Every finding on record at Seasons Hospice & Palliative Care of Georgia, LLC

Based on a review of policy titled "On-Call Weekend Services policy,  policy titled   "Interdisciplinary Group (IDG) Meeting",  policy titled “Pain Assessment and Management “ ,  policy titled “ComfortPak Assessment , ordering and Usage”,  review of clinical records and staff and family  interviews, it was determined that hospice failed to protect and promote the exercise of patient's rights as evidenced  by not following physician's order  and  effectively provide appropriate interventions for pain and  symptom management at the end of life for three Patients(P) (P#1, P#2 and P#3) of four  sample patients.Findings include: --- Review of Policy titled "On-Call Weekend Services revised date of 11/8/2024 revealed:(1) The Hospice shall have a system to make available nursing services 24-hours a day, seven days a week to meet the needs of the patients.(a) A registered nurse must be available at all times to provide or supervise the provision of nursing care.(b) On-site nursing services must be made available within one hour of notification where terminally ill patient and patient with an advanced and progressive disease who has contracted for nursing services, experiences a symptom management crisis situation.Review of policy titled "Interdisciplinary Group (IDG) Meeting" revised April 2022, revealed the following:The Interdisciplinary Group Meeting will meet regularly to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths, change in patient and family /caregiver circumstances.Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less than every 15 days or more often if the patient's condition requires.Procedure:3. Level of services will be reviewed for new and ongoing patients based on hospice team assessments. The group will approve recommendations for a change in the level of care. 4. The patient's care plan will be updated no less frequently than every 15 days or more often if the patient's condition requires. 6. An IDG meeting plan of care update form will be used to update the patient, family /caregiver and the attending physician. It will note the changes, response to treatment, and progress toward targeted outcomes, which may include:A. Pharmacotherapeutic effectiveness of symptom management outcomes.B. Increase or decrease in the frequency of visits by team members and reason for changes. H. Plan for changes in treatments or proceduresReview of Policy titled “Pain Assessment and Management with revision date 11/2022 revealed the following:Pain Management:1.     Patient will be monitored for response to current pain management regime, including the frequency and dosage of pain medication.2.     The hospice nurse will contact the physician for pain that is unacceptable to the patient; to receive further physician orders and adjustments to the plan of care. 5.    The patient will be evaluated for psychosocial /spiritual needs and interventions required to optimize patient comfort.8.    The patient /family goals for pain management and their satisfaction with the current level of pain control shall be assessed and documented. If not satisfied with the efforts to achieve the necessary, level of pain management the medical record shall reflect all efforts to educate the patient /family on interventions ordered by the physician or allowed practitioner including complementary and alternative medicine (CAM) services or short-term inpatient care for symptom management. Review of policy titled “ComfortPak Assessment Ordering and Usage”, revised September 2023, revealed the following:4. If the patient is symptomatic upon admission or becomes symptomatic before the Comfort Pak (CP) arrives at the patient's residence, the nurse and/or prescriber will contact a local pharmacy to provide the necessary medications to manage the patient's symptoms. 5. The CP will be delivered to the patient's residence by the pharmacy vendor's national courier in a sealed container and the patient/caregiver must store it as directed. 1.Review of record review for P#1 revealed that patient was admitted to hospice on 3/13/25.Review of document titled “Visit Note Report,” dated 3/15/25, revealed Registered Nurse (RN) CC documents the following under pain assessment: “patient has total pain score of 8, nosiy (sic) labored breathing, crying, facial grimacing, body language is tense.”Review of client medication report revealed the following: Morphine concentrate 100 mg/5 ML (20 MG/ML) oral solution ;0.25 ML for pain and dyspnea with start date 3/14/25. Morphine concentrate 100 mg/5 ML (20 MG/ML) oral solution; .5 ml for pain and dyspnea, start date 3/16/25. Review of the document, “SHPC of GA DBA Accentcare,” from the contract pharmacy revealed Comfort Pak, which did not include Roxanol (opioid pain medication) and Lorazepam (a narcotic primarily used to treat anxiety) for P#1 ordered 3/14/25 7:30 p.m., was delivered to P#1 on 3/17/25 at 5:17 p.m. Roxanol and Lorazepam dispensed locally (local Pharmacy) on 3/15/25. On 5/12/25 at approximately 2:00 pm, an interview was conducted with the Interim Director Executive of Operations (DEO), and Interim Director of Clinical Operations (DOC) who revealed that the agency did have issues with providing Comfort Pak / pain medications to patients in a timely manner. DEO revealed that the agency also utilizes a contracted courier company to deliver the medications. Interim DOC revealed that the courier company was not used to deliver the ComfortPak as ordered.   On 5/14/25, at 8:10 a.m., a phone interview was conducted with P#1’s family member who revealed a call was made on 3/14/25, by this family member to the agency to inquire about the Comfort Pak.  Family member further reported on 3/15/25, RNCC arrived at the patient home and advised family member that the medications (ComfortPak) were not entered in the system, due to new program, thus medications were not ordered.  Family member stated that on 3/15/25 at 7.00 p.m., she went to the local pharmacy and picked up “Morphine”. Family member of P#1 did not recall any other mediation that she picked up from the pharmacy that evening.  Family member of P#1 revealed that the morphine helped a bit, but the patient was still agitated and gurgling with secretions.  Family member of P#1 stated that the patient was in pain all day on 3/13, 3/14 and 3/15. The patient was moaning and groaning; it was very painful to watch patient go through such suffering.  The family member of P#1 stated that the patient passed away on 3/17 at 4:47 a.m.  and the RNCC arrived at 6:47 a.m. to pronounce patient. Family member of P#1 further stated that it was a traumatic experience for the patient and family.  Family member of P#1 reported that she spoke with the Social Worker (SW) two weeks after the patient passed and SW advised family member that someone from the office will call her.  Family member of P#1 revealed no one has called her or the family back.2.Review of clinical record for P#2 revealed that patient was admitted to hospice on 4/29/25 with diagnosis of Congestive Heart Failure with preserved Ejection Fraction (heart is not able to pump blood), Hypercapnia (too much carbon dioxide in the blood), right pleural effusion (collection of fluid around the lungs). Pt has right side (Pleurex) (chest tube placement to drain fluids from the lungs). Review of Client Coordination Note report dated 5/1/25 for P#2 reads as follows:"Before getting fluid removed from patient, I noticed the patient’s blood pressure was low at 92/50, and the apical pulse very thready at 52. I explained to the family member of P#2 if I pulled out fluids from her lung with low pressure and weak apical pulse, there is a possibility that she might die. Explain to her the best plan is to sedate patient and keep patient sedated or comfortable. I called the DCO to help me get a nearby pharmacist. I didn’t get a response from the DCO, so I called the contracted pharmacy to assist me in getting a nearby pharmacy store to get the comfort medications. The contracted pharmacy team called 10 nearby pharmacy stores and were not able to find the store. Finally, I order the comfort medication through the contracted pharmacy for tomorrow’s delivery."Review of complaint report dated 5/2/25 for P#2 reads as follows: Family member of P#2 called to report that family has decided to transfer patient to a different hospice. Family member reported that the family has little faith that Accent Care can take care of patient and family appropriately. Apologized and asked him if he is willing to explain more. Stated “we do not have comfort meds yet”. No disposable supplies, we called because the concentrator wasn’t working, and triage said patient not in the system”. Apologized again and explained that is not the kind of care Accent Care wants to provide and explained I understand the reasons for transfer and apologized again. On 5/13/25 at approximately 10:00 a.m., a phone interview was conducted with DOC, who revealed that "the family was set in their mind to go with another agency."3. Review of clinical record revealed that P#3 was admitted on 1/16/25. Review of nurse visit note for P#3 dated 2/12/25, at approximately 12:00 p.m., RNAA documents:The reason for visit – Patient care due to unexpected status change- Patient’s pulse – 55, Respirations- 32, Blood pressure 50/32-Lorazepam 0.5 MG given with applesauce at 12:29 p.m.Review of the document titled, “Visit Note Report,” dated 2/12/25 at 1:57 p.m., the aide documents: “Pt is transitioning, in a lot of pain, called RN AA. Total In-home time 50 minutes.”Review of death visit note dated 2/12/25, RNBB documents time of death reported by facility staff 8:57 p.m.Review of P#3 complaint report dated 2/12/25, revealed the following:Regional After-Hours Administrator (RAHA) took call from a facility staff at 1927 CST. Facility staff reports many concerns with Accent Care’s responsiveness today. Facility staff states P#3 was in distress, and they called this morning. States RNAA showed up in the afternoon, gave Lorazepam and left. Now, she states patient has died and an hour later, she does not have an ETA (estimated time of arrival), and no one has pronounced. RAHA advised that she would work on obtaining an ETA. Writer spoke to RAHA who has been working on staffing this death visit and will return the call. Review of client coordination note report dated 2/12/25, (no time documented of call) for P#3, reads as follows:Reason for call: called in the morning to notify Accent Care patient is not doing well and requesting visit. Med tech said they were going to send someone back to sit with patient. She stated no one came in to be with the patient. A nurse arrived today around noon. Clinical records for P#3 failed to reveal physician was notified of patient’s decline in condition, failed to reveal revised care plans to meet patients’ current assessment and/or change in patients’ condition. Clinical records lack evidence of coordination/communication with MD and other clinical staff of patient's current status. Clinical record lacks evidence that a nurse was made available to P#3 who was in symptom management crisis.On 5/14/25 approximately at 12:29 p.m., an interview was conducted with the Director of Executive Operations (DEO), who revealed that the hospice agency was experiencing a shortage of nursing staff. The nurse assigned to patient P#3 was from a contracted agency that failed to fulfill the terms of the contractual agreement with the hospice agency. DEO confirmed that the agency failed to provide the complete Comfort Pak for P#1 and P#2. DEO confirmed that the agency failed to follow the pain management policy to ensure that patient was provided with pain medications at the time of need and a nurse was made available for P#3.

Based on record reviews and staff and family interviews, it was determined that the agency failed to effectively manage the patient's pain and symptoms related to the terminal illness in a timely manner. Specifically, the agency failed to provide Comfort Paks (emergency medication kits) as ordered by the physician in a timely manner for three patients (P) (P#1, P#2, and P#3) of the four patients sampled. --- Findings include: 1.     Review of record for P#1 revealed that patient was admitted to hospice on 3/13/25.  Review of document titled “Visit Note Report,” dated 3/15/25, revealed Registered Nurse (RN) CC documents the following under pain assessment: “patient has total pain score of 8, nosiy (sic) labored breathing, crying, facial grimacing, body language is tense.” Review of the document, “SHPC of GA DBA Accentcare,” from the contract pharmacy revealed Comfort Pak, which did not include Roxanol (opioid pain medication) and Lorazepam (a narcotic primarily used to treat anxiety) for P#1 ordered 3/14/25 7:30 p.m., was delivered to P#1 on 3/17/25 at 5:17 p.m. Roxanol and Lorazepam dispensed locally (local Pharmacy) on 3/15/25.  On 5/12/25, at approximately 2:00 p.m., an interview was conducted with the Interim Director Executive of Operations (DEO), and Interim Director of Clinical Operations (DOC) who revealed that the agency did have issues with providing Comfort Paks to patients in a timely manner. On 5/14/25, at 8:10 a.m., a phone interview was conducted with P#1’s family member who revealed P#1 had been in pain since 3/12/25 and was admitted to hospice care on 3/13/25. Family member reported that the Comfort Pak was on ordered on 3/13/25 and family member was advised that they would receive the Comfort Pak on 3/14/24.  A call was made on 3/14/25, by this family member to the agency to inquire about the Comfort Pak that was not delivered that day. The family member further reported on 3/15/25, RN CC arrived at the patient home and advised family member that the medications (Comfort Pak) were not entered in the system, due to new program, thus medications were not ordered. Family member of P#1 explained that at 7.00 p.m., she went to the local pharmacy and picked up “Morphine”. Family member of P#1 revealed that the morphine helped a bit, but the patient was still agitated and gurgling with secretions. Family member of P#1 explained that the patient was in pain all day on 3/13/25, 3/14/25 and 3/15/25. The patient was moaning and groaning; it was very painful to watch patient go through such suffering. The family member of P#1 explained that the patient passed away on 3/17 at 4:47 a.m. and the RN CC arrived at 6:47 a.m. to pronounce patient. Family member of P#1 further explained that it was a traumatic experience for the patient and family.  Family member of P#1 reported that she spoke with the agency Social Worker (SW) two weeks after the patient passed and SW advised family member that someone from the office will call her.  Family member of P#1 revealed no one has called her or the family back.   On 5/14/25, at 3:30 p.m., a phone interview was conducted with the local pharmacy pharmacist, who revealed the family member of P#1 picked up Morphine and Lorazepam on 3/15/25 at 7:00 p.m. The agency failed to provide the complete Comfort Pak for P#1 when symptoms of oral secretions, agitation, and increase pain occurred at the end of life.  2.     Review of clinical record for Patient (P)#2 revealed that patient was admitted to hospice on 4/29/25. Review of the document titled, “Client Coordination Note Report,” dated 5/1/25 for P#2 reads as follows: “Before getting to removed fluids from patient, I notice patient blood pressure low at 92/50, apical pulse (the pulse felt on the chest) very thready at 52. I explained to the family member of P#2 if I pulled out fluids from her lung with low pressure and weak apical pulse that there is a possibility that she might die. (sic) Explain to her the best plan is to be sedated and keep her sedated or comfortable. I called the DCO to help me getting a nearby pharmacist. I didn’t get a response from the DCO, so I called the contacted pharmacy to assist me in getting a nearby pharmacy store for the comfort medications. The contracted pharmacy team called 10 nearby pharmacy stores and were not able to find a store. Finally, I order the comfort medication through the contracted pharmacy for tomorrow’s delivery.” Review of a complaint report dated 5/2/25 for P#2 reads as follows: “Family member of P#2 called to report that family has decided to transfer patient to a different hospice. Family member reported that the family has little faith that Accent Care can take care of patient and family appropriately. Apologized and asked him if he was willing to explain more. Explained, “we do not have comfort meds yet.”” On 5/13/25 at approximately 10:00 a.m., a phone interview was conducted with DOC, who revealed that “the family was set in their mind to go with another agency.”  3.     Review of clinical record revealed that Patient (P)#3 was admitted on 1/16/25. Review of the document titled, “Visit Note Report,” for P#3 dated 2/12/25, at approximately 12:00 p.m., RN AA documents: “The reason for visit – Patient care due to unexpected status change Patient’s pulse – 55, Respirations- 32, Blood pressure 50/32 Lorazepam 0.5 MG given with applesauce at 12:29 p.m.” Review of the document titled, “Visit Note Report,” dated 2/12/25 at 1:57 p.m., the aide documents: “Pt is transitioning, in a lot of pain, called RN AA. Total In-home time 50 minutes.” Review of the document titled, “Visit Note Report,” dated 2/12/25, RN BB documents time of death reported by facility staff as 8:57 p.m. Review of P#3’s complaint report dated 2/12/25, revealed the following: Regional After-Hours Administrator (RAHA) took call from a facility staff at 1927 CST. “Facility staff reports many concerns with Accent Care’s responsiveness today. Facility staff states P#3 was in distress, and they called this morning. States RN AA showed up in the afternoon, gave Lorazepam and left. Now, she states patient has died and an hour later, she does not have an estimated time of arrival (ETA), and no one has pronounced. RAHA advised that she would work on obtaining an ETA.” Writer spoke to RAHA, who has been working on staffing this death visit and will return the call.  Review of the document titled, “Client Coordination Note Report,” dated 2/12/25, (no time documented of call) for P#3, reads as follows: Reason for call: “called in the morning to notify Accent Care patient is not doing well and requesting visit. Med tech said they were going to send someone back to sit with the patient. She explained that no one came in to be with the patient. A nurse arrived today around noon.” On 5/14/25 approximately at 12:29 p.m., an interview was conducted with the Director of Executive Operations (DEO), who revealed that the hospice agency was experiencing a shortage of nursing staff. The nurse assigned to patient P#3, RN AA, was from a contracted agency that failed to fulfill the terms of the contractual agreement with the hospice agency, no interview obtained with RN AA.

Based on record reviews, and staff interviews, it was determined the hospice failed to ensure the plan of care included interventions to manage pain and symptoms for two patients (P) (P#1 and P#2) of four sample patients.Findings include: --- 1.Review of document titled “Hospice Certification and Plan of Care” Effective 3/13/25, the Plan of Care (POC) revealed that P#1 was admitted to hospice on 3/13/25 with the diagnosis of Acute systolic congestive heart failure (heart can’t pump blood well enough to meet body’s needs). and chronic respiratory failure with hypoxia (condition that occurs when lungs can't remove enough carbon dioxide or take in enough oxygen).Further review of the POC revealed the POC failed to reveal interventions to manage pain or respiratory distress.2. Review of document titled “Hospice Certification and Plan of Care” Effective 4/29/25, the Plan of Care (POC) revealed that P#2 was admitted to hospice on 4/29/25 with the diagnosis of hypertensive heart disease with heart failure( when high blood pressure  prevents the heart from pumping blood effectively) and end stage heart failure(when the heart cannot pump enough blood to meet the body’s needs) and pleural effusion ( collection of fluid around your lungs). Further review of the POC revealed the POC failed to reveal interventions to manage pain or respiratory distress and heart failure.On 5/12/25, at approximately 1:30 p.m., an interview was conducted with Interim Director of Clinical Operations, (DCO) and Interim Director Executive of Operations (DEO), who revealed that physical assessment includes pain assessments.

Based on  review of policy titled "On-Call Weekend Services, policy titled “Interdisciplinary Group Meeting",  policy titled “ComfortPak Assessment Ordering and Usage”, clinical record reviews and, staff and family interviews, it was determined the agency failed to organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions for patients as evidenced by agency’s failure to provide and manage appropriate end of life care for three patient (P) (P#1,P#2 and P#3) of four sampled patients.Findings include: --- Review of policy titled "On-Call Weekend Services revised date of 11/8/2024 reveals:(1) The Hospice shall have a system to make available nursing services 24-hours a day, seven days a week to meet the needs of the patients.(a) A registered nurse must be available at all times to provide or supervise the provision of nursing care.(b) On-site nursing services must be made available within one hour of notification where terminally ill patient and patient with an advanced and progressive disease who has contracted for nursing services, experiences a symptom management crisis situation.Review of policy titled "Interdisciplinary Group (IDG) Meeting" revised April 2022, reveals the following:The Interdisciplinary Group Meeting will meet regularly to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths, change in patient and family /caregiver circumstances.Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less than every 15 days or more often if the patient's condition requires.Procedure:3. Level of services will be reviewed for new and ongoing patients based on hospice team assessments. The group will approve recommendations for a change in the level of care. 4. The patient's care plan will be updated no less frequently than every 15 days or more often if the patient's condition requires. 6. An IDG meeting plan of care update form will be used to update the patient, family /caregiver and the attending physician. It will note the changes, response to treatment, and progress toward targeted outcomes, which may include:A. Pharmacotherapeutic effectiveness of symptom management outcomes.B. Increase or decrease in the frequency of visits by team members and reason for changes. H. Plan for changes in treatments or procedures. Review of policy titled “ComfortPak Assessment Ordering and Usage”, revised September 2023, reveals the following:4. If the patient is symptomatic upon admission or becomes symptomatic before the Comfort Pak (CP) arrives at the patient's residence, the nurse and/or prescriber will contact a local pharmacy to provide the necessary medications to manage the patient's symptoms. 5. The CP will be delivered to the patient's residence by the pharmacy vendor's national courier in a sealed container and the patient/caregiver must store it as directed.1.Record review for P#1 revealed that patient was admitted to hospice on 3/13/25. Review of nurse visit note dated 3/15/25, nurse documents the following under pain assessment: patient has pain score of 8, noisy labored breathing, crying, facial grimacing, body language, and tense. Review of client medication report revealed the following: Morphine concentrate 100 mg/5 ML (20 MG/ML) oral solution ;0.25 ML for pain and dyspnea (difficulty breathing) with start date 3/14/25.  Morphine concentrate 100 mg/5 ML (20 MG/ML) oral solution; .5 ml for pain and dyspnea, start date 3/16/25. Review of medication tracker from contract pharmacy revealed ComfortPak meds (minus Roxanol & Lorazepam) for P#1 ordered 3/14/25 7:30 p.m., was delivered to P#1 on 3/17/25 at 5:17p.m. Roxanol and Lorazepam dispensed locally (local Pharmacy) on 3/15/25 at 7:00 p.m.On 5/14/25, at 8:10 a.m., a phone interview was conducted with P#1’s family member who revealed a call was made on 3/14/25, by this family member to the agency to inquire about the ComfortPak. Family member further reported on 3/15/25, RNCC arrived at the patient’s home and advised family member that the medications (ComfortPak) were not entered in the system, due to new program, thus medications were not ordered. Family member of P#1 revealed that at 7:00p.m., family member went to a local pharmacy and received morphine.   Family member stated that morphine helped a bit, but the patient was still agitated and gurgling with secretions.The family member of P#1 stated that the patient passed away on 3/17 at 4:47 a.m. and the RNCC arrived at 6:47 a.m. to pronounce patient.An interview was conducted on 5/12/25 at approximately 2:00 pm, with the Interim Director Executive of Operations (DEO), Interim Director of Clinical Operations (DOC) who revealed that the agency did have issues with providing Comfort Pak / pain medications to patients in a timely manner.2. Review of clinical record for P#2 revealed that patient was admitted to hospice on 4/29/25, with diagnosis Congestive Heart Failure with preserved Ejection Fraction (HPEF), (heart is unable to pump blood), Hypercapnia (too much carbon dioxide in your blood), chronic right pleural effusion (collection of fluid around your lung). Pt has right side (Pleurex) (chest tube placement to drain fluid). Review of Client Coordination Note report dated 5/1/25 for P#2 reads as follows:Before getting fluid removed from patient, I noticed the patient’s blood pressure was low at 92/50, and the apical pulse very thready at 52. I explained to the family member of P#2 if I pulled out fluids from her lung with low pressure and weak apical pulse that there is a possibility that she might die. Explain to her the best plan is to sedate patient and keep patient sedated or comfortable. I called the DCO to help me get a nearby pharmacist. I didn’t get a response from the DCO, so I called the contracted pharmacy to assist me in getting a nearby pharmacy store to get the comfort medications. The contracted pharmacy team called 10 nearby pharmacy stores and were not able to find the store. Finally, I order the comfort medication through the contracted pharmacy for tomorrow’s delivery. Review of complaint report dated 5/2/25 for P#2 reads as follows: Family member of P#2 called to report that family has decided to transfer patient to a different hospice. Family member reported that the family has little faith that Accent Care can take care of patient and family appropriately. Apologized and asked him if he is willing to explain more. Stated “we do not have comfort meds yet”. No disposable supplies, we called because the concentrator wasn’t working, and triage said patient not in the system”. Apologized again and explained that is not the kind of care Accent Care wants to provide and explained I understand the reasons for transfer and apologized again. On 5/13/25 at approximately 10:00 a.m., a phone interview was conducted with DOC, who revealed that the family was set in their mind to go with another agency.3. Review of clinical record revealed that P#3 was admitted on 1/16/25.  Review of nurse visit note for P#3 dated 2/12/25, at approximately 12:00 p.m., RNAA documents:The reason for visit – Patient care due to unexpected status changePatient’s pulse – 55, Respirations- 32, Blood pressure 50/32Lorazepam 0.5 MG given with applesauce at 12:29 p.m.Review of the nurse visit note total In -home time 1 hour and 33 minutes. Review of aide visit note dated 2/12/25 at 1:57 p.m., the aide documents: Pt is transitioning, in a lot of pain, called RNAA.Total In-home time 50 minutes. Review of death visit note dated 2/12/25, RNBB documents time of death reported by facility staff 8:57 p.m.Review of P#3 complaint report dated 2/12/25, revealed the following:Regional After-Hours Administrator (RAHA) took call from a facility staff at 1927 CST. Facility staff reports many concerns with Accent Care’s responsiveness today. Facility staff states P#3 was in distress, and they called this morning. States RNAA showed up in the afternoon, gave Lorazepam and left. Now, she states patient has died and an hour later, she does not have an ETA (estimated time of arrival), and no one has pronounced. RAHA advised that she would work on obtaining an ETA. Writer spoke to RAHA who has been working on staffing this death visit and will return the call. Review of client coordination note report dated 2/12/25, (no time documented of call) for P#3, reads as follows:Reason for call: called in the morning to notify Accent Care patient is not doing well and requesting visit. Med tech said they were going to send someone back to sit with patient. She stated no one came in to be with the patient. A nurse arrived today around noon. On 5/14/25 approximately at 12:29 p.m., an interview was conducted with the Director of Executive Operations (DEO), who revealed that the hospice agency was experiencing a shortage of nursing staff. The nurse assigned to patient P#3 was from a contracted agency that failed to fulfill the terms of the contractual agreement with the hospice agency. The DEO confirmed that the agency failed to meet the needs of P#1, P#2, and P#3, and failed to follow their policies and procedures in providing appropriate patient care.

Based on review of policy titled "On-Call weekend services" , record reviews, and staff interviews, it was determined that the agency failed to provide On-site nursing services within one hour of notification where the terminally ill patient and the patient with an advanced and progressive disease who has contracted for nursing services experiences a symptom-management crisis situation for one Patient P (P#3) of four sample patients.Findings include: --- Policy titled "On-Call Weekend Services revised date of 11/8/2024 reveals:(1) The Hospice shall have a system to make available nursing services 24-hours a day, seven days a week to meet the needs of the patients.(a) A registered nurse must be available at all times to provide or supervise the provision of nursing care.(b) On-site nursing services must be made available within one hour of notification where terminally ill patient and patient with an advanced and progressive disease who has contracted for nursing services, experiences a symptom management crisis situation.Review of clinical record revealed that Patient (P)#3 was admitted on 1/16/25. Review of the document titled, “Visit Note Report,” for P#3 dated 2/12/25, at approximately 12:00 p.m., RN AA documents: “The reason for visit – Patient care due to unexpected status change Patient’s pulse – 55, Respirations- 32, Blood pressure 50/32 Lorazepam 0.5 MG given with applesauce at 12:29 p.m.” Review of the document titled, “Visit Note Report,” dated 2/12/25 at 1:57 p.m., the aide documents: “Pt is transitioning, in a lot of pain, called RN AA. Total In-home time 50 minutes.” Review of the document titled, “Visit Note Report,” dated 2/12/25, RN BB documents time of death reported by facility staff as 8:57 p.m. Review of P#3’s complaint report dated 2/12/25, revealed the following: Regional After-Hours Administrator (RAHA) took call from a facility staff at 1927 CST. “Facility staff reports many concerns with Accent Care’s responsiveness today. Facility staff states P#3 was in distress, and they called this morning. States RN AA showed up in the afternoon, gave Lorazepam and left. Now, she states patient has died and an hour later, she does not have an estimated time of arrival (ETA), and no one has pronounced. RAHA advised that she would work on obtaining an ETA.” Writer spoke to RAHA, who has been working on staffing this death visit and will return the call.  Review of the document titled, “Client Coordination Note Report,” dated 2/12/25, (no time documented of call) for P#3, reads as follows: Reason for call: “called in the morning to notify Accent Care patient is not doing well and requesting visit. Med tech said they were going to send someone back to sit with the patient. She explained that no one came in to be with the patient. A nurse arrived today around noon.” On 5/14/25 approximately at 12:29 p.m., an interview was conducted with the Director of Executive Operations (DEO), who revealed that the hospice agency was experiencing a shortage of nursing staff. The nurse assigned to patient P#3, RN AA, was from a contracted agency that failed to fulfill the terms of the contractual agreement with the hospice agency, no interview obtained with RN AA.DEO confirmed that the agency failed to provide onsite nursing services within one hour of notification where P#3 was transitioning and was in lots of pain at end of life.

Based on clinical record review, staff and family interviews, it was determined that the agency failed to order patients' medication (Morphine). According to regulation, drugs must be made routinely available on 24 hours basis 7 days a week for all patients the hospice agency failed to comply with this regulation for one (1) of three (3) sampled patients (P#1). The finding include: Record review conducted on 3/31/22, at 1:00 p.m., revealed that Registered Nurse (RN) AA, did admission assessment for P#1, on 3/18/22, with a diagnosis of blood disease, myelofibrosis, atrial fibrillation, pulmonary embolism, heart disease, asthma, hypothyroidism, acute pancreatitis, gastrointestinal hemorrhage, and hypertension. The surveyor reviewed P#1's hospice agency's medication profile and plan of care. A discrepancy was found because Morphine was missing in comfort pack. (RN) AA did not order the Morphine upon admission. On 3/31/22, at 2:25 p.m., an interview was conducted with (RN) AA, who stated that the discrepancy was her mistake. (RN) AA also confirmed that she forgot to order Morphine for P#1, upon admission.

Based on clinical record review, staff and family interviews, it was determined that the agency failed to obtain physician order to administer Oxycodone rectal, for one (1) of three (3) sampled patients (P#1). The findings include: Review of the initial Skilled Nurse (SN) assessment and Plan of Care (POC) dated 3/18/22, revealed P#1 had physician's order for Oxycodone 5milligrams (MG), give one tablet oral every six hours as needed for pain. On 3/21/22, Registered Nurse (RN) AA, administered Oxycodone 5mg rectal to P#1, without physician's order. Patient #1 was admitted on 3/18/22 with a diagnosis of blood disease, myelofibrosis, atrial fibrillation, pulmonary embolism, heart disease, asthma, hypothyroidism, acute pancreatitis, gastrointestinal hemorrhage, and hypertension. During an interview on 3/31/22, at 2:25 p.m., (RN) AA, confirmed that she did not obtain physician's order to administer Oxycodone 5mg rectally for P#1. (RN) AA, stated she administered the above listed medication, because Morphine was not available when P #1 transitioned.