Every finding on record at Sacred Journey Hospice, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by interview and observation. In 3 of 22 (14%) clinical records reviewed and home visits observed, the hospice did not ensure that the patient's drug profile included current medications or that the drug profile was updated at each comprehensive assessment. Clinical Record 1/Home Visit 1: The patient elected hospice care on 12/10/2020. During the home visit on 02/05/2024, a medication reconciliation was completed with the patient's primary caregiver, which revealed these medications documented on the agency's medication profile as active medications were no longer in use: Cephalexin 250mg by mouth 3 times a day for UTI (urinary tract infection) was ordered for the patient on 5/10/2023; Hycodan (with homatropine) 5mg - 1.5mg/5mL take 10mL every 4 hours as needed for cough was ordered on 9/19/2023; and amoxicillin/potassium (pot) clavulanate 875mg/125mg by mouth 2 times a day for upper respiratory vs. aspiration. In an interview, the patient's primary caregiver confirmed the patient was no longer taking this medication. The caregiver stated the patient was taking Macrodantin 50mg by mouth daily and Sertraline 100mg by mouth daily. Clinical Record 3/Home Visit 3: The patient elected hospice care on 06/01/2023 and resided in a skilled nursing facility (SNF). A medication reconciliation was completed with the facility staff on 02/06/2024 during the home visit. The SNF medication list documented: Albuterol Sulfate Inhalation Nebulization Solution (2.5mg/3mL) 0.083% (Albuterol Sulfate) 1 vial inhale orally every 4 hours as needed for wheezing or SOB, effective 10/22/2023; Opcon-A Ophthalmic Solution 0.027-0.315% (Naphazoline w/Pheniramine) instill 1 drop in both eyes as needed for redness, allergies, effective 07/18/2023; and Tussin DM Oral Syrup 10-100mg/5mg (Dextromethorphan-Guaifenesin) Give 10ml by mouth every 4 hours as needed for s/s infection/cough effective 10/24/2023. The hospice medication profile did not include documentation of the medications. During an interview on 02/06/2024, the medication technician confirmed that all the medications on the SNF medication list are active and being given to the patient. Clinical Record 4/Home Visit 4: The patient elected hospice care on 03/15/2023 and resided in a SNF. A medication reconciliation was completed with the facility staff on 02/06/2024 during the home visit. The SNF medication list documented as active: Sertraline HCI Oral 25mg Give 1 tablet by mouth at bedtime for depression effective 4/3/2023. This medication was not documented on the hospice medication profile. During an interview, the SNF staff confirmed that the patient's medications were active and current. During an interview and a review of the medication discrepancies on 2/6/2024, the Clinical Manager stated, "I am not surprised it is hard to keep up with the medications in the facilities."

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The assessment update is completed: as frequently as the condition of the patient requires; [and] no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 22 (5%) clinical records reviewed, the hospice did not ensure the Registered Nurse (RN) completed an update to the comprehensive assessment at least every 15 days. Clinical Record 9: The patient elected hospice care on 03/13/2023 with a diagnosis of senile degeneration of the brain. The RN documented comprehensive assessments in the visit notes dated 01/17/2024 and 02/02/2024, 16 days later. A review of the clinical record revealed that between these visits, the patient was seen by the Licensed Practical Nurse (LPN) and the Hospice Aide; there were no additional RN visits. On 2/6/2024, the Administrator stated, "This is my fault; the RN called in sick, and I sent the LPN; I didn't realize we went over the 15 days."

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 22 (9%) clinical records reviewed, the hospice did not ensure the plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 7: The patient elected hospice care on 07/21/2023 with a diagnosis of Amyotrophic Lateral Sclerosis (ALS). The initial comprehensive assessment completed by the Registered Nurse (RN) on 07/21/2023 documented "Decreasing oral intake due to chewing and swallowing difficulties." The initial certification of terminal illness signed 07/26/2023 documented a diagnosis of dysphagia. The recertification for terminal illness completed by the physician, signed 01/22/2024, documented "Worsening dysphagia...his diet was changed to pureed due to the potential of dysphagia and choking hazard." The plan of care, dated 07/21/2023 to present, did not include documentation of problems, goals, or interventions related to dysphagia, aspiration precautions, or dietary modifications. Clinical Record 15: The patient elected hospice care on 12/21/2023 with a diagnosis of Congestive Heart Failure. The initial comprehensive assessment dated 12/21/2023 documented, "He had a Pleurx drain placed on 12/19/2023 and has required frequent paracentesis for fluid removal in abdomen." The admission notes documented that the Pleurx remained intact at the time of the hospice admission, and "wife states next draining would need to be on Saturday." The plan of care, dated 12/21/2023 through discharge on 01/02/2024, did not include documentation of problems, goals, or interventions related to the ascites or the Pleurx drain. During an interview and a joint record review on 02/07/2024, the Clinical Manager confirmed, "They did not include the dysphagia, diet change, or the Pleurx drain," and the care plan for the patient still on services had been "fixed."

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by interview and observation. In 2 of 22 (9%) clinical records reviewed, the hospice did not ensure that the patient’s plan of care included drugs and treatment necessary to meet the needs of the patient. Clinical Record 3/Home Visit 3: The patient elected hospice care on 06/01/2023 and resided in a skilled nursing facility (SNF). A medication reconciliation was completed with the facility staff on 02/06/2024 during the home visit. The SNF medication list documented: Albuterol Sulfate Inhalation Nebulization Solution (2.5mg/3mL) 0.083% (Albuterol Sulfate) 1 vial inhale orally every 4 hours as needed for wheezing or SOB, effective 10/22/2023; Opcon-A Ophthalmic Solution 0.027-0.315% (Naphazoline w/Pheniramine) instill 1 drop in both eyes as needed for redness, allergies, effective 07/18/2023; and Tussin DM Oral Syrup 10-100mg/5mg (Dextromethorphan-Guaifenesin) Give 10ml by mouth every 4 hours as needed for s/s infection/cough effective 10/24/2023. During an interview on 02/06/2024, the medication technician confirmed that all the medications on the SNF medication list are active and being given to the patient. The hospice plan of care for the benefit period dated 01/27/2024 through 03/26/2024 did not include documentation of the medications. Clinical Record 4/Home Visit 4: The patient elected hospice care on 03/15/2023 and resided in a SNF. A medication reconciliation was completed with the facility staff on 02/06/2024 during the home visit. The SNF medication list documented as active: Sertraline HCI Oral 25mg Give 1 tablet by mouth at bedtime for depression effective 4/3/2023. During an interview, the SNF staff confirmed that the patient's medications were active and current. Sertraline HCI was not documented on the hospice plan of care for the benefit period dated 01/09/2024 through 03/08/2024. During an interview and a review of the medication discrepancies on 2/6/2024, the Clinical Manager stated, "I am not surprised it is hard to keep up with the medications in the facilities."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed in which aide services were accepted, the hospice did not ensure the Registered Nurse (RN) provided the Hospice Aide (HA) specific information to meet the patient's personal care needs. Clinical Record 2: The patient elected hospice care on 12/12/2023 with a diagnosis of Cirrhosis of the Liver. The initial assessment completed by the RN on12/12/2023 documented that the patient was sent home from the hospital on 12/11/2023 with a Pleurx drain in the right upper quadrant. The HA care plan, effective as of 12/12/2023, assigned the HA the relevant tasks of bathing (tub bath), bathing (shower), and skincare. The HA care plan did not alert the HA that the patient had a Pleurx drain in place or instructions on what to do if the dressing was wet or fell off. Clinical Record 15: The patient elected hospice care on 12/21/2023 with a diagnosis of Congestive Heart Failure. The initial nursing assessment completed by the RN on 12/21/2023 documented, "He had a Pleurx drain placed on 12/19/2023 and has required frequent paracentesis for fluid removal in abdomen." The admission notes documented that the Pleurx remained intact at the time of hospice admission, and "wife states next draining would need to be on Saturday." The HA care plan, effective from 12/21/2023 to the patient's discharge on 01/02/2024, assigned the HA the relevant tasks of bathing (bed/bath), skin care (apply lotion), and turn and position in bed. The HA care plan did not alert the aide that the patient had a Pleurx drain in place or instructions on what to do if the dressing was wet or fell off. During an interview on 02/07/2024, the Administrator and Clinical Manager (Personnel Record 3) confirmed that the HA care plans did not address the Pleurx drains. Per the clinical manager, "It makes sense, but we hadn't thought to add them."

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed of patients receiving Hospice Aide services, the hospice did not ensure that the Hospice Aide (HA) provided services included in the care plan. Clinical Record 12: The patient elected the hospice benefit on 06/02/2023 with a diagnosis of Neurocognitive Disorder with Lewy Body. The plan of care dated 11/14/2023 ordered Hospice Aide visits three (3) times a week for one (1) week and five (5) times a week for eight (8) weeks, effective 11/29/2023. The HA care plan written by the RN for the certification period dated 11/29/2023 through 01/27/2024 documented "Shampoo twice a week on Monday and Fridays." The HA documented HA visits on 01/15/2024, 01/16/2024, 01/17/2024, 01/18/2024, and 01/19/2024. The HA documented that a shampoo was completed during all five (5) visits. During an interview and a joint record review on 02/06/2024, the Clinical Manager confirmed that the shampoo was completed on all five (5) visits and should not have been.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed in which Hospice Aide (HA) services were accepted, the hospice did not ensure the HA was supervised by the Registered Nurse (RN) no less frequently than every 14 days. Clinical Record 9: The patient elected hospice care on 03/13/2023 with a diagnosis of senile degeneration of the brain. The HA plan of care dated 01/07/2024 to 03/06/2024 ordered HA services two times per week. HA visits were documented on 01/18/2024, 01/22/2024, 01/25/2024, 01/20/2024, and 02/01/2024. The RN documented HA supervisory visits on 01/17/2024 and 02/02/2024, with 16 days outstanding. During an interview on 02/06/2024, the Administrator confirmed that there were 16 days between RN visits, and thus, the supervisory visit was late.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #6-022.1 "Clinical/Service Data Collection" (last revised 01/15/2021) stated in relevant parts, "4. Entries into the clinical/service record will be legible...13. Errors in documentation will be corrected as follows: Draw a line through the entry, date and initial." In 1 of 22 (5%) clinical records reviewed, the hospice did not ensure that all entries in the patient's record contained legible information. Clinical Record 16: A review of the patient's signed "The Notice of Medicare Non-Coverage" (NOMNC) form revealed the dates were scribbled and written over. In the form section labeled: "The effective date coverage of your current hospice period," the year was written over multiple times, making it illegible. In the form section labeled: "Hospice Services will end on this date," the month and year were crossed out with multiple lines, and the numbers were written over each other, making the date illegible. The form was signed and dated 01/08/2024, with the effective date for hospice services to end identified as 01/21/2024. During an interview and a joint review of the record on 02/06/2024, the Administrator agreed that the corrections made to these dates did not follow the agency policy and made the dates illegible.

Based on staff and family interviews, record reviews including the policy titled "Complaint/Grievance Process", the hospice failed to ensure that the family's complaints were handled based on the agency's policy and with a timely resolution that included follow up notification to the family for two patients (P) (P#1, P#7) of four patients receiving hospice services. Findings include: --- Review of the hospice's policy titled "Complaint /Grievance Process" Policy No. 9-003.1 revealed the following: Procedure: 1. The organization staff member receiving the complaint will discuss, verbally and in writing, the grievance with a supervisor within five (5) days of the alleged grievance. The supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt. 2. If the grievance cannot be resolved to the patient's satisfaction, the patient or his/her representative is to notify, verbally or in writing, the Executive Director/Administrator. The grievance must state the problem or action alleged and the date the supervisor was notified. The Executive Director/Administrator or designee will then investigate the grievance and contact the patient or his/her representative regarding the grievance in an attempt to resolve the differences. The Executive Director/Administrator will respond to the patient within ten (10) days of notification of failure to resolve the complaint. 3. If the patient feels his/her grievance has not been resolved after working with hospice personnel, he/she will be informed of his/her right to notify the state or CHAP via the respective toll-free telephone numbers. 4. Complaints and any action taken will be documented on a complaint form. 1. Clinical record revealed, P#7 was admitted on 2/3/2023 with a diagnosis of malignant neoplasm of brain unspecified (cancer of the brain). A review of the complaint report for the month of February 2023 revealed a complaint dated 2/4/2023, at 12:00 p.m. The complaint revealed that the patient was in pain crisis from the time the patient was admitted (2/3/2023) until the pain medication was provided to the patient which was on 2/4/2023. The complainant stated that the nurse did not order the pain medication at the time of the admission. The complaint report lacks evidence of resolution to this complaint and follow up communication with P#7 family regarding this specific complaint. An office interview was conducted on 3/21/2023 at 10:00 a.m. with the Administrator. The Administrator confirmed RN AA should have initiated an order for the E-Kit (emergency kit contains medications to assist with pain and suffering) at the time of admission. The Administrator revealed that the E-kit was ordered on 2/4/2023. The Administrator revealed that there was no additional documentation regarding this complaint, the follow up notification made to the complainant had not been documented on the clinical record for P#7, and that the agency failed to follow their policy for complaints. 2. Clinical record revealed, P#1 was admitted to hospice on 6/14//2022, with a diagnosis of end stage renal disease (the last stage of long-term (chronic) kidney disease), and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Patient resides in an Assisted Living Facility (ALF). Review of the agencys on-call log revealed the following: On 6/14/2022 at 8:25 p.m., P#1s son called the hospice agency to alert that the facility has not received the medications. P#1 is crying in pain and does not have pain medications. On 6/14/2022 at 8:26 p.m., from the facility stating that pain meds have not arrived, and P#1 is in a lot of pain. On 6/14/2022 at 9:48 p.m., from the facility stating that the pain medication still has not arrived. On 6/14/2022 at 11:33 p.m., the facility called the agency stating that the pain medication still has not arrived and P#1 is in a lot of pain. A review of the complaint report for the month of June 2022 failed to have entries related to P#1 complaint. This complaint was not entered on the Hospice's "Complaint Report". No further documentation was presented to the surveyors. An office interview conducted with the Administrator on 3/21/2023 at 3:00 p.m., revealed that there were no communications or phone calls made to the son of P#1 or the pharmacy to inquire about the status of the medication. The Administrator revealed the complaints received by the son on 6/14/2023 were not documented on the complaint report or handled based on agency complaint policy. Furthermore, the Director stated the follow up (if any) made to the complainant had not been clearly documented. An office interview conducted with the Administrator on 3/22/2023 at 11:20 a.m., revealed that there was no additional complaint related documentation for P#1 and P#7. The complaint for P#1 was not documented on the Complaint report. Administrator further revealed that both complaints for P#1 and P#7 failed to be handled based on agency complaint policies and procedures. A phone interview with the son of P#1 was conducted on 3/23/2023 at 3:45 p.m. Son revealed that P#1 was in a lot of pain for seven hours prior to receiving pain medication. Son also revealed that he notified the agency about his frustration of P#1 not having the pain medications and that no one from the agency called to inquire about the delay in receiving pain medication.

Based on review of clinical records, staff and family interviews, review of the agencys on-call reports, and review of policies and procedures, it was determined that the agency failed to effectively provide appropriate interventions for symptom management: comfort/E- Kit (emergency kit contains medications to assist with pain and suffering) at the end of life for two patients (P) (P#1, P#7) of seven sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7). Findings include: --- Review of policy titled, Comfort Kits- Georgia policy No. 2-005. A.1 dated October 2019, revealed the following: Procedure: 1. At the time of the admission, the hospice nurse performing the admission will contact the patients physician or Hospice Director to obtain orders for specific emergency medications to be supplied in a comfort Kit. This applies to all hospice patient except for residing in the nursing home. 2. The Hospice nurse will request a comfort Kit order and coordinate with the pharmacy. The physician will fax written orders or may e-prescribe drugs in accordance with regulatory requirements. 1. Clinical record review revealed P#7 was admitted on 2/3/2023 with a diagnosis of malignant neoplasm of brain unspecified (cancer of the brain). Review of the complaint log for the month of February 2023 revealed a complaint dated 2/4/2023, at 12:00 p.m. The complaint revealed that the patient was in pain crisis from the time the patient was admitted (2/3/2023) until the pain medication was provided to the patient on 2/4/2023. The complainant stated that the nurse did not order the pain medication at the time of the admission. Admission visit note dated 2/3/2023 at 3:17 p.m., written by Registered Nurse (RN) AA documented P#7 presents lethargic, speech limited to 1-2 words, patient denies pain currently, but son reports patient has chronic back pain. RN AA documents that written information regarding comfort/E- Kit (emergency kit contains medications to assist with pain and suffering) given to family. However, the clinical record for P#7 failed to document interventions made by RN AA to order pain medication (E-Kit) for the patient. Review of the medication profile reveals the E-Kit was ordered on 2/4/2023 at 10:00 a.m. E-Kit medications: Morphine (an analgesic (pain-reliever) used to relieve short-term (acute) or long-term (chronic) moderate to severe pain) concentrate 100mg/5ml (20 mg/ml oral solution) take 0.25 ml (milliliters) every three hours as needed for pain/shortness of breath. Lorazepam (antianxiety agent) 0.5 mg (milligram). Take one tablet every four hour as needed for anxiety or agitation. A visit note dated 2/4/2023 at 11:35 a.m., written by Licensed Practical Nurse (LPN) AA, reveals that patient's son stated patient was up all night with a lot of pain and agitation. Patient's son was upset that patient did not receive E-kit or was offered a stronger pain medication the evening of admission. Visit note additionally reveals LPN AA documented that patient was in pain and LPN AA opened the E-KIT and administered 0.5 ML of Morphine and 0.5 MG of Lorazepam. ";Medication began to work within ten minutes, PT began to relax and actually fall asleep." An office interview conducted with the Administrator on 3/21/2023 at 10:00 a.m., revealed the E-kit was ordered on 2/4/2023 and confirmed RN AA should have initiated and order for the E-kit at the time of admission. 2. Review of clinical record revealed P#1 was admitted to hospice on 6/14//2022 with a diagnosis of end stage renal disease (the last stage of long-term (chronic) kidney disease) and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Patient resides in an Assisted Living Facility (ALF). Review of the agency on-call log revealed the following: On 6/14/2022 at 8:25 p.m., the son of P#1 called the agency to alert that facility has not received the medications, patient is crying in pain, and does not have pain medications. On 6/14/2022 at 8:26 p.m., call received from facility reveals that pain meds have not arrived and P#1 is in a lot of pain. On 6/14/2022 at 9:48 p.m., call from facility reveals that the pain medication still has not arrived. On 6/14/2022 at 11:33 p.m., the facility called the agency stating that pain medication has not arrived and the patient is in a lot of pain. E-KIT medications: Hydromorphone (medication is used to relieve moderate to severe pain) 4 mg oral tablet. Take one tablet sublingually (under the tongue) every 4 hours, for severe pain and shortness of breath. Lorazepam 1 mg. Take 1 tablet sublingually every 4 hours for agitation. Review of admission visit note dated 6/14/2022 at 3:45 p.m., written by Registered Nurse (RN) BB, documented P#1 showing signs of pain. E-KIT ordered, to be delivered from Christian pharmacy. An on-call visit note dated 6/14/2022 at 11:56 p.m., written by Registered Nurse (RN) CC, documented, patient found to be moaning and moving around in bed in supine position, the RN CC documented that the E-Kit was delivered to the wrong building at 9:00 p.m. Upon retrieval of the E-KIT, the RN administered Hydromorphone 4mg sublingually and Lorazepam 1 mg of sublingually to the patient as ordered. A phone interview conducted with RN BB on 3/20/2023 at 1:00 p.m. revealed that the E-Kit was ordered through the physician and through the pharmacy. RN BB reveals that RN called the physician and obtain verbal order for STAT (without delay, immediately) E- Kit, faxed all information to pharmacy and notified the pharmacy as a STAT order. The RN revealed the delivery time for the pharmacy is 2-3 hours. Review of a verbal order dated 6/14/2022 at 4:15 p.m. revealed a STAT E-kit order for P#1. Review of the pharmacy delivery document revealed the E-Kit order was received at 6:15 p.m., and it was delivered at the facility at 9:21 p.m. Additionally, the pharmacy delivery document reveals the E-Kit was received and signed by the facility personnel at 9:21 p.m. A phone interview conducted with pharmacist/owner at Christian pharmacy on 3/21/23 at 10:00 a.m. revealed that the delivery time for STAT orders after 3:00 p.m. is two to three hours. E-Kit order for P#1 was delivered at 9:21 p.m., at the given location of the ALF. An office interview was conducted on 3/21/23 at 3:00p.m, with the Administrator. The Administrator revealed that there were no communication or phone calls made to the son of P#1 or the pharmacy to inquire about the status of the medication. An office interview was conducted on 3/22/23 at 10:00 a.m. with the Administrator. The Administrator revealed that the E-Kit was not provided to P#1 and P#7 in a timely manner. A phone interview conducted with the son of P#1 on 3/23/23 at 3:45 p.m. revealed P#1 was in lots of pain for seven hours prior to receiving pain medication and he notified the hospice nurses about his frustration of P#1 not having the pain medications. Son revealed that no one from the agency called to inquire about the delay in receiving pain medication.

Based on review of clinical records, staff and family interviews, review of the agencys on-call reports, and review of policies and procedures, it was determined the agency failed to ensure medications were readily available to effectively manage pain and symptoms at the end of life for two patients (P) (P#1 and P#7) of four sampled patients (P#1, P#7, P#5, P#6) causing undue pain and suffering at the end of life. Findings include: --- Review of policy titled, Comfort Kits- Georgia policy No. 2-005. A.1 dated October 2019 revealed the following: Procedure: 1. At the time of the admission, the hospice nurse performing the admission will contact the patients physician or Hospice Director to obtain orders for specific emergency medications to be supplied in a comfort Kit. This applies to all hospice patient except for residing in the nursing home. 2. The Hospice nurse will request a comfort Kit order and coordinate with the pharmacy. The physician will fax written orders or may e-prescribe drugs in accordance with regulatory requirements. 1. Review of the clinical record revealed P#7 admitted on 2/3/2023 with a diagnosis of malignant neoplasm of brain unspecified (cancer of the brain). Record review of the complaint log for the month of February 2023 revealed a complaint dated 2/4/2023, at 12:00 p.m. The complaint revealed that the patient was in pain crisis from the time the patient was admitted (2/3/2023) until the pain medication was provided to the patient on 2/4/2023. The complainant revealed that the nurse did not order the pain medication at the time of the admission. Review of the admission visit note dated 2/3/2023 at 3:17 p.m., written by Registered Nurse (RN) AA reveals P#7 presents lethargic, speech limited to 1-2 words, patient denies pain currently, but son reports patient has a chronic back pain. RN AA documents that written information regarding comfort/E- Kit (emergency kit contains medications to assist with pain and suffering) given to family. E-Kit medications: Morphine (narcotic analgesic (pain medicine) concentrate 100mg/5ml (20 mg/ml oral solution). take 0.25 ml every three hours as needed for pain/shortness of breath. Lorazepam (anti-anxiety) 0.5 mg. Take one tablet every four hour as needed for anxiety or agitation. Review of the medication profile reveals an order for the E-Kit on 2/4/2023 at 10:00 a.m. A visit note dated 2/4/2023 at 11:35 a.m., written by Licensed Practical Nurse (LPN) AA, reveals that patient's son stated that patient was up all night with a lot of pain and agitation. Patient's son was upset that patient did not receive E-kit or was offered a stronger pain medication the evening of admission. Visit note additionally reveals LPN AA opened the E-KIT and administered 0.5 ML (milliliter) of Morphine and 0.5 MG (milligram) of Lorazepam. ";Medication began to work within ten minutes, PT began to relax and actually fall asleep." An office interview with the Administrator on 3/21/2023 at 10:00 a.m. revealed E-Kit was ordered on 2/4/2023 and confirmed RN AA should have initiated an order for the E-Kit at the time of admission. 2. Review of clinical record reveals P#1 was admitted to hospice on 6/14//2022 with a diagnosis of end stage renal disease (the last stage of long-term (chronic) kidney disease) and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Patient resides in an Assisted Living Facility (ALF). Review of the agencys on-call log revealed the following: On 6/14/2022 at 8:25 p.m., P#1s son called the hospice agency to alert that the facility has not received the medications. P#1 is crying in pain and does not have pain medications. On 6/14/2022 at 8:26 p.m., from the facility stating that pain meds have not arrived, and P#1 is in a lot of pain. On 6/14/2022 at 9:48 p.m., from the facility stating that the pain medication still has not arrived. On 6/14/2022 at 11:33 p.m., the facility called the agency stating that the pain medication still has not arrived and P#1 is in a lot of pain. Admission visit note dated 6/14/22 at 3:45 p.m., written by Registered Nurse (RN) BB, documented P#1 showing signs of pain. E-KIT ordered, to be delivered from Christian pharmacy. E-KIT medications: Hydromorphone (medication used in the management and treatment of moderate to severe acute pain as well as severe chronic pain) 4 mg oral tablet. Take one tablet sublingually (under the tongue) every 4 hours, for severe pain and shortness of breath. Lorazepam (anti-anxiety) 1 mg. Take 1 tablet sublingually every 4 hours for agitation. Review of a verbal order dated 6/14/22 at 4:15 p.m. revealed a STAT (without delay: immediately) E-kit order for P#1. Review of the pharmacy delivery document revealed the E-Kit order was received at 6:15 p.m., and it was delivered at the facility at 9:21 p.m. Additionally, the pharmacy delivery document reveals the E-Kit was received and signed by the facility personnel at 9:21 p.m. An on-call visit note dated 6/14/222 at 11:56 p.m., written by Registered Nurse (RN) CC, documented patient found to be moaning and moving around in bed in supine position, the RN CC documented that the E-Kit was delivered to the wrong building at 9:00 p.m. Upon retrieval of the E-KIT, the RN administered Hydromorphone 4mg sublingually and Lorazepam 1 mg of sublingually (under the tongue) to the patient as ordered. A phone interview conducted with RN BB on 3/20/2023 at 1:00 p.m. revealed that the E-Kit was ordered through the physician and through the pharmacy. RN BB reveals that RN called the physician and obtain verbal order for STAT E- Kit, faxed all information to pharmacy and notified the pharmacy as a STAT order. The RN revealed the delivery time for the pharmacy is 2-3 hours. A phone interview conducted with pharmacist/owner at Christian pharmacy on 3/21/23 at 10:00 a.m. revealed that the delivery time for STAT orders after 3:00 p.m. is two to three hours. E-Kit order for P#1 was delivered at 9:21 p.m., at the given location of the ALF. An office interview was conducted on 3/21/23 at 3:00p.m, with the Administrator. The Administrator revealed that there were no communication or phone calls made to the son of P#1 or the pharmacy to inquire about the status of the medication. An office interview was conducted on 3/22/23 at 10:00 a.m. with the Administrator. The Administrator revealed that the E-Kit was not provided to P#1 and P#7 in a timely manner. A phone interview conducted with the son of P#1 on 3/23/23 at 3:45 p.m. revealed P#1 was in a lot of pain for seven hours prior to receiving pain medication and he notified the hospice nurses about his frustration of P#1 not having the pain medications. Son revealed that no one from the agency called to inquire about the delay in receiving pain medication

Based on clinical record review, staff interviews, review of the agencys on-call reports, and review of policies and procedures, it was determined the agency failed to maintain a system of communication and integration in accordance with the hospice's own policies and procedures and to provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings directly or under arrangements for one patient (P) (P#1) of seven sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7). Findings include: --- Review of policy titled, Comfort Kits- Georgia policy No. 2-005.A.1 dated October 2019, revealed: Procedure: 1. At the time of the admission, the hospice nurse performing the admission will contact the patients physician or Hospice Director to obtain orders for specific emergency medications to be supplied in a comfort Kit. This applies to all hospice patient except for residing in the nursing home. 2. The Hospice nurse will request a comfort Kit order and coordinate with the pharmacy. The physician will fax written orders or may e-prescribe drugs in accordance with regulatory requirements. Clinical record review revealed P#1 was admitted to hospice on 6/14//2022 with a diagnosis of end stage renal disease and congestive heart failure. Patient resides in an Assisted Living Facility (ALF). Review of the agencys on-call log revealed the following: On 6/14/2022 at 8:25 p.m., P#1s son called the hospice agency to alert that the facility has not received the medications. P#1 is crying in pain and does not have pain medications. On 6/14/2022 at 8:26 p.m., from the facility stating that pain meds have not arrived, and P#1 is in a lot of pain. On 6/14/2022 at 9:48 p.m., from the facility stating that the pain medication still has not arrived. On 6/14/2022 at 11:33 p.m., the facility called the agency stating that the pain medication still has not arrived and P#1 is in a lot of pain. Admission visit note dated 6/14/22 at 3:45 p.m., written by Registered Nurse (RN) BB, documented P#1 showing signs of pain. E-KIT (emergency kit contains medications to assist with pain and suffering) ordered, to be delivered from Christian pharmacy. An interview was conducted on 3/20/2023 at 1:00 p.m. with RN BB, who stated that the E-Kit was ordered through the physician and through the pharmacy. RN BB stated that RN called the physician and obtain verbal order for STAT (without delay, immediately) E- Kit and faxed all information to pharmacy and notified the pharmacy as a STAT order. The RN stated the delivery time for the pharmacy is two to three hours. Review of the pharmacy delivery document revealed the E-Kit order was received at 6:15 p.m., and it was delivered at the facility at 9:21 p.m. and received and signed by the facility personnel at 9:21 p.m. A phone interview was conducted on 3/21/23 at 10:00 a.m. with the pharmacist/owner at Christian pharmacy. Pharmacist stated that the delivery time for STAT orders after 3:00 p.m. is two to three hours. E-Kit order for P#1 was delivered at 9:21 p.m., at the given location of the ALF. An office interview was conducted on 3/21/23 at 3:00p.m., with the Administrator. The Administrator revealed that there was no communication or phone calls made to the ALF, pharmacy, and patient's son to inquire about the status of the E-KIT.

Based on record review, staff interview and review of Agency contracts, it was determined the hospice failed to establish a contractual agreement for pharmacy related services which addressed the hospice's professional management responsibilities, authorization of services, safety and provision of services by qualified staff, and delivery of arranged service for seven of seven sampled patients. Findings include: --- During an office interview with the Administrator on March 20, 2023, at 2:00 p.m., the Administrator revealed that the agency utilizes Christian pharmacy and Bowden pharmacy for all pharmacy related supplies but does not have written agreement/contracts with these specific pharmacies. The Administrator stated that the agency has a contract with Enclara, a PBM (Pharmacy Benefit Management) company, who manages all claims and billing for the pharmacy related supplies. During a phone interview on March 21, 2023, at 11:15 a.m., with the Pharmacist/owner from Christian Pharmacy, the Pharmacist revealed that they do not have a written contract with Sacred Journey Hospice. During a phone interview on March 21, 2023, at 12:30 p.m., with an account representative from Enclara, revealed that the contract with Sacred Journey Hospice is used for claims and billing purposes and Enclara does not dispense any pharmacy related supplies to hospice patients. According to Enclara, the agency can use any pharmacy of their choice to provide services to their patients. This surveyor was unable to determine that the agency ensures a written agreement for pharmacy services where supplies/medications are furnished in a safe and effective manner by qualified personnel and delivered in accordance with the patient plan of care. During the survey, the agency failed to provide a contractual agreement for pharmacy services.