and should be discarded. During an interview on 10/18/2022 at 4:50 pm, the ADM/DPCS stated the parameter for the amlodipine should have been corrected to avoid any hypotensive episode. The ADM/DPCS further stated that the bubble packs of Ativan should have been discarded by the SNF nurse because the order was discontinued. c. A review of Patient 3's Patient Profile indicated a start of care (SOC) date 9/1/5/2022 with a primary diagnosis of severe protein-calorie malnutrition (the inability to consume enough protein and calories leading to muscle loss, fat loss, and decline of body functions) and secondary diagnosis of a fracture (a crack or break) of the thoracic vertebra (the spine starting a base of neck and ending at the bottom of the ribs) and lumbar vertebra (the spine starting from the lower thoracic spine to the sacrum (bottom of the spine). A review of Patient 3s POC/IDG Review, dated 10/7/2022, indicated a Hospice Aide (HA) was to visit twice times per week and a Skilled Nurse (SN) was to visit three times per week an additional 3 visits as needed (PRN). The POC/IDG indicated an Integumentary/Skin Care Plan interventions to teach the Patient Caregiver (PCG) the calmoseptine/zinc oxide rationale for use and administration. The IDG/POC indicated to teach PCG to apply calmoseptine or zinc oxide, two to four times per day and as needed diaper change per physician order. A review of Patient 3's Medication Profile indicated the following orders: A medication order dated 8/3/2022, indicated Docusate Sodium 100 mg, one capsule orally, give one tablet by mouth two times a day for constipation, hold if loose stools. A medication order dated 8/3/2022, indicated Docusate Sodium 100 mg, one capsule orally at bedtime for constipation. On 10/18/2022 at 9:00 am, a home visit was conducted at Patient 3's Skilled Nursing Facility (SNF) with Licensed Vocational Nurse (LVN 2). Patient 3 was lying in bed, alert and oriented, and watching television. LVN 2 performed a head-to-toe assessment and checked Patient 2s skin. LVN 2 performed medication review with the SNF nurse and it was observed there were two routine orders for Docusate Sodium. Further review of Patient 3s clinical record did not indicate a physician order for calmoseptine/zinc oxide. During an interview on 10/18/2022 at 5:02 pm, the ADM/DPCS stated that if the patient had an intervention to be treated with calmoseptine/zinc oxide, it should have been ordered by the physician. e. A review of Patient 7s Patient Profile indicate a Start of Care (SOC) date of 12/21/2021 with a primary diagnosis of hypertensive heart disease with our heart failure and secondary diagnoses of diabetes (define) and chronic kidney disease (define). During an interview on 10/18/2022 at 12:45 pm, LVN 1 stated she was at the Skilled Nursing Facility on 5/27/2022, when Patient 1 was admitted for respite care. LVN 1 stated that Patient 1 was agitated and trying to get out of bed, so she handed Patient 1s Medication Profile to the Admitting SNF nurse and went to help the SNF Certified Nursing Assistant (CNA) with the patient. LVN 1 stated she helped the SNF CNA take Patient 1 to the bathroom and changed Patient 1s bed sheets. LVN 1 stated she looked for the Admitting SNF nurse at the nursing station to give report but was unable to find her. LVN 1 stated that she gave a report about Patient 1 to another SNF nurse at the nursing station but did not go over the medication list because she handed it to the admitting SNF nurse. LVN 1 stated she did not realize she gave the Admitting SNF nurse Patient 7s medication profile. LVN 1 stated she remembered that she printed Patient 7s medication profile and then Patient 1s medication profile. LVN 1 stated when she took the documents, Patient 1s medication profile was on top and she did not realize that Patient 7s medication profile was included with Patient 1s documentation. LVN 1 stated she thought that the documents she handed the SNF nurse belonged to Patient 1. During an interview on 10/18/2022 at 5:25 pm, the Administrator/Director of Patient Care Services (ADM/DPCS) stated that medication review should be performed when the LVNs visit their patients. The ADM/DPCS stated the LVN should do a medication review with the medication list from the hospice, medication list from the SNF, and the physical medications. The ADM/DPCS stated that the five rights of medications (the right patient, the right drug, the right dose, the right route and the right time) should be checked. The ADM/DPCS stated that medication reconciliation is performed when the registered nurse (RN) admits the patient into hospice care. A review of the hospice agencys policy, Medication Profile, dated 2015, indicated patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. The policy indicated medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. The policy indicated that for accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient's current medications upon the patient's entry to the organization. A comparison of the medications ordered for the patient while under the organization's care will be made to those on the list. The policy further indicated that the admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, route, frequency and a diagnosis, condition, or indication for use for each medication ordered. If the patient is enrolled in Medicare Part D, the nurse will review medications with the patient or their representative and determine the relationship of the medication to the patient's terminal illness and related conditions that contribute to the terminal prognosis. The policy indicated a drug regimen review will be performed at the time of initial and comprehensive assessment. The policy indicated the review will assist in evaluating effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicative therapy and noncompliance issues, omissions and unclear information. The policy indicated that the drug regimen review will be completed by the interdisciplinary group in consultation with an individual with education and training in hospice and palliation drug management to ensure that drugs and biological meet each patient's needs. A review of the hospice agencys policy titled, Transfer of Patient from a Point of Service to Another, dated 2015, indicated the workflow that needs to be followed when transferring a patient from a place of service (POS) or location to another, such as, when transferring from home to a skilled nursing facility, from the hospital to an assisted living facility. The policy indicated that the case manager will review the current medications, diet, treatment ordered by the doctor, place an order to the pharmacy and ensure that these are delivered before or on the same day as the patient arrives in the new POS.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation for IDG, Care Planning and Coordination of Services were met as follows: The HA failed to develop and implement the patient's plan of care were specific to the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment by; 1.The HA failed to update the plan of care according to each patients specific needs for 2 out of 7 sampled patients (Patients 2 and Patient 3). (Refer to L543) 2. The HA failed to follow its policy for the delivery, monitoring and tracking, contracted pharmacy services to supply the medications for 2 of 7 sampled patients (Patient 1 and 4). (Refer to L 554). The cumulative systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with Federal regulations for Care Planning, and Coordination of services to ensure highest quality of care were provided to the patients and to meet patients care goal and services. --- .

Based on observation, interview, and record review, the hospice agency failed to follow and implement the plan of care (POC) for two of 7 sampled patients (Patient 2 and 3). For Patient 2,there was no care plan develop for the patient use of anticoagulant (blood thinners-to prevent and treat blood clots) medications and its risk. For Patient 3, there was no care plan develop for the use of Augmentin antibiotic medication for urinary tract infection and use of indwelling catheter for urine retention. These failures had the potential to cause serious harm, injury or complications that could affect the patients health status, safety and well-being. --- a. A review of Patient 2's Patient Profile indicated a start of care (SOC) date 6/28/2022 with a primary diagnosis of cerebral infarction due to embolism of left middle cerebral artery (stroke), aphasia (language disorder caused by damage in a specific area of the brain that controls language expression and comprehension) and hemiplegia (paralysis of one side of the body) affecting the right dominant side. A review of Patient 2's Plan of Care (POC)/ Interdisciplinary Group (IDG) Review, dated 10/7/2022, indicated a Hospice Aide (HA) was to visit three times per week and a Skilled Nurse (SN) was to visit three times per week with an additional 3 visits as needed (PRN) for any change of condition, and symptom control and management. A review of Patient 2's Medication Profile indicated the following orders: A medication order dated 6/28/2022, indicated aspirin, 81 milligram (mg), one tablet, orally, once daily for antiplatelet (prevent platelets from sticking together and forming blood clot). A medication order dated 6/28/2022, indicated clopidogrel, 75 mg, one tablet, orally, one daily for antiplatelet. Further review of Patient 2's clinical record indicated no care plan was developed identifying the use of the anticoagulant medications. During an interview on 10/18/2022 at 4:52 pm, the ADM/DPCS stated Patient 2 should have been a care plan for safety which included breeding precautions. The ADM/DPCS stated that it was important because if the patient falls and is on anticoagulants, we will know the patient is on bleeding precautions. b. A review of Patient 3's Patient Profile indicated a start of care (SOC) date 9/1/5/2022 with a primary diagnosis of severe protein-calorie malnutrition (the inability to consume enough protein and calories leading to muscle loss, fat loss, and decline of body functions), fracture (a crack or break) of the thoracic vertebra (the spine starting a base of neck and ending at the bottom of the ribs) and lumbar vertebra (the spine starting from the lower thoracic spine to the sacrum (bottom of the spine). A review of Patient 3s POC/IDG Review, dated 10/7/2022, indicated a Hospice Aide (HA) was to visit twice times per week and a Skilled Nurse (SN) was to visit three times per week an additional 3 visits as needed (PRN) for any change of condition, and symptom control and management. A review of Patient 3's Medication Profile indicated the following orders: A medication order dated 10/7/2022, indicated Augmentin, 875 mg tablet, one tab orally, twice a day for ten days for urine infection. A medication order dated 9/15/2022 indicated for Robitussin Adult DM Cough & Chest Congestion, Sugar-Free Liquid, 10 mg Dextromethorphan /100mg Guaifenesin per 5 milliliters (ml), 10 ml, orally every four hours as needed for cough. Further review of Patient 3s clinical record indicated no care plan was developed identifying the use of a foley catheter or the antibiotic and cough medications. During an interview on 10/18/2022 at 5:00 pm, the Administrator/Director of Patient Care Services (ADM/DPCS) stated that the intervention to administer Augmentin (antibiotic) to Patient 3 should have been included in the care plan for urinary or infection. c. A review of Patient 4's admission record indicated Patient 4 is a 96-year-old male admitted to the hospice agency on 9/9/2022, with the primary diagnosis of senile degeneration of the brain, not elsewhere classified ( an old-fashioned term for dementia- a group of conditions that affect the ability to think, concentrate, or remember) and unspecified mood affective disorder (general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function). A review of the " Plan of Care (POC) Summary" dated 9/11/2022, indicated the SN visit frequency for Patient 4 was twice to three times a week and three as needed (PRN "Latin for pro-re-nata" meaning as needed) visits for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary group (IDG) A review of Patient 4s document titled ";Current Treatment/Medication/DME (Durable Medical Equipment) List" indicated Patient 4 was taking following medications: 1. Acetaminophen 325 milligrams (mg- unit of measurement for solid medications) 2 tablets as needed every 4 hours for pain 2. Admelog 100 unit/milliliter (ml-unit of measurement for liquid medications) three times a day with meals for diabetes 3. Carvedilol 3.125 mg 1 tablet every 12 hours with food. Hold if with systolic blood pressure(SBP) less than 110 and for heart rate (HR) less than 60 for hypertension. 4. Hydrocodone/Acetaminophen 5/325mg 1 tablet every 4 hours as needed for moderate to severe pain 5. Latanoprost 0.005% ophthalmic solution to both eyes at bedtime for glaucoma. 6. Milk of Magnesia 400 mg/5 ml give 30 ml as needed for constipation 7. Nitroglycerin 0.4 mg sublingual (under the tongue) 1 tablet every 5 minutes three doses as needed for chest pain 8. Omeprazole 10 mg delayed release capsule once in the morning for gastritis 9. Senna 8.6 mg 1 tablet at bedtime to prevent constipation 10. Zinc oxide apply to sacrum every diaper change as skin protectant 11. Acetaminophen 500 mg extra strength 2 tablets at bedtime for pain 12. Divalproex Sodium 125 mg delayed release tablet twice daily for mood disorder 13. Escitalopram 10 mg 1 tablet at bedtime for depression 14. Famotidine 20 mg 1 tablet twice daily for gerd (gastroesophageal reflux disease) 15. Lisinopril 5 mg 2 tablets in the morning. Hold for SBP less than 110 for hypertension. 16. Zolpidem Tartrate 5 mg 1 tablet at bedtime for sleeplessness. 17. Zyprexa 2.5 mg 1 tablet at bedtime for depression. 18. Levemir Flextouch 100 units/ml per sliding scale for diabetes 19. Invokana 100 mg 1 tablet before breakfast for diabetes 20. Lorazepam 1 mg 1 tablet every 12 hours for agitation, restlessness and difficulty breathing 21. Hydrocodone/acetaminophen 5/325 mg 1 tablet every morning, lunch and bedtime for pain and agitation 22. Lasix 20 mg 1 tablet once daily for 10 days for edema 23. Oxygen 2-5 liters per minute via nasal cannula as needed for difficulty breathing and congestion 24. Zofran oral disintegrating tablet (ODT) 4 mg every 4 hours as needed for nausea and vomiting (comfort pack) 26. Morphine sulfate IR 20 mg/ml give 0.25 ml every 2 hours as needed for breakthrough pain or difficulty breathing (comfort pack) 27. Lorazepam 0.5 mg 1 tablet every 2 hours as needed for anxiety and difficulty breathing (comfort pack) 28. Hyoscamine Sulfate 0.125 mg ODT 1 tablet sublingual every 4 hours as needed for increased secretions (comfort pack) 29. Ipratropium Bromide/Albuterol 0.5mg/3.0mg per 3mlnebule 1 nebule via nebulizer every 4 hours as needed for wheezing and congestion (comfort pack) 30. Bisacodyl 10mg suppository once daily if without bowel movement for 3 days (comfort pack) 31. Acetaminophen 650 mg 1 suppository as needed every 4 hours for pain or fever greater than 99 degrees Fahrenheit (comfort pack) A review of the HA's communication log for Patient 4 showed that on 10/4/2022 at 4:04 p.m., indicated that the assisted living facility (ALF) called the HA that patient fell off his wheelchair with no injuries. HA instructed a nurse to go visit. During an interview with Registered Nurse 2 (RN2) on 10/18/2022 at 11:15 a.m., after the home visit stated that Patient 4 had an unwitnessed fall on 10/17/2022 inside his room and was seen lying on the floor by assisted living staff. RN2 arrived that day for her visit and the ALF staff informed her of what happened. RN2 stated she conducted her assessment and noted that patient suffered a large skin tear on the right forearm. RN 2 stated the ALF performed a neuro-check (an assessment of an individual's neurological functions, motor and sensory response, and level of consciousness), implemented fall and safety protocol and sent a full report to the hospice agency. A review of the HAs document titled ";POC/IDG Review" dated 10/7/2022, indicated ";Environment/Safety Issue: Goal: Patient will have no fall and /or injury during this certification period. Intervention: Assess safety concerns every visit and address. Teach patient/family risks for fall (e.g. side effects of medications, confusion, weakness. Teach family fall prevention measures: check on patient frequently, assess need to use potty, eat/drink, assess for signs and symptoms and/or discomfort. Teach fall precautions keeping hospital bed in a low position when patient is lefty alone, keeping bed and chair alarm/sensor, camera monitor in place, providing constant supervision, removing environmental hazards, providing frequent reorientation when confused. Assess environment for threats to safety. Provide low bed and fall mats. There was no written documentation or updated plan of care specifically for the 2 episodes that Patient 4 had a fall and no written documentation or updated care plan for side effects for each psychotropic medications given. A review of the HA's Policy No. 2-044.1 tiled " Plan of Care" by the CA Joint Commission Hospice/Revised October 2015, indicated that a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the IDG and will be reviewed on a regular basis but no less than every 15 days. This plan will focus on the identified problems, goals and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care.

Based in observation, interviews and record reviews, the hospice agency (HA) failed to implement their policy in coordinating and tracking of medications with contracted pharmacy for 2 out of 7 sampled patients (patient 1 and 4) by; 1. The HA failed to correct the wrong name and no follow up with the contracted pharmacy for Patient 1 that resulted in medication errors in administration of medications for Patient 1 who was transferred to the skilled nursing facility (SNF) for respite care. 2. The HA failed to coordinate with the assisted living facility (ALF) for medications ordered for Patient 4 when the comfort kit was found to be stored at the Director of Nursings (DON) office and not at the medication room. 3. The HA failed to implement their policy for the delivery of medications from their contracted pharmacy. 4. The HA failed to monitor field staff in tracking and coordinating with facilities (ALF and SNF) for the delivery of medications for Patient 1 and 4. These deficient practices had the potential to cause medication error, complications from the medications, and could affect the patients health status, safety and well-being. --- b. A review of Patient 4's admission record indicated Patient 4 is a 96-year-old male admitted to the hospice agency on 9/9/2022, with the primary diagnosis of senile degeneration of the brain, not elsewhere classified ( an old-fashioned term for dementia- a group of conditions that affect the ability to think, concentrate, or remember) and unspecified mood affective disorder (general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function). A review of the " Plan of Care (POC) Summary" dated 9/11/2022, indicated the SN visit frequency for Patient 4 was twice to three times a week and three as needed (PRN "Latin for pro-re-nata" meaning as needed) visits for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary group (IDG). On 10/18/2022, at 11:15 a.m., during a joint home visit with the registered Nurse 2 (RN 2), Patient 4 was observed sitting on his wheelchair with no chair alarm and no bilateral footrests in the main room with other residents. Patient 4 is mostly non-verbal due to hard of hearing and had a skin tear on the right forearm covered with a dry dressing. RN 2 brought Patient 4 to his room and continued to do her home visit. After the home visit, RN 2 went to the wellness center where Patient 4s medication was kept. A review of Patient 4s document titled ";Medication Profile" indicated the following medication discrepancies: 1. An order for Ipratropium-Albuterol inhalation solution 0.5/2.5 milligrams per 3 milliliter 1 dose as needed every 4 hours for difficulty breathing/congestion was not found in the medication box. RN 2 stated the ALF does not allow the administration of the medication per ALF policy due to Covid-19. RN 2 confirmed it was not discontinued because it was included in the comfort pack. 2. An order for Lorazepam 0.5 milligram every 12 hours as needed for anxiety and agitation, was not seen in the medication box. LVN stated it is locked at the Director of Nursing (DON) office. 3. An order for Senna 8.6 milligrams 1 tablet at bedtime for constipation was not seen in the medication box. LVN stated the HA needs to refill it. 4. Nitroglycerin Sublingual (under the tongue) 0.4 milligrams 1 tablet every 5 minutes as needed for chest pain for 3 doses. Was not found inside the medication box. LVN stated it may be in the DONs office also. 5. Lasix 20 milligram tablet for edema 1 tablet every day for 10 days was ordered. There was no verification for start and stop date on the medication profile. RN 2 did not know when it was started and could not figure out the stop date. 6. Patient 4s Medications were delivered from 3 different pharmacies (Omnicare Pharmacy, Phar-Merica and The Medicine Shoppe (contracted hospice pharmacy). During an interview on 10/18/2022 at 12:55 p.m., with the Licensed Vocational Nurse 2 of the ALF, LVN 2 stated that per their policy the narcotics and comfort kits were being stored at their DONs office. On concurrent interview with the DON of the ALF, DON stated they do keep narcotics and comfort kits locked in her office because they are having a medication issue at their facility. DON further stated that in case resident needs it, there is an RN supervisor 24/7 on duty that will grant them access code where the medications are kept and the staff in their facility knows about this. On concurrent interview with RN 2 , RN 2 stated she did not know that the patients narcotics and comfort kit were being kept at the DONs office and will have to ask them when patient requires comfort kit for any symptom management. During an interview with the HAs administrator/director of patient care services (Admin/DPCS) on 10/18/2022 at 1:35 p.m., Admin/DPCS stated that she did not know that was the assisted living facilitys policy and ";I will have to call them and ask them". On concurrent review of the communication log for Patient 4 , there was no written documentation that this was discussed in between the assisted living facility and the hospice agency. 078 A review of the policy no. 2-049.1 titled ";Interdisciplinary Group (IDG) Coordination of Care" form the CA Joint Commission Hospice/Revised October 2015, indicated that Prestigious Health Services Inc. personnel will communicate changes in a timely manner via telephone, one to one meetings, IDG meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, IDG meeting form and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed and the outcome of the communication. Exchange of information between the hospice staff and the contracted providers will be documented in the clinical record. a. A review of Patient 1's Patient Profile indicated a start of care (SOC) date 5/19/2022 with a primary diagnosis of malignant neoplasm (cancerous tumor) of connective and soft tissue (fat, muscle, nerves, blood and lymph vessels and tissues around joints that support and connect all organs and structures of the body) and secondary diagnoses of chronic atrial fibrillation (an irregular and often very rapid heart rhythm [arrhythmia] that can lead to blood clots in the heart) and secondary malignant neoplasm of lung, retroperitoneum (the space behind the abdominal cavity) and peritoneum (the serous membrane that forms the abdominal cavity). A review of Patient 1s Plan of Care (POC)/ Interdisciplinary Group (IDG) Review, dated 5/19/2022, indicated a Hospice Aide (HA) was to visit three times per week and a Skilled Nurse (SN) was to visit three times per week with an additional 3 visits as needed (PRN). The POC/IDG indicated that medications and care plans were reviewed and implemented as directed. A review of Patient 1s Comprehensive Assessment, dated 5/19/2022, indicated RN 2 admitted Patient 1 to Hospice care from Patient 1s home/residence. The assessment indicated that RN 2 provided the patient and family teaching on Patient 1s medications (administration, side effects/contraindications, comfort pack, use and risk of opioids and prescription services). A review of Patient 1s Continuous Care Visit note dated 5/19/2022, indicated at 5:30 pm, the ADM/DPCS provided Family Member (FM 1) with teaching on comfort medications (morphine, Ativan, and Imodium). A review of LVN Visit Note dated 5/27/2022 indicated Patient 1 was transferred from home to a Skilled Nursing Facility (SNF) for respite care. The visit note indicated that medication list was handed to SNF nurse. During a concurrent interview and record review on 10/17/2022 at 1:20 pm with the Administrator (ADM)/Director of Patient Care Services (DPCS), Patient 1s HospiceMD (an accessible and secure web-based application used to manage, access and update patient electronic health records) Audit Log and Fax Order/History was reviewed. The Audit log indicated that on 5/19/2022 at 10:17 am, the ADM/DPCS entered Patient 1s last name incorrectly and on 5/19/2022 at 10:30 am the ADM/DPCS entered the correct the spelling of Patient 1s last name. The Fax Order/History indicated that a fax was sent to the Pharmacy at 10:28 am. The ADM/DPCS stated that she had initially entered Patient 1s name incorrectly, made a phone order/read back order to the pharmacy, and then corrected the spelling of Patient 1s last name. The ADM/DPCS stated she did not call back the pharmacy to verify or confirm the corrected spelling of Patient 1s last name. During an interview on 10/17/2022 at 1:40 pm, the ADM/DPCS stated that FM 1 signed for the medications when the Pharmacy delivered to the home. The ADM/DPCS stated she visited the Patient 1 on 5/19/2022 and went over the medications with FM 1. The ADM/DPCS stated she did not remember the name on the medication and that her priority at the time was the instruction. The ADM/DPSC stated she should have performed the five rights of medication administration and checked for the right patient, the right drug, the right dose, the right route, and the right time. During a concurrent interview and record review on 10/17/2022 at 1:45 pm, the Pharmacy delivery log was reviewed and indicated FM 1 signed and received medications on 5/27/2022 and 5/31/2022. The ADM/DPCS stated on 5/27/2022, Patient 1 was admitted to a SNF for respite level of care. The ADM/DPCS stated she notifed the Pharmacy to deliver five days worth of medications to the SNF. The ADM/DPCS stated she received a call on 5/31/2022 from LVN 1 during Patient 1s admission to the AL and was notified that the physical medications that were delivered with the patient from the SNF did not match the medications on Patient 1s Medication Profile. The ADM/DPCS instructed LVN 1 to give the medication to FM 1 who was also present at the AL. The ADM/DPCS stated she was not aware of a medication discrepancy until 06/01/2022 after Patient 1 was transferred AL facility. The ADM/DPCS confirmed the medication error on 6/7/2022 during a meeting with SNF and FM 1. During an interview on 10/18/2022 at 12:37 pm, Licensed Vocational Nurse (LVN 1) stated that during SN visits, head-to-toe assessment and vitals were performed. LVN 1 stated that patient medication reviews were performed twice a month. LVN 1 stated during medication review, each medication on the profile from HospiceMD would be matched with the physical bottle on hand. LVN 1 stated that each bottle was checked for the five rights of medication, which included name, medication, dose, time med is to be given. LVN 1 stated she did not remember if Patient 1s medication review was scheduled or performed when the Patient 1 was staying at home. During an interview on 10/18/2022 at 12:45 pm, LVN 1 stated she was at the Skilled Nursing Facility on 5/27/2022, when Patient 1 was admitted for respite care. LVN 1 stated that Patient 1 was agitated and trying to get out of bed, so she handed Patient 1s Medication Profile to the Admitting SNF nurse and went to help the SNF Certified Nursing Assistant (CNA) with the patient. LVN 1 stated she helped the SNF CNA take Patient 1 to the bathroom and changed Patient 1s bed sheets. LVN 1 stated she looked for the Admitting SNF nurse at the nursing station to give report but was unable to find her. LVN 1 stated that she gave a report about Patient 1 to another SNF nurse at the nursing station but did not go over the medication list because she handed it to the admitting SNF nurse. LVN 1 stated she did not realize she gave the Admitting SNF nurse Patient 7s medication profile. LVN 1 stated she remembered that she printed Patient 7s medication profile and then Patient 1s medication profile. LVN 1 stated when she took the documents, Patient 1s medication profile was on top and she did not realize that Patient 7s medication profile was included with Patient 1s documentation. LVN 1 stated she thought that the documents she handed the SNF nurse belonged to Patient 1. During an interview on 10/18/2022 at 12:50 pm, LVN 1 stated that Patient 1 was admitted to the AL on 5/31/2022. LVN 1 stated she performed medication review with the AL Medication Technician and identified that there were more physical medications that were transferred to the AL from the SNF. LVN 1 stated she notified the ADM/DPCS and was instructed to return the medications to FM 1. LVN 1 stated FM 1 asked her why more medications were given to Patient 1 and ended up taking the medications home. LVN 1 stated she notified the ADM/DPCS of FM 1 concerns. During an interview on 10/18/2022 at 5:25 pm, the Administrator/Director of Patient Care Services (ADM/DPCS) stated that medication review should be performed when the LVNs visit their patients. The ADM/DPCS stated the LVN should do a medication review with the medication list from the hospice, medication list from the SNF, and the physical medications. The ADM/DPCS stated that the five rights of medications (the right patient, the right drug, the right dose, the right route and the right time) should be checked. The ADM/DPCS stated that medication reconciliation is performed when the registered nurse (RN) admits the patient into hospice care. The ADM/DPCS stated if there are discrepancies, to follow up physician or the pharmacy. A review of the hospice agencys policy titled, Transfer of Patient from a Point of Service to Another, dated 2015, indicated the workflow that needs to be followed when transferring a patient from a place of service (POS) or location to another, such as, when transferring from home to a skilled nursing facility, from the hospital to an assisted living facility. The policy indicated that the case manager will review the current medications, diet, treatment ordered by the doctor, place an order to the pharmacy and ensure that these are delivered before or on the same day as the patient arrives in the new POS.

Based on interview and record review, the hospice agency failed to ensure the protection and confidentiality of patient clinical records for one of seven sampled patients (Patient 7). This failure had the potential to result in disclosure and unauthorized use of patient health information without the patient's consent or knowledge. --- A review of Patient 7s Patient Profile indicated a Start of Care (SOC) date of 12/21/2021 with a primary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and secondary diagnoses of diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar) and chronic kidney disease (condition where the kidneys are damaged and lose their ability to filter waste and fluid out of blood). During an interview on 10/18/2022 at 12:45 pm, LVN 1 stated she was at the Skilled Nursing Facility on 5/27/2022, when Patient 1 was admitted for respite care. LVN 1 stated that Patient 1 was agitated and trying to get out of bed, so she handed Patient 1s Medication Profile to the Admitting SNF nurse and went to help the SNF Certified Nursing Assistant (CNA) with the patient. LVN 1 stated she helped the SNF CNA take Patient 1 to the bathroom and changed Patient 1s bed sheets. LVN 1 stated she looked for the Admitting SNF nurse at the nursing station to give report but was unable to find her. LVN 1 stated that she gave a report about Patient 1 to another SNF nurse at the nursing station but did not go over the medication list because she handed it to the admitting SNF nurse. LVN 1 stated she did not realize she gave the Admitting SNF nurse Patient 7s medication profile. LVN 1 stated she remembered that she printed Patient 7s medication profile and then Patient 1s medication profile. LVN 1 stated when she took the documents, Patient 1s medication profile was on top and she did not realize that Patient 7s medication profile was included with Patient 1s documentation. LVN 1 stated she thought that the documents she handed the SNF nurse belonged to Patient 1. During an interview on 10/18/2022 at 5:25 pm, the Administrator/Director of Patient Care Services (ADM/DPCS) stated that medication review should be performed when the LVNs visit their patients. The ADM/DPCS stated the LVN should do a medication review with the medication list from the hospice, medication list from the SNF, and the physical medications. The ADM/DPCS stated that the five rights of medications (the right patient, the right drug, the right dose, the right route and the right time) should be checked. The ADM/DPCS stated that medication reconciliation is performed when the registered nurse (RN) admits the patient into hospice care. A review of the hospice agencys policy titled, Confidentiality of Information, dated 10/2015 indicated to ensure that the patient's right to privacy is protected by following the policies and procedures regarding confidentiality and use and disclosure of protected health information (PHI), as necessary. The policy indicated the hospice agency and its personnel will maintain as confidential all patient protected health information. A review of the hospice agencys policy titled, Patient Privacy Rights, dated 10/2015 indicated that the agency will respect and safeguard all protected health information about the patients it serves. The policy indicated that patient privacy rights include an adequate notice of the uses and disclosures of protected health information that may be made by Prestigious Health Services Inc.

Based on interview and record review, the hospice agency failed to ensure medications were labelled with the correct patient name for one of seven patients (Patient 1). This failure had the potential to result in a medication error and adverse reaction from the medications. --- A review of Patient 1's Patient Profile indicated a start of care (SOC) date 5/19/2022 with a primary diagnosis of malignant neoplasm (cancerous tumor) of connective and soft tissue (fat, muscle, nerves, blood and lymph vessels and tissues around joints that support and connect all organs and structures of the body) and secondary diagnoses of chronic atrial fibrillation (an irregular and often very rapid heart rhythm [arrhythmia] that can lead to blood clots in the heart) and secondary malignant neoplasm of lung, retroperitoneum (the space behind the abdominal cavity) and peritoneum (the serous membrane that forms the abdominal cavity). A review of Patient 1s Plan of Care (POC)/ Interdisciplinary Group (IDG) Review, dated 5/19/2022, indicated a Hospice Aide (HA) was to visit three times per week and a Skilled Nurse (SN) was to visit three times per week with an additional 3 visits as needed (PRN). The POC/IDG indicated that medications and care plans were reviewed and implemented as directed. A review of Patient 1s Comprehensive Assessment, dated 5/19/2022, indicated RN 2 admitted Patient 1 to Hospice care from Patient 1s home/residence. The assessment indicated that RN 2 provided the patient and family teaching on Patient 1s medications (administration, side effects/contraindications, comfort pack, use and risk of opioids and prescription services). A review of Patient 1s Continuous Care Visit note dated 5/19/2022, indicated at 5:30 pm, the ADM/DPCS provided Family Member (FM 1) with teaching on comfort medications (morphine, Ativan, and Imodium). A review of Patient 1s LVN Visit Note dated 5/23/2022 and 5/25/2022, indicated Comfort Pack and Medications were checked. A review of LVN Visit Note dated 5/27/2022 indicated Patient 1 was transferred from home to a Skilled Nursing Facility (SNF) for respite care. The visit note indicated that medication list was handed to SNF nurse. A review of Patient 1s LVN Visit Note dated 5/30/2022, indicated Comfort Pack and Medications were checked. A review of Patient 1s LVN Visit Note date 5/31/2022, indicated LVN 1 went over medication orders with the AL Medication Technician and confirmed that the durable medical equipment (DME, such as hospital bed, portable oxygen equipment, bedside commode, suction set up) arrived at AL facility. During a concurrent interview and record review on 10/17/2022 at 1:20 pm with the Administrator (ADM)/Director of Patient Care Services (DPCS), Patient 1s HospiceMD (an accessible and secure web-based application used to manage, access and update patient electronic health records) Audit Log and Fax Order/History was reviewed. The Audit log indicated that on 5/19/2022 at 10:17 am, the ADM/DPCS entered Patient 1s last name incorrectly and on 5/19/2022 at 10:30 am the ADM/DPCS entered the correct the spelling of Patient 1s last name. The Fax Order/History indicated that a fax was sent to the Pharmacy at 10:28 am. The ADM/DPCS stated that she had initially entered Patient 1s name incorrectly, made a phone order/read back order to the pharmacy, and then corrected the spelling of Patient 1s last name. The ADM/DPCS stated she did not call back the pharmacy to verify or confirm the corrected spelling of Patient 1s last name. During an interview on 10/17/2022 at 1:40 pm, the ADM/DPCS stated that FM 1 signed for the medications when the Pharmacy delivered to the home. The ADM/DPCS stated she visited the Patient 1 on 5/19/2022 and went over the medications with FM 1. The ADM/DPCS stated she did not remember the name on the medication and that her priority at the time was the instruction. The ADM/DPSC stated she should have performed the five rights of medication administration and checked for the right patient, the right drug, the right dose, the right route, and the right time. During a concurrent interview and record review on 10/17/2022 at 1:45 pm, the Pharmacy delivery log was reviewed and indicated FM 1 signed and received medications on 5/27/2022 and 5/31/2022. The ADM/DPCS stated on 5/27/2022, Patient 1 was admitted to a SNF for respite level of care. The ADM/DPCS stated she notified the Pharmacy to deliver five days worth of medications to the SNF. The ADM/DPCS stated she received a call on 5/31/2022 from LVN 1 during Patient 1s admission to the AL and was notified that the physical medications that were delivered with the patient from the SNF did not match the medications on Patient 1s Medication Profile. The ADM/DPCS instructed LVN 1 to give the medication to FM 1 who was also present at the AL. The ADM/DPCS stated she was not aware of a medication discrepancy until 06/01/2022 after Patient 1 was transferred AL facility. The ADM/DPCS confirmed the medication error on 6/7/2022 during a meeting with SNF and FM 1. During an interview on 10/18/2022 at 12:37 pm, Licensed Vocational Nurse (LVN 1) stated that during SN visits, head-to-toe assessment and vitals were performed. LVN 1 stated that patient medication reviews were performed twice a month. LVN 1 stated during medication review, each medication on the profile from HospiceMD would be matched with the physical bottle on hand. LVN 1 stated that each bottle was checked for the five rights of medication, which included name, medication, dose, time med is to be given. LVN 1 stated she did not remember if Patient 1s medication review was scheduled or performed when the Patient 1 was staying at home. During an interview on 10/18/2022 at 12:50 pm, LVN 1 stated that Patient 1 was admitted to the AL on 5/31/2022. LVN 1 stated she performed medication review with the AL Medication Technician and identified that there were more physical medications that were transferred to the AL from the SNF. LVN 1 stated she notified the ADM/DPCS and was instructed to return the medications to FM 1. LVN 1 stated FM 1 asked her why more medications were given to Patient 1 and ended up taking the medications home. LVN 1 stated she notified the ADM/DPCS of FM 1 concerns. During an interview on 10/18/2022 at 5:25 pm, the Administrator/Director of Patient Care Services (ADM/DPCS) stated that medication review should be performed when the LVNs visit their patients. The ADM/DPCS stated the LVN should do a medication review with the medication list from the hospice, medication list from the SNF, and the physical medications. The ADM/DPCS stated that the five rights of medications (the right patient, the right drug, the right dose, the right route and the right time) should be checked. The ADM/DPCS stated that medication reconciliation is performed when the registered nurse (RN) admits the patient into hospice care. The ADM/DPCS stated if there are discrepancies, to follow up physician or the pharmacy. A review of the hospice agencys policy, Medication Profile, dated 2015, indicated patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. The policy indicated medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. The policy indicated that for accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient's current medications upon the patient's entry to the organization. A comparison of the medications ordered for the patient while under the organization's care will be made to those on the list. The policy further indicated that the admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, route, frequency and a diagnosis, condition, or indication for use for each medication ordered. If the patient is enrolled in Medicare Part D, the nurse will review medications with the patient or their representative and determine the relationship of the medication to the patient's terminal illness and related conditions that contribute to the terminal prognosis. The policy indicated a drug regimen review will be performed at the time of initial and comprehensive assessment. The policy indicated the review will assist in evaluating effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicative therapy and noncompliance issues, omissions and unclear information. The policy indicated that the drug regimen review will be completed by the interdisciplinary group in consultation with an individual with education and training in hospice and palliation drug management to ensure that drugs and biological meet each patient's needs.

Observed in Emergency Management Session. During review of the Emergency Operations Plan, it was noted the organization had not addressed the recovery phase. This was reviewed and discussed by the Administrator and validated.

Observed in HR File Review. In 1 of 11 HR files reviewed, During HR# 10's personnel record review the surveyor noted the documentation of completion of orientation was not available in the personnel record. This was reviewed and validated by Leadership

Observed in Record Review. Review of the Admission packet revealed information regarding advanced directives, however, it did not provide written information about the organization's policies on advanced directives. This was discussed with Leadership and validated.

Observed in Record Review. In 2 of 11 patient records reviewed, During HV# 1 and RR# 2's patient record review, it was noted the organization had not ensured the plan of care had been revised to reflect the changes in patient condition. For example: review of HV# 1's patient record revealed documentation that the patient was having difficulty swallowing and thickened liquid was initiated and suctioning was also initiated. However there were no related/or updated problem, goals or interventions noted on the current plan of care or the previous three updates to the IDG/POC. This was reviewed and discussed with the Administrator and validated. Review of RR# 2's plan of care revealed home health aide visit frequency of 2-3 visits a week. Review of the patient's record revealed the HHA had not completed a visit for approximately four weeks. This was reviewed by the Administrator that shared the HHA was put on hold and a homemaker was sent in for those four weeks. However, review of the patient record and plan of care revealed no documentation regarding the HHA on hold or that a homemaker was now providing services. This was reviewed and validated by the Administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, During review of the patients' records, it was noted the Chaplain had a frequency of one time a month visit and one as needed visit for all of the patient records reviewed. However, none of the patients' plans of care had a goal or interventions. This was reviewed and discussed with the Administrator and validated.

Observed in Record Review. In 6 of 11 patient records reviewed, During HV# 1, HV# 3, RR# 1, RR# 3, RR# 5, and RR# 6's patient records review, it was noted the organization had not ensured a detailed statement of the scope and frequency of services necessary to meet the patient and family needs was included in the plan of care. For example: review of RR# 1's patient record revealed no Skilled Nurse (SN) or Home Health Aide (HHA) visit frequency. Further review of the RR# 1's patient record revealed six SN visits and three HHA visits. Review of HV# 1, HV# 2, RR# 3, RR# 5, and RR# 6's patient record, revealed SN as needed with no indication for the as needed visit. This was reviewed and discussed with the Administrator and validated.

Observed in Patient Home. In 2 of 11 patient records reviewed, During HV# 1 and RR# 7's patient records review it was noted the organization had not ensured the plan of care included all the services needed for the palliation and management of the terminal illness and related conditions. For example: during HV# 1's home observation it was noted the patient was receiving nectar thickened liquids and the a history of staff deep suctioning per conversation with the wife and Administrator. Review of the patient's record revealed documentation the patient was given liquid thickening approximately 50 days prior to the surveyor review of the record. In addition, further review of the patient's record revealed documentation regarding the initiation of suctioning and training of caregiver to suction approximately 42 days prior to the surveyor review of the record. Further review revealed documentation of the licensed vocational nurse (LVN) providing deep suction three times, approximately 37 days prior to the surveyor review of the record and documentation of the LVN providing deep suctioning, approximately 16 days and 13 days prior to the surveyor review of the record. However, review of four updates to the IDG/POC, after the initiation of treatment, revealed no documentation of the patient receiving thickened liquids or suctioning and no documentation of aspiration precautions. This was observed, reviewed, and discussed with the Administrator and validated. Review of RR# 7's patient record revealed documentation on the start of care registered nurse comprehensive assessment that the patient had a mechanical soft diet and at risk for aspiration. Review of the IDG/POC revealed no documentation of aspiration precautions. This was reviewed and discussed with the Administrator and validated.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR# 6's patient record review, it was noted the hospice nurse performed additional visits that were not approved by the interdisciplinary group (IDG). For example: review of the patient plan of care revealed skilled nurse (SN) visits once a week. However, review of the SN visits revealed twice a week SN visits since start of care. this was reviewed and discussed with the Administrator and validated.

Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 1's home observation it was noted the registered nurse (RN) failed to perform hand hygiene consistent with policy. For example: the RN was observed cleaning the vital sign equipment with gloves and with the same gloves placed the vital sign equipment in the nurse bag without completing hand hygiene. This was observed and discussed with the Administrator/DPCS designee and validated.

Observed in Data Session. During the Data Management Session the hospice nurse surveyor noted and it was confirmed by the Administrator that the organization had not developed an Infection Control Plan and there were no documented goals that included limiting unprotected exposure to pathogens. Observed in Data Session. During the Data Management Session the hospice nurse surveyor noted and it was confirmed by the Administrator that the organization had not developed an Infection Control Plan and there were no documented prioritized risk goals. Observed in Data Session. During the Data Management Session the hospice nurse surveyor noted and it was confirmed by the Administrator that the organization had not developed an Infection Control Plan and there were no documented goals that included limiting the spread of infections associated with the use of medical equipment, devices, and supplies. Observed in Data Session. During the Data Management Session the hospice nurse surveyor noted and it was confirmed by the Administrator that the organization had not developed an Infection Control Plan and there were no documented goals that included limiting the spread of infections associated with procedures.

Observed in Record Review. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.60 Infection Control; §418.100 Organization and administration of services; and §418.104 Clinical Records

Observed in Record Review. In 1 of 11 patient records reviewed, During HV# 3's patient record review, it was noted the organization had not ensured the patient record contained responses to medications, symptom management, treatments, and services in the patient record. For example: review of HV# 3's recertification registered nurse (RN) comprehensive assessment, dated approximately 75 days prior to the surveyor review of the record, revealed it had not been completed with missing documentation throughout the assessment. This was reviewed and discussed with the Administrator and validated. Observed in Patient Home. In 1 of 2 home visits conducted with medication review, During HV# 1's home observation it was noted that the record did not contain an accurate medication list. For example: during HV# 1's home observation of medication reconciliation, it was confirmed by the wife that the patient had never been on Risperidone, however it was on the current medication profile. This was observed and reviewed by the Administrator and validated during the visit.

Observed in Record Review. In 1 of 11 patient records reviewed, During HV# 1's patient record review, it was noted the organization had not ensured the physician's initial certification of terminal illness statement was filed in the patient record. This was discussed with Leadership and validated.

Observed in Record Review. In 5 of 11 patient records reviewed, During HV# 2, Hv# 3, RR# 1, RR# 6, and RR# 8's patient record review it was noted the organization had not ensured all entries into the patient record were authenticated to include a signature and title. For example: HV# 3's recertification registered nurse comprehensive assessment date approximately 75 days prior to the surveyor review of the record, revealed no signature or title. Review of RR# 1's initial certificate of terminal illness, dated approximately 13 days prior to the surveyor review of the record, revealed the date of the verbal order, however, there was no signature of the clinician that received the verbal order. Review of HV# 2's patient record revealed a verbal order to admit the patient to hospice with no signature of the clinician that received the order. Review of RR# 6 and RR# 7 revealed home health aide written assignments with no signature of the clinician that developed the written assignment. This was reviewed and discussed with the Administrator and validated.

Observed in Record Review. In 11 of 11 patient records reviewed, During the patient records review, it was noted all patients' electronic medical record (EMR) documentation could be manipulated. For example: Review of RR# 5's patient record revealed a registered nurse (RN) comprehensive assessment signed by the RN five days prior to the date of the documented visit date and start of care. In addition, the oxygen safety assessment and fall risk assessment were signed and dated by the RN eight days prior to the start of care. Further review of the record revealed documentation by the MSW that the initial psychosocial assessment had been completed one day prior to start of care and the initial assessment dated one day after the start of care. Further review of the record revealed a hospice election of benefit dated five days prior to the start of care. This was reviewed and discussed with the Administrator that shared the start of care and the RN comprehensive assessment were actually completed on the date of the election of benefit and the EMR allowed office staff to change the date of documents that were completed and signed in the EMR. Review of RR# 8's patient record, it was noted the organization had not protected health information against unauthorized alteration. For example: review of the electronically signed consents and election of benefit revealed documentation of a handwritten day change of election of benefit. This was reviewed and discussed with the Administrator and validated.

Observed in Patient Home. In 1 of 2 home visits conducted in a nursing facility, During HV# 3's home observation it was noted the organization had not ensured the hospice plan of care identified which provider is responsible for performing the functions that have been agreed upon and included in the plan of care. For example: review of HV# 3's plan of care revealed daily wound care to right lower leg with no indication if provided by nursing facility or hospice. This was reviewed and discussed with the Administrator and validated.