Every finding on record at Solutions for Home Health and Hospice D/B/A Wasatch Hospice

Based on interview and record review, it was determined that the interdisciplinary group (IDG) did not adequately manage patients' pain and symptoms. Specifically, for 1 of 14 sampled patients, the IDG did not timely and sufficiently implement interventions to manage the patients uncontrolled pain. (Patient identifier: 2) --- Findings include: Patient 2 was admitted to the agency on 4/08/2024 with a terminal diagnosis of COPD (Chronic obstructive pulmonary disease). Patient 2s medical record was reviewed on 12/02/2024 and revealed the following: Registered Nurse (RN) 1 documented in the medical record on 6/12/2024, ";pt (patient) stated pt had trouble sleeping with pain at night, took oxycodone (a prescribed pain medication used to treat moderate to severe pain) about 5 hours ago and finally pt was resting with minimum pain. SN (skilled nurse) taught to increase pain med but pt refused. Pt only uses oxycodone 1x day and Tylenol (over the counter pain medication that relieves minor aches and pains) 3 x (times per) day. Pts pain seems (sic) getting worse since pt was admitted to hospice but pt has strong personality and hard to change habit." RN 1 documented in the medical record on 6/25/2024, ";Patient reports increased pain in the morning but does not want to take pain medication throughout the day. SN discussed methadone (a prescribed long-acting pain medication used to treat severe pain) for prolonged pain relief, she agreed to try it. SN will contact physician for order. Patient continues to be hesitant about taking it, stating her friend told her it was addictive. Patient reported extreme pain when calves are palpated." There was no documented evidence in the medical record that RN 1 contacted the physician for the methadone order. RN 1 documented in the medical record on 8/20/2024, ";Patient experiences chronic pain of hands and legs. Patient expressed concern with taking too much hydrocodone (a prescribed pain medication used to treat moderate to moderately severe pain). Patient currently taking 1 dose of hydrocodone per day in the morning." On 8/27/2024, it was documented in the medical record by RN 1, ";Patient contacted agency for visit r/t (related to) uncontrolled pain in upper right leg, reporting she was not able to stand up. SN instructed patient to immediately take pain medication. Patient is extremely hesitant to take pain medication out of fear of becoming addicted. SN instructed patient on medication safety and dosing to control pain, she vu (verbalized understanding) but will require reinforcement." IDG meetings were conducted on 08/29/2024, 09/05/2024, 09/19/2024, 10/03/2024, 10/17/2024, 10/31/2024, 11/07/2024, 11/21/2024 and 12/05/2024 signed by Social worker, Administrator, RN 1, chaplain and Medical Director. No documented evidence was noted for further interventions or reinforcement for help with patient 2s anxiety with taking pain medication, nor did they address her uncontrolled pain. It was documented that there were ";no issues for next IDG meeting." On 9/17/2024 and 10/12/2024, there were documented visits by the social worker. There was no documented evidence that the social worker addressed patient 2s concerns with pain medication addiction. There was no documented evidence of other interventions being offered to manage pain and symptoms. In physician notes dated 09/14/2024 and 11/22/2024, there was no documented evidence of addressing pain and symptom management or alternative interventions to help with anxiety related to taking pain medication. On visit notes dated 11/19/2024 and 11/26/2024, RN 1 checked the box pain is relieved by ";medication and massage" in patient 2s medical record. There was no follow-up documentation regarding massage for pain relief. On visit notes dated 11/12/2024 and 12/03/2024, RN 1 checked the box for Pain is relieved by ";compression therapy" in Patient 2s medical record. There was no documentation of follow-up regarding compression therapy. On 12/03/2024 at 10:30 AM, a surveyor conducted a home visit at patient 2s home. The surveyor asked patient 2 why she had refused home health aide services multiple times. Patient 2 stated, ";the pain is bad enough that I cant remove my clothes to bathe." The surveyor asked RN 1 about the pain issue. RN 1 stated, ";They have been working on it, but the patient is concerned about addiction." On 12/04/2024 at 9:45 AM, an interview was conducted with the DON (director of nursing) about Patient 2s pain regimen. The DON stated that ";she sometimes is an anxious and difficult patient and refuses to take her other doses of pain medication because she doesnt want to get addicted." Throughout the medical record, there was no documented evidence that the agency offered Patient 2 other pain relief interventions beyond medication, nor was there documented evidence that the RN or social worker addressed Patient 2s anxiety regarding pain medications.

Based on observation, interview, and record review, it was determined the hospice 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. Findings include: The hospice failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. (Refer to tag L651) The hospice failed to ensure a physician was designated by the hospice to assume the same responsibilities and obligations as the medical director when the medical director was not available. (Refer to tag L664) The hospice failed to implement interventions to manage pain and symptoms of pain in a timely manner. (Refer to tag L546)

Based on interview and record review, it was determined the Governing Body (GB) did not assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement (QAPI). Specifically, the GB meeting minutes provided by the agency did not encompass the scope and aspects of hospice services, and the documentation showed potential for improper discharge. (Patient identifiers: 5, 7, 11, 13 and 15) --- On 12/2/2024 the hospice agency provided the last 12 months of GB meeting minutes. The meeting minutes were reviewed and revealed the following: On 11/15/2023, it was documented: Objective: ";Getting ready for holidays checking on finances. Think ok for CAP (aggregate cap calculations) will get penalty but shouldnt be too big." Moving Forward: ";Really track patients and market to hospital to change the level of care – acuity to ensure that we are in the clear for CAP." On 1/9/2024, it was documented: Objective: ";Review 2023. Create new goals and plan for new year. Looked back on what was spent/how. Go through good/bad/better decisions and how to improve processess. (sic)" Moving Forward: ";- (Name redacted) will take over as Administrator (ADM) starting 4/1/2024 - Create updated budgets with proper timing - Cost savins (sic) through structured ordering and applying DME (durable medical equipment) owned by Wasatch" On 6/17/2024, it was documented: Objective: ";Unfortunately deciding on how to proceed with giant CAP penalties." Moving Forward: ";We are going to DC (discharge) patients and only keep patients on 1st benefit period trying not to add anymore CAP repayments right now. Consultant attributes additional $200 K (thousand) in addition to the $270 K current." There was no documented evidence that the GB addressed the functioning of specific hospice operations, services, and the QAPI program. On 12/4/2024 at 4:00 PM, an interview was conducted with the ADM. The ADM was asked about the comments from the 6/17/2024 meeting minutes regarding discharging patients. She stated, ";I was under stress when I was writing this." She stated they transferred six patients due to penalties for keeping patients on service too long. When asked about the first benefit period, she stated, no, the plan was not to discharge or transfer after the first benefit period. On 12/9/2024 at 11:15 AM, the caregiver (CG) of patient 7 was interviewed. The CG stated the hospice agency discharged patient 7 without notice, and he had to go to the hospital to be admitted to another agency. However, the CG also stated she has had a stroke and does not have a good memory. On 12/9/2024 at 11:24 AM, the CG of patient 13 was interviewed. The CG stated that the hospice agency explained that patient 13 needed to be discharged because they had ";removed that program" and that patient 13 needed to go to the hospital to be admitted to another agency. On 12/9/2024 at 11:28 AM, the CG of patient 5 was interviewed. The CG stated there were no issues with patient 5s discharge from the agency, and patient 5 was later admitted to another agency. On 12/11/2024 at 8:30 AM, an interview was conducted with the hospice agency's current Medical Director (MD). The MD stated he had only been the MD since 10/2/2024. He stated that he has never been asked to discharge any patients, and the patients he had admitted since 10/2/2024 have all been hospice appropriate. He further stated that live discharge criteria would be a general lack of decline or if the patient starts to improve, such as not losing weight, being no longer frail, becoming more active, and progressing in activities of daily living. He stated that sometimes, the extra care received by hospice services can improve a patients health to the point that they are no longer hospice appropriate. Five live discharge medical records (Patient identifiers: 5, 7,11,13 and 15) were reviewed for improper discharge. All five medical records documented minimal decline, and the discharges appeared appropriate on paper.

Based on interview and record review, it was determined that the agency failed to ensure a physician was designated by the hospice to assume the same responsibilities and obligations as the medical director when the medical director was not available. --- On 12/2/2024, during entrance conference, surveyors asked who acted in the medical directors stead when he was not available. The agency stated their contracted nurse practitioner (NP) would be available when the medical director was not. The agency provided a contract with the NP stating he was the backup medical director. On 12/4/2024 at 4:00 PM, an interview was conducted with the administrator (ADM). The ADM stated she did not know a physician was required to be the backup medical director or that a NP could not be the backup medical director.

Based on interview and record review, it was determined the hospice agency did not complete a discharge summary that included a summary of the patient's stay including treatments, symptoms and pain management; the patient's current plan of car; the patient's latest physician orders; and any other documentation that would assist in post-discharge continuity of care that was sent to the patient's attending physician for 2 of 2 patients that revoked their hospice care. (Patient identifiers: 7 and 8). Findings include: 1. The medical records for patients 7 and 8 were reviewed on 10/6/2021. There was no evidence that a discharge summary was completed when the patients revoked their hospice care. 2. A telephone interview was conducted with the Director of Nursing (DON) on 10/6/2021 at 3:35 PM. The DON confirmed that a discharge summary was not completed for patients 7 and 8. The DON stated the hospice agency completed a "Discharge Visit" but did not complete discharge summaries.

Based on interview and record review, it was determined the agency did not obtain criminal background checks on all hospice employees who had direct patient contact. Specifically, for 3 of 10 sampled employees who had direct patient contact, background checks were not completed or not completed prior to providing direct patient contact. (Employee identifiers: 1, 7, and 8.) Findings include: On 10/7/21, personnel file reviews for employees 1, 7, and 8 was completed. A background check was completed on 8/6/21, for employee 8. A background check could not be found for employees 1 and 7. Note: Employees 1, 7, and 8 had direct patient contact prior to the submission of their background checks. On 10/7/21 at 10:30 AM, an interview was conducted with the agency's administrator (ADM)). The ADM stated they realized yesterday that employees 1 and 8 did not have background checks in their personnel files. The ADM stated they obtained one for employee 8 through the State system on 10/6/21. The AD further stated the agency had provided employee 1 the paperwork to obtain a background check several months ago, but never followed through to ensure that it had been completed. No documented evidence was provided to indicate employee 7 had completed a background check.