Every finding on record at Spanish Meadows Healthcare LLC

Based on document review and staff interview, the Hospice failed to develop and implement a plan to follow up with on-duty staff and patients and inform State and local officials of any on-duty staff or patients the Hospice is unable to contact during an emergency situation. This deficient practice had the potential to place all staff and patients at risk during an emergency. Findings include: --- Review of the Hospice’s Emergency Preparedness plan, reviewed 01/2025, revealed the Hospice failed to identify a plan to follow up with on-duty staff and patients during an emergency and notify State and local officials of any they were unable to contact.An interview with the Director of Clinical Services on 06/20/25 at 1:30 PM confirmed the Hospice failed to document a plan to follow up with on-duty staff and patients and notify State and local offices of on-duty staff and patients the Hospice might be unable to contact during an emergency.

Based on document review and staff interview, the Hospice failed to develop procedure to inform State and local emergency preparedness officials about homebound patients in need of evacuation due to an emergency. The Hospice’s failure to develop a procedure placed patients at risk of harm during an emergency.Findings include: --- Review of the Hospice’s Emergency Preparedness plan, reviewed 01/2025, revealed the Hospice failed to develop a procedure to inform State and local emergency preparedness officials of patients in need of evacuation during an emergency. During an interview on 06/20/25 at 1:30 PM, the Director of Clinical Services confirmed the Hospice failed to document a plan to notify State and local emergency preparedness officials of patients in need of evacuation during an emergency.

Based on document review and staff interview, the Hospice failed to develop procedures for the use of volunteers and other emergency staffing strategies to address patient surge needs during an emergency. This placed all patients at risk of lack of care during an emergency.Findings include: --- Review of the Hospice’s Emergency Preparedness plan, reviewed 01/2025, revealed the Hospice failed to develop a procedure for staffing strategies to meet patient care needs during an emergency. During an interview on 06/20/25 at 1:30 PM, the Director of Clinical Services confirmed the Hospice failed to develop and implement a plan for staffing strategies to meet patient care needs during an emergency.

Based on medical record review, interview, and policy review, the hospice agency failed to ensure the spiritual care assessment was completed within five days of the election of hospice care for four patients (Patient (P)10, P11, P13, and P18) of 19 patients reviewed. The failure of all members of the interdisciplinary group to complete the comprehensive assessment had the potential for the patient/family members spiritual, psychosocial, and emotional needs to not be adequately addressed in a timely manner in the patient's hospice plan of care. --- Findings include: 1. Review of P10's Hospice RN [Registered Nurse] Start of Care revealed the date of the election of hospice care was 12/28/22. Review of the Medical Social Worker Hospice Evaluation revealed it was completed on 01/05/23 more than five days after the election of hospice care. A Chaplain Hospice Evaluation was not located in the Electronic Medical Record (EMR). Review of the Coordination Notes section failed to show documentation for why the Social Work initial evaluation was completed more than five days after the election of hospice or why a Chaplain spiritual care assessment was not completed. During an interview on 02/22/23 at 9:30 AM, Chaplain1 stated that P10 had been on hospice care with the agency before and they were aware that P10 was Muslim and the patient did not want spiritual care services from the hospice. 2. Review of P11's Hospice RN Start of Care revealed the date of the election of hospice care was 11/23/22. Review of the Coordination Notes section revealed Chaplain 2 attempted a visit on 12/12/22 but no one answered the door. Review of the Coordination Notes failed to show that a phone call to the patient/family was made, or a visit was attempted within the initial five days. 3. Review of P13's Hospice RN Start of Care revealed the date of the election of hospice care was 12/15/22. Review of the Chaplain Hospice Evaluation revealed the evaluation was completed on 12/27/22, which is more than five days after the election of hospice care. Review of the Coordination Notes section failed to identify a reason for the delay. 4. Review of P18's Hospice RN Start of Care revealed the date of the election of hospice care was 02/14/23. As of 02/22/23, the EMR did not include a Chaplain Hospice Evaluation or a Medical Social Worker Hospice Evaluation. Review of the Coordination Notes failed to show a reason for the lack of interdisciplinary assessments being completed within five days of the election of hospice care. During an interview on 02/22/23 at 3:30 PM, the Administrator confirmed the findings and stated the interdisciplinary team members are required to complete an assessment within five days of the election of the hospice Medicare benefit, unless the patient or family member refuses or requests a delay in meeting with the Social Worker or Chaplain. Review of the agency policy titled, "Interdisciplinary Group Membership and Responsibilities," dated April 2021, revealed "The interdisciplinary group responsibilities include but are not limited to ... Consulting with the patient's attending physician (if any), completes the initial comprehensive assessment within five (5) calendar days after the election of hospice care."

Based on medical record review, policy review, and interview, the hospice agency failed to ensure the Registered Nurse (RN) documented a verbal order for a medication for one of 19 patients (Patient (P)2). This failure had the potential to cause serious harm to a patient. --- Findings include: Review of the Coordination Notes revealed a Narrative note written by Registered Nurse (RN)1 on 10/13/22 which documented, increased pain this past 3-5 days to 8-10/10 [pain rated as eight to ten on a one to ten scale], also has right hip and generalized pain and neuropathy to feet. Takes Lortab [narcotic oral medication] ½ to1 tab q4hr [one-half to one tablet every four hours], and fentanyl [narcotic pain medication] 25 mcg [micrograms] patch [a patch containing the medication that is placed on the skin to apply the medication slowly over time]. Review of the RN Hospice PRN [as needed] Visit note documented on 10/13/22 by RN1 revealed, physician ordered fentanyl 50 mcg. Put on second patch of 25 mcg to patients right shoulder, already has 25 mcg to left shoulder. Pharmacy will deliver 50 mcg tomorrow. Review of the orders revealed a verbal order written by RN1 and signed by the hospice physician showing D/C [discontinue] fentanyl patch 25 mcg every three days. Start fentanyl 50 mcg 1 patch topically q3 days for pain. Review of the orders failed to show a physician order for the fentanyl 25 mcg patch that was on the patient. Review of the Medications record failed to show fentanyl 25 mcg per hour patch every 3 days, had been added to the Medication list. The medication list did include the order for fentanyl 50 mcg per hour transdermal patch every three days taken as a verbal order by RN1. During an interview on 02/22/23 at 9:15 AM, the Clinical Manager confirmed that the medical record did not include a written order for fentanyl 25 mcg patch every three days and that this order was not on the P2's medication list. The Clinical Manager stated was aware there had been an order for fentanyl 25 mcg patch and was not sure why this order had not been written, signed by the physician, or added to the patient's medication list. Review of an agency policy titled, "Verification of Physician Orders," dated April 2021, revealed, "Verbal orders will be spoken to, taken and documented only by professional, licensed hospice personnel ... a qualified individual will review each order or prescription before care is provided ... Orders will be documented on a form provided by [name of the hospice], dated and signed by the professional receiving the order ... A copy of the physician's or licensed independent practitioner's order will be kept in the clinical record." Review of an agency policy titled, "Medication Profile," dated April 2021, revealed "The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications."