Every finding on record at St. Croix Hospice, LLC

Based on clinical record review, hospice policy review, nursing home record review, nursing home staff interview and hospice staff interview, the hospice failed to: ensure the hospice nurse member of the interdisciplinary group updated the comprehensive assessment with changes to the patient condition and included wound assessment and measurements per hospice policy (see L0533). Findings include: --- The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel completed a comprehensive assessment of all patient care and treatment needs to their hospice patients.

Based on clinical record review, hospice policy review, and staff interview, the hospice failed to ensure nurse members of the Interdisciplinary Group (IDG) updated the comprehensive assessment with changes to the patient condition regarding wound description, measurements, and changes to treatment for 2 of 6 sampled patients with a wound (Patients #2 and #5). Failure by the hospice IDG registered nurses to update the comprehensive assessment with complete wound descriptions and measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient's wound status and effectiveness of treatments and interventions. Findings include: --- According to the undated hospice policy titled, Comprehensive Assessment, during the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including an assessment of severity of skin integrity. During an interview on 4/9/24 at 11:10 AM, Staff C, RN (Registered Nurse) stated Patient #5 developed a pressure sore that appeared out of nowhere. The patient also had necrotic toes and the hospice was treating the necrotic toes with betadine and gauze. During an interview with Staff L, Licensed Practical Nurse (LPN) on 4/10/24 at 9:34 AM she stated Patient #5 had wounds on the toes that were superficial. I did not measure the toe wounds because I did not feel the toe wounds were any type of wound that needed to be measured. During an interview on 4/10/24 9:47 AM, the Administrator stated she was unaware patient # 5 had any wounds. She further stated the expectation of staff was to assess wounds weekly and include measurements in the assessment. During an interview on 4/10/24 at 2:48 PM, Staff F, Hospice Aide (HA) stated she noticed an open are on Patient #5 bottom. She further stated she notified Staff C, RN of the open area. Staff F reported, Staff C stated he would look at the wound at his next visit. 1. Patient #5 had a hospice admission date of 1/5/24 and date of death of 2/27/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The hospice aide visit note, dated 2/12/24, Staff F , HA documented the patient had open area to both buttocks soiled through the pants, sheet and chuck. Registered Nurse Case Manager notified. b. Staff B, Clinical Manager, skilled nurse visit notes, dated 2/13, 2/15 and 2/16/24, lacked documentation of assessment of the patient's buttocks. c. Staff L, LPN, skilled nurse visit notes, dated 2/17/24, included documentation the patient toes were necrotic with sores on the toes. New order included Vaseline gauze to provide wound care. The documentation lacked assessment of the sores on the toes. d. Staff M, RN, skilled nurse visit note, dated 2/18/24, included documentation the aide reported a reddened area on the patient's coccyx during the visit. The documentation included the patient refused to allow the RN to assess the area. e. Staff C, RN skilled nurse visit note, dated 2/19/24, included documentation the patient had a stage 2 pressure area to the coccyx. Staff C contacted the physician and received new orders which included zinc oxide ointment, cover with optifoam pad. Change daily and as needed if soiled. The nurse to assess every visit. The document also included a Roho cushion ordered. The note failed to include documentation of an assessment of the pressure wound on the coccyx or necrotic toes including measurements. f. The physician's order, dated 2/19/24, included orders for zinc oxide 20% ointment: apply thin layer to affected area 2 times a day and as needed for pressure wounds, cover with optifoam pad. Change daily and as needed if soiled for pressure wounds. Caregiver to complete. Hospice nurse to assess every visit. Wound care for necrotic left toes, paint with betadine, wrap with Vaseline gauze. Caregiver to complete daily and as needed. Hospice nurse to assess every visit. g. Staff C, RN skilled nurse visit notes, dated 2/21/24 and 2/26/24, included documentation the patient had wounds to the left dorsum foot and necrotic toes and a stage 2 pressure area to the coccyx. The document failed to include assessment including measurements. The hospice staff failed to complete timely assessment which caused a delay in receiving Physician orders. The skilled nurse failed to fully assess the patients' wounds in order to provide a complete description of the patient's current physical status with updates to the comprehensive assessment. 2. Patient #2 had a hospice admission date of 11/29/23 and received hospice services while residing in a nursing facility. Review of the clinical record revealed the following: a. The plan of care (POC) dated 2/27/24 to 5/26/24, included skilled nursing services 1 time per week. b. Comprehensive assessments completed by Staff O, RN, dated 3/25/24 included documentation of a skin tear to the left proximal dorsum (top foot/ankle) with an onset on 3/22/24 due to a fall. The facility provided wound care and dressing change this morning so no assessment of the wound was made. The assessment failed to include documentation of the Nursing facilities findings or any further description or measurements of the wound. c. A comprehensive assessment completed by Staff P, RN, dated 4/1/24, included documentation of skin tear to the left proximal dorsum and a new skin tear to the left mid pretibial area (shin). The assessments failed to include a description or measurements of the wounds. d. The skilled nurse visit note, dated 4/5/24, Staff O, RN included documentation of skin tear to the left proximal dorsum and a skin tear to the left mid pretibial area (shin). The assessments failed to include a description or measurements of the wounds. The hospice failed to complete assessments of wounds or identify the facilities assessments including wound measurements. The above findings were reviewed with the Administrator and Clinical Manager.

Based on clinical record review, home visit observation, family interview and hospice policy review, the hospice failed to ensure the hospice plan of care included all necessary treatments to meet the needs of the patient for 2 of 6 sampled patients (Patient #2 and #4). Failure to ensure the plan of care included complete and accurate physician orders for all necessary medications and treatments placed patients at risk to receive inappropriate treatment of symptoms. Findings include: --- Review of the hospice's policy, titled Plan of Care (POC), dated 2/1/23, identified the Interdisciplinary Group (IDG) gathers the information from the initial and comprehensive assessment to develop the POC. Review of the hospice's policy, titled Interdisciplinary Team Meetings, dated 7/28/21, identified the IDG reviews and updates each patient's Plan of Care (POC) at least every 15 days, or more frequently, if needed. 1. Patient #2 had a hospice admission date of 11/20/23 and received routine home care services from the hospice while residing in an assisted living facility. Review of the clinical record revealed the following: a. The plan of care (POC), dated 3/19/24 through 5/17/24, identified the patient had orders for skilled nursing services and medications. b. The assisted living physician's ordered, dated 4/9/24, included orders for lorazepam 0.5 mg every 6 hours as needed for agitation/anxiety effective 9/5/23. c. The Interdisciplinary Group (IDG) meeting, dated 3/21/24, did not include any information about the patient's order for Lorazepam. d. The hospice medication report, dated 4/9/24, did not include the order for Lorazepam. The hospice failed to include the patient's order for Lorazepam on the plan of care. 2. Patient #4 had a hospice admission date of 2/7/24 and received routine home care services from the hospice while residing in a private residence. a. The POC, dated 2/7/24 to 5/6/24, included orders for skilled nursing services and the medication cranberry supplements. b. The hospital discharge orders, dated 2/7/24, included orders for cranberry supplement 500 mg 3 times a day. c. The IDG note, dated 2/15/24, 2/29/24 and 3/1424, included orders for cranberry supplement 500 mg daily. The hospice failed to include IDG orders for correct, current medication of cranberry supplement of cranberry supplement 500 mg 3 times a day or clarify the discrepancy with the physician. The above findings were reviewed with the Administrator and Clinical Manager.

Based on clinical record review, hospice policy review, police report review, local law enforcement officer interview, family interview and hospice staff interview, the hospice failed to ensure the care services furnished by hospice staff to patients followed an individualized written plan of care established by the interdisciplinary group in collaboration with the attending physician, patient or representative and primary caregiver (See L0543). --- The effects of this practice resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel promoted and supported the safe, comprehensive and effective delivery of patient care to its hospice patients, as evidenced by a hospice nursing staff administering medications without a physician order resulting in the potential hastening of a patient's death.

During the investigation of the complaint and the hospice's self-reported incident, the on-site survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Interdisciplinary Group (IDG), Care Planning and Coordination of Services (CFR 481.56). The hospice failed to ensure hospice nursing staff administered medications to hospice patients per the patient's Plan of Care (POC) and physician orders. While on-site, the survey team identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 7/13/23 at 1:15 PM. The hospice staff acted and removed the immediacy of the situation prior to the survey team exiting the complaint investigation when the hospice administrative staff took the following steps: Provided reeducation of all hospice nursing staff on verification of physician orders, following and updating the patient's plan of care and death at home visits, as well as monitoring of all medication orders and monitoring of daily nursing visit notes by the administrative staff. The following Condition level deficiency remained for the Condition of Participation for 42 CFR 481.56 IDG, Care Planning and Coordination of Services. Based on clinical record review, hospice policy review, family interview, local law enforcement officer interview, current and former hospice staff interviews, the hospice failed to ensure nursing hospice staff provided hospice care and services based on the patient's POC and physician orders for 2 of 8 sampled patients (Patients #3 and #4). Failure to ensure hospice nursing staff provide care and services in accordance with the patient's POC and physician orders resulted in the potential hastening of a patient's death and another patient not receiving treatment as ordered. --- Review of the hospice's policy, titled IDG Coordination of Care, dated 3/3/23, revealed the IDG is made up of physicians, nurses, social workers, clergy, therapists, counselors, volunteers, hospice aides and homemakers. The hospice IDG maintains professional management of the provision of services and ensures the safe and effective delivery of care and services. The registered nurse (RN) case manager is responsible for the communication of changes in the patient's status and coordination of services with the IDG and the patient's attending physician (if a patient chooses an attending physician). Hospice staff are responsible for the communication and documentation of changes in a timely manner in the clinical record. Hospice staff will document the date and time of communication and the individuals involved in the communication. The IDG will conduct assessments, develop and update the POC and review the effectiveness of the POC at a minimum of every 15 days. The IDG will consult on the selection of the most appropriate drugs to meet the patient's needs with an individual that has experience and education in the management and the use of drugs per acceptable standards of practice for hospice patients. Review of the hospice's undated policy, titled Plan of Care, revealed hospice staff are required to provide care and services to patients in accordance with an individualized POC based on the initial and ongoing assessment of the patient and family/caregiver. The POC will identify the patient's needs and services to meet those needs including the management of pain and symptom relief. Review of the hospice's policy, titled Verification of Physician Orders, dated 12/2018, revealed hospice licensed professional staff are responsible for obtaining and documenting verbal orders from a licensed physician or other authorized independent practitioner for hospice care and services provided to patients. The hospice licensed professional staff are responsible for reading back all verbal and telephone orders to the healthcare practitioner or representative issuing the order and documenting the order in the electronic medical record. Hospice staff will send a copy of the order to the healthcare practitioner for signature and retain a copy of the signed order in the patient's clinical record within 30 days of initiation of the order. 1. Patient #4 had a hospice admission date of 4/14/22, received routine home care hospice services while residing in a private residence until 5/24/22, then received continuous (services provided daily, up to 8 hours per day) hospice services at home from 5/25/22 until the patient's death at the patient's home on 6/7/22. a. Review of the hospice's self reported incident to the State Agency and the hospice's complaint log, dated 6/28/23, included documentation that a family member(s) of Staff V, Former Hospice RN, reported Staff V informed the family members that Staff V assisted a terminally ill hospice patient to commit suicide. The hospice's Chief Compliance Officer confirmed Staff V, Former Hospice RN, had provided nursing services to this patient prior to the patient passing in June 2022. b. On 7/10/23 at 2:00 PM, during a phone interview with the hospice's Chief Compliance Officer and the hospices attorney, the Chief Compliance Officer reported on 6/24/23, she received a call from a family member of Staff V's, Former Hospice RN, but had been unable to reach and speak with the family member until 6/28/23. Family Member #2 reported Staff V, Former Hospice RN, had been historically diverting drugs and had assisted a patient with hastening their death. Family Member #2 reported Staff V, Former Hospice RN, had talked about helping to hasten the death of Patient #4, a former hospice patient, and Family Member #2 thought this patient was a former physician. The Chief Compliance Officer confirmed the hospice had a patient by that name the Family Member #2 had reported and the patient had been a physician. The Chief Compliance Officer explained the hospice was still in the process of investigating the complaint, but the hospice did find concerns with a clinical narrative note written by Staff V, Former Hospice RN, on 6/7/22, the date that Patient #4 died. The clinical narrative note stated Staff V, Former Hospice RN, delivered Oxycodone (controlled medication used to treat pain/ a controlled medication is any medication that requires government regulation for the manufacture, distribution and use) and Ativan (drug trade name for Lorazepam, a controlled medication used to treat anxiety, agitation and restlessness) every 15 minutes to control pain and restlessness. The clinical record lacked an order for Ativan and Oxycodone every 15 minutes. The Chief Compliance Officer explained this was not a typical order and staff should never administer a narcotic pain medication and Ativan (the potential drug interaction between Lorazepam and Opioids such Oxycodone or Morphine can lead to slowed and difficulty breathing and possibly death) at this frequency without a physician order. c. Review of a police report, dated 6/27/23, revealed a local law enforcement investigator found, photographed and seized prescription drugs/narcotics in the vehicle and garage belonging to Staff V, Former Hospice RN. The local law enforcement office identified the prescription medications belonged to former hospice patients (See L0694). On 6/27/23, according to documentation by the local law enforcement officer, Family Member #1 reported to the officer that Staff V, Former Hospice RN, bragged about assisting in the suicide of Patient #4, but had no other information. d. On 7/6/23 at 11:38 PM, during an interview, the Local Law Enforcement Officer who wrote the police report on 6/27/23 reported the officers on the scene removed medication bottles from Staff V's, Former Hospice RN, vehicle belonging to 4 different persons. The Local Law Enforcement Officer reported they had been unable to obtain any information in regards to whether or not Staff V, Former Hospice RN, had assisted the patient in committing suicide or hastening their deaths. The Local Law Enforcement Officer reported he tried to contact the hospice for information, but the hospice agency would only provide a policy on the disposal of controlled drugs. e. On 7/10/23 at 1:19 PM, during an interview, a Law Enforcement Officer with their agency's records department, reported their was no information regarding any possible pursuit of case concerning Staff V, Former Hospice RN, regarding the death of Patient #4. f. On 7/12/23 at 11:55 AM, during an interview, Family Member #1 (family member of Staff V, Former Hospice RN) reported not knowing any specifics about how Staff V assisted Patient #4 end the patient's life. Family Member #1 explained Staff V, Former Hospice RN, talked about Patient #4 all of the time, and Family Member #1 knew Patient #4 had been a hospice patient. Family Member #1 reported Staff V, Former Hospice RN, told the family member that Patient #4 asked Staff V to help end Patient #4's life. Staff V told Family Member #1 that Staff V did help end the patient #4's life. Family Member #1 reported Staff V, Former Hospice RN, wanted to tell Family Member #1 the details about the patient's death, but Family Member #1 would not let Staff V tell them about the specifics of patients death. According to Family Member #1, Staff V, Former Hospice RN, expressed that Staff V thought she might get money from Patient #4 when the patient passed, but Family Member #1 was not sure if this had anything to do with why Staff V helped to end the patient's life. Family Member #1 thought Staff V, Former Hospice RN, told them about ending Patient #4's life sometime this last fall in 2022. g. On 7/12/23 at 1:54 PM, during an interview, Family Member #2 (family member of Staff V, Former Hospice RN) reported Staff V told Family Member #2 that Patient #4 asked Staff V to help end the patient's life. Family Member #2 explained Staff V, Former Hospice RN, hesitated at first, but in the end, Staff V reported Staff V helped to end the patient's life. Staff V, Former Hospice RN, did not inform Family Member #2 how Staff V assisted the patient. Family Member #2 thought Staff V, Former Hospice RN, told Family Member #2 around September 2022 about assisting with ending the life of Patient #4. Family Member #2 reported knowing Patient #4's name and that the patient was a former doctor. Family Member #2 reported Staff V, Former Hospice RN, was close with family of Patient #4, and Patient #4 was Staff V's favorite patient. h. Review of Patient #4's clinical record revealed the following: 1) The POC, dated 4/14/22 to 7/12/22, identified the patient had a terminal diagnosis of tonsillar cancer with metastasis to the patient's bones and received medications and nutrition through a percutaneous endoscopic gastrostomy (Peg) tube. The same POC identified Patient #4 chose the hospice Medical Director as the attending physician and included IDG orders for skilled nursing services 2 times per week. The same POC included the following medication orders: Aspirin (used as a blood thinner), Plavix (used to prevent the formation of blood clots), Calcium Citrate (vitamins used to help balance the patient's blood minerals known as electrolytes), Levothyroxine (used to treat an underactive thyroid gland), Trazadone (used to treat sleeping difficulties) and Two Cal oral liquid (liquid nutrition). The patient/family self administered medications. 2) The clinical record included documentation of the following medication orders: On 4/18/22, the Medical Director ordered Hydrocodone-Acetaminophen 10 milligrams (mg)-325 mg 1 tablet every 6 hours as needed (PRN) for pain and Lorazepam 1 mg tablets 1mg every 2 hours PRN for anxiety via the Peg tube . 3) The IDG meetings, dated 4/28/22, 5/12/22, 5/26/22 and 6/9/22, included documentation Staff V, Former Hospice RN, was the patient's RN Case Manager. 4)The clinical record included documentation of an order from the Medical Director, dated 5/25/22, for daily RN visits per the patient's request, change in the patient's condition and (the patient's) feelings of impending doom. The hospice's orders indicated the hospice staff placed the patient on their "Voyage Program" (the hospice program for patient's in their final days of life) which included continuous care daily visits. The clinical record included an order from the Medical Director, dated 5/25/22, to give Dexamethasone 4 mg 1 tablet every day for bone pain via the Peg tube. The IDG meeting, dated 5/26/22, included documentation of the IDG's approval of the Voyage Program and medication orders. 5) A skilled nursing visit note, dated 5/27/22, included documentation Staff V, Former Hospice RN, reported the patient had talked about possibly doing something to end his/her own life. Staff V, Former Hospice RN, documented she contacted the hospices Social Worker on 5/27/22 to come to assess the patient. 6) A social worker visit note, dated 5/27/22, included documentation the hospice social worker assessed the patient and the patient denied that the patient would harm themselves and did not have a plan for harming themselves. 7) A physician's order, dated 5/28/22, included documentation of an order given by the Medical Director for Morphine oral concentrate 20 mg/milliliters (ml), give 0.25 ml every 2 hours as needed for pain. 8) The skilled nursing visits, dated 5/28/22 and 5/29/22, included documentation by Staff W, RN, that the patient's respirations were 18 breaths per minute and shallow on 5/28/22, and 20 breaths per minute and labored on 5/29/22. The hospice nurse did not document a pain level intensity, but did document liquid Morphine concentrate had been started on 5/28/22. 9) A skilled nursing visit, dated 5/30/22, included documentation by Staff P, RN, that the patient's respirations were in normal limit and the patient felt their pain was controlled. 10) A skilled nursing visit, dated 5/31/22, included documentation by Staff V, Former Hospice RN, assessed the patient's pain was at an "8" intensity level out of 10, (with 10 being the worst in the last 24 hours, and described the pain as crushing, nagging, constant and affecting all areas of the patient's life). The patient reported a pain of "10" in the last 24 hours with a goal of a pain level intensity rating of "4". Staff V, Former Hospice RN, documented that the Medical Director gave Staff V an order for Hydrocodone-Acetaminophen 10 mg-325 mg 2 tabs every 4 hours for pain. Staff V, Former Hospice RN, documented that she helped in administering the medication. The clinical record lacked documentation of an order for Hydrocodone-Acetaminophen 10 mg-325 mg 2 tabs every 4 hours. 11) A skilled nursing visit, dated 6/1/22, included documentation by Staff V, Former Hospice RN, assessed the patient's pain was at an "8" intensity level out of 10. The patient reported a pain level of 9 being the worst in the last 24 hours, and described the pain as crushing, gnawing and constant. Staff V, Former Hospice RN, documented the patient was resting in a chair upon arrival, the patient was oriented, confused at times and very drowsy. Staff V, Former Hospice RN, administered Lorazepam and Dexamethasone via the patient's Peg tube. 12) A skilled nursing visit, dated 6/2/22, included documentation by Staff V, Former Hospice RN, assessed the patient's pain was at an "8" intensity level out of 10, with 9 being the worst in the last 24 hours, and described the pain as crushing, gnawing and constant. Staff V, Former Hospice RN, documented the patient was resting in a recliner, the patient's pain seemed to be under control at that time, the patient was smiling and conversing about various properties the patient owned, and the patient seemed in much better spirits today. Staff V, Former Hospice RN, documented "oral solutions meds ordered to avoid further hassle with Peg tube." The patient's clinical record lacked documentation of any new or changed medication orders. 0n 7/11/23 at 1:43 PM, during an interview, the hospice's Director of Integration reported that Staff V, Former Hospice RN, wrote an order in the hospice's electronic script system, a system separate from the clinical records for hospice patients, on 6/2/22. Staff V, Former Hospice RN, wrote an order for liquid Lorazepam and liquid Oxycodone on 6/2/22. The Director of Integration confirmed that the dose and frequency for the liquid Lorazepam and Oxycodone were not documented in the patients clinical record. The hospice's Director of Integration reported Staff V, Former Hospice RN, did not write an order for the patient to take take 2 Hydrocodone-Acetaminophen 10mg-325mg every 4 hours for pain on 5/31/22 in either the patient's clinical record or in the hospice electronic prescription system. 13) Review of the hospice electronic prescription record revealed 2 physician orders signed by the hospice Medical Director, dated 6/2/22. The orders were as follows: Oxycodone 20 mg/ml concentrate, take one ml (20 mg) by mouth every 4 hours for pain and Lorazepam 2 mg/ml oral concentrate, take 0.5 ml by mouth every 2 hours as needed for anxiety. 14) A social worker visit note, dated 6/3/22 at 11:50 AM to 12:44 PM, included documentation the social worker assessed the patient was alert and oriented to person, place and time, but was also forgetful and lethargic. The social worker documented the patient stated having feelings of depression and loss of quality of life due to the patient's illness. The patient did not indicate that the patient was at risk for harm to themselves, but did express an overall frustration with having to live in the patient's current state. The patient expressed confusion with taking medications and requested only comfort medications (medications used to treat pain and alleviate other symptoms that would cause the patient discomfort, such as anxiety or nausea). The social worker reported informing the RN case manager (Staff V, Former Hospice RN) at the visit of the patient's request for comfort medications only. 15) A skilled nursing visit note, dated 6/3/22 at 2:27 PM to 3:31 PM, included documentation by Staff V, Former Hospice RN, assessed the patient's pain was at a "7" intensity level out of 10, with 8 being the worst in the last 24 hours, taking breakthrough pain medication as needed 2 to 3 times per day, abnormal breath sounds with diminished lung sounds (indicated some difficulty in breathing), fatigue at a 2 of 10, alert and orientated to person, place and time, but also confused, and no signs or symptoms of depression, anxiety or abnormal psychiatric findings. The clinical record lacked documentation of any medication changes to accommodate the patient's request for comfort medications only. The patient continued to have physician orders to take the following medications not used for comfort: Aspirin, Plavix, Calcium Citrate, Levothyroxine and Trazadone. 16) A skilled nursing visit note, dated 6/4/22, included documentation by Staff P, RN, that she assessed the patient's pain was at a "6" intensity level out of 10, with 7 being the worst in the last 24 hours, respirations within normal limits and a fatigue score of 7 of out 10 (with 10 being the worst) and drowsiness a "5" out of 10 (with 10 being the worst). Staff P, RN documented the patient reported uncontrolled pain, frustrated with not feeling well and confusion. The patient did not know what to take for comfort and could not find the Dexamethasone. Staff P, RN, documented she contacted the Medical Director for clarification of the plan. The nurse documented she obtained new orders for a refill of Dexamethasone and sent the medication order to the pharmacy. The patient is to use Oxycodone for routine needs and Morphine for breakthrough pain. 17) A skilled nursing visit, dated 6/5/22, included documentation by Staff U, RN, that the patient's respirations were 18 breaths per minute and within normal limits, had a pain intensity rating of zero. The nurse documented that the patient's family reported they were running out of resources to care for the patient in the home. The patient's primary caregiver was not going to be available for the next 90 days. The patient was ready for placement outside of the home. Staff U, RN, documented she contacted the IDG members. The nurse documented the patient's pain was well controlled. 18) A skilled nursing visit note, dated 6/6/22 at 9:36 AM to 10:24 AM, included documentation by Staff V, Former Hospice RN, assessed the patient's pain was at a "7" intensity level out of 10, with 8 being the worst in the last 24 hours, respirations within normal limits with lung sounds diminished. Staff V, Former Hospice RN, documented the patient reported feeling a lot better and post nasal drainage was gone and pain was better with pain only when mobile. The patient reported being interested in placement over the weekend, but now does not want to leave the patient's home. Staff V, Former Hospice RN, documented she discussed respite services (a temporary stay in a nursing facility for up to 5 days) and the patient was interested. Staff V, Former Hospice RN, documented she informed the hospice's social worker of the patient's discussion about respite services. 19) The clinical record included documentation of 2 separate nurses visit notes, dated 6/7/22; one note was titled, "RN Continuous Care Evaluation" and a second note was titled, "Death Visit", and Staff V, Former Hospice RN, signed both visit notes. a) The visit note, titled, "RN Continuous Care Evaluation", dated 6/7/22, included the following documentation: Staff V, Former Hospice RN, documented she arrived at the patient's home at 9:19 AM and the visit lasted until 3:07 PM. Staff V, Former Hospice RN, documented the patient was restless and agitated due to pain and had a pain intensity rating of 10. Staff V, Former Hospice RN, documented that Staff V administered Oxycodone and Lorazepam every 15 minutes and that Staff V sat with the patient and family administering medications and providing comfort. The clinical record lacked documentation of a physician order for the patient to have Oxycodone or Lorazepam at the frequency of every 15 minutes as documented by Staff V, Former Hospice RN. The clinical record and electronic prescription record lacked documentation of any new physician orders after 6/2/22. Staff V, Former Hospice RN, documented that Staff V assessed the patient's vital signs as follows: Temperature at 9:42 AM was 98.3 degrees Fahrenheit (within normal range of temperature), a radial (wrist) pulse of 86 and irregular at 9:46 AM, a blood oxygen saturation level of 69 percent at 9:46 AM at room air (values under 90 percent are considered low) and respirations at 18 breaths per minute and "within normal limits" at 10:39 AM (which would indicate the patient was not in any kind of respiratory distress). Staff V, Former Hospice RN, documented, "approximately noon; patient displaying periods of apnea (absence of breath). Breaths per minute reduced to 9." Staff V, Former Hospice RN, documented, "2:00 PM significant changes-shallow breathing. Breaths per minute 4." b) The visit note, titled "Death Visit", dated 6/7/22, included the following documentation: Staff V, Former Hospice RN. Staff V, Former Hospice RN, documented the patient died at 3:02 PM with Staff V and family present at the bedside. Staff V, Former Hospice RN, documented Staff V provided post mortem cares and a family member would destroy the patient's medications including Oxycodone 20 ml (liquid) and Lorazepam 25 ml (liquid). The skilled nursing visit notes, dated 6/7/22, lacked documentation of an ongoing clinical assessment by the nurse every 15 minutes or every hour which warranted the administering of medications every 15 minutes (as documented by Staff V, Former Hospice RN) or every hour (as reported by Staff V), lacked documentation of contact with a physician or licensed healthcare practitioner (such as the Medical Director or the hospice ARNP) and lacked an order by physician or other licensed health care practitioner for the administration of any medications every 15 minutes or every hour, either at a scheduled frequency or as needed. i. On 7/12/23 at 9:16 AM, during an interview, the hospice Medical Director reported working for the hospice since October 2021. The Medical Director remembered Patient #4, but could not recall if Staff V, Former Hospice RN, contacted him/her for orders on either 6/2/22 or 6/7/22. The Medical Director explained a typical dose for liquid Oxycodone would be 20 mg/ml, give 5 mg every 4 hours as needed, not scheduled, and then advance to every 2 hours as needed. A typical dose for Lorazepam Intensol (liquid) would be 2 mg/ml, give 0.5 mg every 4 hours as needed. The Medical Director was unsure why the hospice would have switched over to liquid since the medications could be crushed and put through Patient #4s Peg tube. If a patient was not responding to the current dose and frequency of a pain medication, the Medical Director reported he would look first at increasing the dose before increasing the frequency. The Medical Director reported he would also use longer-acting pain medications (slower acting medication with a longer duration of pain relief), such as Fentanyl through a patch or Oxycontin (same as Oxycodone) to decrease the amount of as needed pain medication. The Medical Director reported he did not do euthanasia, and he would never give a patient pain medication if their respirations were down to 9 breaths per minute. If a patients breath is down to 9 breaths per minute, this indicates that the patient is comfortable. The Medical Director reported he would not prescribe the pain (Oxycodone) and antianxiety (Lorazepam) medication every 15 to 30 minutes except for extreme circumstances such as episodes of air hunger where the patient is gasping and choking for every breath, and the Medical Director reported he could remember ordering medication at this frequency less than 10 times in their entire career. The Medical Director explained that he will almost never schedule pain medications shorter than 6 hours, because ";it is too much drug and not enough assessment" to schedule pain medications any shorter than 6 hours apart. The Medical Director explained that with as needed pain medications, the nurse should always be assessing the patient prior to giving the medication. The Medical Director reported he could not make a determination on whether or not the medications Staff V, Former Hospice RN, caused the premature death of the patient, but remembered the patient had been on their ";Voyage Program" (the hospices procedures for when the patient is near death that includes daily visits by hospice staff) and the patient's death was not unexpected. The Medical Director explained that if Staff V, Former Hospice RN, continued to give the patient the medications for pain and anxiety once the patients respirations were down to 9 and then 4, this could have resulted in the patient passing sooner. j. On 7/12/23 at 10:12 AM, during an interview, the hospice's Advanced Registered Nurse Practitioner (ARNP) reported she has worked for the hospice since 2014. The ARNP explained her role as mainly doing visits to recertify patients for hospice services, provides support to the nurses and Clinical Manager and works under the direction of the hospice Medical Director. The ARNP reported she frequently ordered medication changes and refills for hospice patients if the patient did not have an attending physician. The ARNP reported she did not remember Patient #4, and explained she never saw the patient in person. The ARNP reported she may have ordered comfort medications for the patient, but she could not recall. The ARNP explained she worked closely with the Medical Director, talks with the Medical Director "a lot" and would prescribe medications the same as the Medical Director. The ARNP reported she would not order the use of Oxycodone and Morphine at once and she would never order any medication every 15 minutes. The ARNP further explained the medications should be ordered as needed, not any shorter than every 2 hours and not scheduled. The ARNP reported she might do a one time order if a patient was in pain, and then go back to as needed. The ARNP reported the ARNP has never ordered a medication for every 15 minutes. k. On 7/11/23 at 3:35 PM, during an interview, Staff V, Former Hospice RN,(dates of employment 2/15/22 to 5/9/23) confirmed she was present in the patient # 4's home and with the patient when the patient died. Staff V, Former Hospice RN, described the patient as incoherent and terminally restless when Staff V arrived to the home on 6/7/22.. Staff V, Former Hospice RN, reported she and a family member of the patient's helped the patient into bed and the family member laid down with the patient in the bed. Staff V, Former Hospice RN, reported the patient asked for Staff V to call another family member to come to the home. Staff V, Former Hospice RN, reported she ended up staying close to 8 hours that day (6/7/22). Staff V, Former Hospice RN, explained she administered hourly medications while present in the home and she contacted the hospice's ARNP for medication orders. Staff V, Former Hospice RN, explained she administered all of the patient's medications through the patient's Peg tube. Staff V, Former Hospice RN, further explained that she would flush the Peg tube with water, put medications through the Peg Tube and then flush the tube again with water after administering the medications. Staff V, Former Hospice RN, reported she gave the patient Morphine and Lorazepam together every hour, and, at one point, had to send a family member to pick up more medication from the pharmacy. When the surveyor read the visit note documentation to Staff V, Former Hospice RN, and questioned the documentation of administering Oxycodone and Lorazepam every 15 minutes, Staff V responded, "Every 15 minutes was probably how it was ordered by the Medical Director (stated the Medical Director by name) or ARNP (stated the ARNP by name)." Staff V, Former Hospice RN, explained she did not recall if she gave the patient Oxycodone or Morphine. Staff V just knew that she was giving the patient medications frequently and giving the medications as ordered. Staff V, Former Hospice RN, denied the patient ever asked her to hasten the patient's death. Staff V, Former Hospice RN, explained the patient told her weeks before the patient's death that the patient had spent the last 10 years not eating, and if the patient could go, the patient would. Staff V, Former Hospice RN, reported she educated the patient on not being the purpose of hospice to help end the patient's life. Staff V, Former Hospice RN, reported she received physician orders from both the Medical Director and ARNP for medications the day the patient died. l. On 7/11/23 at 1:51 PM, during an interview, Patient # 4's family member and identified patient representative, reported being present for the day the patient died on 6/7/22. The Patient's family member reported spending the last 10 hours with the patient and Staff V, Former Hospice RN. Patient # 4's family member reported Staff V, Former Hospice RN, was present the whole time administering medications to the patient. The family member reported the patient had not been suicidal. On 7/11/23 at 11:50 AM, during an interview with the Administrator, Clinical Manager and Director of Integration, the Clinical Manager reported she provided 1:1 education to each nurse regarding the hospices policy for attending the patients death at home on 7/6/23. She also performed wellness and medication checks on any patient Staff V, Former Hospice RN, provided services to while working for the hospice. The Director of Integration reported the hospices Quality Assurance and Performance Improvement (QAPI) program reviews 100 percent of admission visits and death visits. The Administrator and Clinical Manager also reviews 100 percent of all medication orders for controlled medications as they are written. The Director of Integration reported the reason the hospice did not identify the concern with Patient #4 was due to the documentation of Staff V, Former Hospice RN, administering the Oxycodone and Lorazepam every 15 minutes was not in the death visit note, but in a regular nursing visit note. The hospice QAPI did not have a process in place to review 100 percent of all regular visit notes. Staff V, Former Hospice RN, also did not write an order to provide the controlled medications every 15 minutes. The hospice failed to ensure hospice nursing staff administered medication only as ordered by a physician (or other licensed healthcare practitioner) and followed the patient's Plan of Care. 2. Patient #3 had a hospice admission date of 4/29/22, received routine home care hospice services while residing in a private home and died at home on 5/13/23. Review of the clinical record revealed the following: a. The POCs, dated 2/23/23 to 4/23/23 and 4/24/23 to 5/13/23, included IDG orders for skilled nursing services and a physician order for the hospice nurse to insert/maintain a urinary catheter size 16 French with a 10 cubic centimeter (cc) balloon (device inserted into the bladder and filled with fluid to hold the catheter in place), may irrigate with normal saline and change catheter every 30 days or as needed. b. A skilled nursing visit completed by Staff V, Former Hospice RN, dated 3/27/23, included documentation Staff V changed the patient's urinary catheter on 3/27/23. Staff V, Former Hospice RN, documented she planned to change the patient's catheter next on 4/27/23. c. The skilled nursing visits completed by Staff V, Former Hospice RN, dated 4/20/23 and 4/27/23, included documentation the patient had not had a change in genitourinary (bladder and structures of the body related to the urinary system) status and lacked documentation Staff V changed the patient's urinary catheter. On 4/27/23, Staff V, Former Hospice RN, documented the patient's urinary catheter was in place, draining dark colored urine, pus-like with large amounts of sediment. d. The skilled nursing visits completed by Staff V, Former Hospice RN, dated 4/24/23 and 5/1/23, included documentation that the patient's urinary catheter was last changed on 4/20/23 and was next due to be changed on 5/20/23. On 5/1/23, Staff V, Former Hospice RN, documented the patient's catheter was in place draining pus-like amber colored urine. The clinical record lacked documentation of the patient's urinary catheter change per physician orders and the POC after 3/27/23 and prior to the the patient's death on 5/13/23. The Administrator, Clinical Manager and Director of Integration received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, hospice staff personnel records, a police report, interview with law enforcement, interviews with family members and current and former hospice staff, the hospice failed to ensure: 1) hospice clinical staff receiving medication orders, record the order, sign the order immediately and have the prescribing person sign the order (See L0690); and, 2) hospice staff follow written policies and procedures for the management and disposal of controlled drugs in the patient's home (See L0694). 3) hospice staff document in the patient's clinical record the provision and discussion of the written policies and procedures for managing controlled drugs at the time when the licensed healthcare practitioner first orders a controlled medication (See L0697). --- The cumulative effect of these practices resulted in the potential for patients to be at risk for undocumented medication orders and inconsistencies in the palliative treatment of patients' conditions and the potential for the diversion and inappropriate use of controlled medications.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure hospice clinical staff receiving medication orders record the order, sign the order immediately and have the prescribing person sign the order for 1 of 8 sampled patients (Patient #4). Failure to ensure hospice clinical staff receiving medication orders record the order, sign the order immediately and have the prescribing person sign the order placed patients for undocumented medication orders and inconsistencies in the palliative treatment of patients' conditions. --- Review of the hospice's policy, titled Verification of Physician Orders, dated 12/2018, revealed hospice licensed professional staff are responsible for obtaining and documenting verbal orders from a licensed physician or other authorized independent practitioner for hospice care and services provided to patients. The hospice licensed professional staff are responsible for reading back all verbal and telephone orders to the healthcare practitioner or representative issuing the order and documenting the order in the electronic medical record. Hospice staff will send a copy of the order to the healthcare practitioner for signature and retain a copy of the signed order in the patient's clinical record within 30 days of initiation of the order. Patient #4 had a hospice admission date of 4/14/22, received routine home care hospice services while residing in a private residence until 5/24/22, then received continuous (services provided daily, up to 8 hours per day) hospice services at home from 5/25/22 until the patient's death at the patient's home on 6/7/22. Review of the clinical record revealed the following: a. The "RN Continuous Care Evaluation" visit note, dated 6/7/22, Staff V, Former Hospice RN, documented she arrived at the patient's home at 9:19 AM and the visit lasted until 3:07 PM. Staff V, Former Hospice RN, documented that Staff V administered Oxycodone and Lorazepam every 15 minutes. The clinical record lacked documentation of a physician order for the patient to receive Oxycodone or Lorazepam at the frequency of every 15 minutes as documented by Staff V, Former Hospice RN, and the clinical record and electronic prescription record lacked documentation of any new physician orders after 6/2/22. a. The POC, dated 4/14/22 to 7/12/22, identified the patient had a terminal diagnosis of tonsillar cancer with metastasis to the patient's bones and received medications and nutrition through a percutaneous endoscopic gastrostomy (Peg) tube. The same POC identified Patient #4 chose the hospice Medical Director as the attending physician and included IDG orders for skilled nursing services 2 times per week. b. A skilled nursing visit, dated 5/31/22, included documentation by Staff V, Former Hospice RN, assessed the patient's pain was at an "8" intensity level out of 10 (the worst pain possible), with 10 being the worst in the last 24 hours, and described the pain as crushing, nagging, constant and affecting all areas of the patient's life. The patient reported a pain of "10" in the last 24 hours with a goal of a pain level intensity rating of "4". Staff V, Former Hospice RN, documented that the Medical Director gave Staff V an order for Hydrocodone-Acetaminophen 10 mg-325 mg 2 tabs every 4 hours for pain, and that Staff V helped in administering this medication. The clinical record lacked documentation of what medication Staff V administered and documentation of an order for Hydrocodone-Acetaminophen 10 mg-325 mg 2 tabs every 4 hours. c. A skilled nursing visit, dated 6/2/22, included documentation by Staff V, Former Hospice RN, assessed the patient's pain was at an "8" intensity level out of 10, with 9 being the worst in the last 24 hours, and described the pain as crushing, gnawing and constant. Staff V, Former Hospice RN, documented the patient was resting in a recliner, the patient's pain seemed to be under control at that time, the patient was smiling and conversing about various properties the patient owned, and the patient seemed in much better spirits today. Staff V, Former Hospice RN, documented "oral solutions meds ordered to avoid further hassle with Peg tube." The patient's clinical record lacked documentation of any new or changed medication orders. 0n 7/11/23 at 1:43 PM, during an interview, the hospice's Director of Integration reported that Staff V, Former Hospice RN, wrote an order in the hospice's electronic script system for ordering medications on 6/2/22, a system separate from the clinical records for hospice patients. Staff V, Former Hospice RN, wrote an order for liquid Lorazepam and liquid Oxycodone on 6/2/22. The Director of Integration confirmed that the dose and frequency for the liquid Lorazepam and Oxycodone were not documented in the patients clinical record. The hospice's Director of Integration reported Staff V, Former Hospice RN, did not write an order for the patient to take take 2 Hydrocodone-Acetaminophen 10mg-325mg every 4 hours for pain on 5/27/23 in either the patient's clinical record or in the hospice electronic script system. d. Review of the hospice electronic prescription record revealed 2 physician orders signed by the hospice Medical Director, dated 6/2/22. The orders were as follows: Oxycodone 20 mg/ml concentrate, take one ml (20 mg) by mouth every 4 hours for pain and Lorazepam 2 mg/ml oral concentrate, take 0.5 ml by mouth every 2 hours as needed for anxiety. e. A skilled nursing visit note, dated 6/4/22, included documentation by Staff P, RN, that she assessed the patient's pain was at a "6" intensity level out of 10, with 7 being the worst in the last 24 hours, respirations within normal limits and a fatigue score of 7 of out 10 (with 10 being the worst) and drowsiness a "5" out of 10 (with 10 being the worst). Staff P, RN documented the patient reported uncontrolled pain, frustrated with not feeling well and confusion. The patient did not know what to take for comfort and could not find the Dexamethasone. Staff P, RN, documented she contacted the Medical Director for clarification of the plan. The nurse documented she obtained new orders for a refill of Dexamethasone and sent the medication order to the pharmacy. The patient is to use Oxycodone for routine needs and Morphine for breakthrough pain. f. The clinical record included documentation of 2 separate nurses visit notes, dated 6/7/22; one note was titled, "RN Continuous Care Evaluation" and a second note was titled, "Death Visit", and Staff V, Former Hospice RN, signed both visit notes. 1) The visit note, titled, "RN Continuous Care Evaluation", dated 6/7/22, included the following documentation: Staff V, Former Hospice RN, documented the patient was restless and agitated due to pain and had a pain intensity rating of 10. Staff V, Former Hospice RN, documented that Staff V administered Oxycodone and Lorazepam every 15 minutes and that Staff V sat with the patient and family administering medications and providing comfort. The clinical record lacked documentation of a physician order for the patient to receive Oxycodone or Lorazepam at the frequency of every 15 minutes as documented by Staff V, Former Hospice RN, and the clinical record and electronic prescription record lacked documentation of any new physician orders after 6/2/22. Staff V, Former Hospice RN, documented that she assessed the patient's vital signs as follows: Temperature at 9:42 AM was 98.3 degrees Fahrenheit (within normal range of temperature), a radial (wrist) pulse of 86 and irregular at 9:46 AM, a blood oxygen saturation level of 69 percent at 9:46 AM (values under 90 percent are considered low) and respirations at 18 breaths per minute and "within normal limits" at 10:39 AM (which would indicate the patient was not in any kind of respiratory distress). Staff V, Former Hospice RN, documented, "approximately noon; patient displaying periods of apnea (absence of breath). Breaths per minute reduced to 9." Staff V, Former Hospice RN, documented, "2:00 PM significant changes-shallow breathing. Breaths per minute 4." 2) The visit note, titled "Death Visit", dated 6/7/22, included the following documentation: Staff V, Former Hospice RN, documented travel time to the visit from 3:07 PM to 3:37 PM, then arrival at the home at 3:37 PM until 5:01 PM. Staff V, Former Hospice RN, documented the patient died at 3:02 PM with Staff V and family present at the bedside. Staff V, Former Hospice RN, documented Staff V provided post mortem cares and a family member would destroy the patient's medications including Oxycodone 20 ml (liquid) and Lorazepam 25 ml (liquid). On 7/12/23 at 9:16 AM, during an interview, the hospice Medical Director reported working for the hospice since October 2021. The Medical Director remembered Patient #4, but could not recall if Staff V, Former Hospice RN, contacted him/her for orders on either 6/2/22 or 6/7/22. The Medical Director explained a typical dose for liquid Oxycodone would be 20 mg/ml, give 5 mg every 4 hours as needed, not scheduled, and then advance to every 2 hours as needed. A typical dose for Lorazepam Intensol (liquid) would be 2 mg/ml, give 0.5 mg every 4 hours as needed. The Medical Director was unsure why the hospice would have switched over to liquid since the medications could be crushed and put through Patient #4s Peg tube. If a patient was not responding to the current dose and frequency of a pain medication, the Medical Director reported he would look first at increasing the dose before increasing the frequency. The Medical Director reported he would also use longer-acting pain medications (slower acting medication with a longer duration of pain relief), such as Fentanyl through a patch or Oxycontin (same as Oxycodone) to decrease the amount of as needed pain medication. The Medical Director reported he did not do euthanasia, and he would never give a patient pain medication if their respirations were down to 9 breaths per minute. If a patients breath is down to 9 breaths per minute, this indicates that the patient is comfortable. The Medical Director reported he would not prescribe the pain (Oxycodone) and antianxiety (Lorazepam) medication every 15 to 30 minutes except for extreme circumstances such as episodes of air hunger where the patient is gasping and choking for every breath, and the Medical Director reported he could remember ordering medication at this frequency less than 10 times in their entire career. The Medical Director explained that he will almost never schedule pain medications shorter than 6 hours, because ";it is too much drug and not enough assessment" to schedule pain medications any shorter than 6 hours apart. The Medical Director explained that with as needed pain medications, the nurse should always be assessing the patient prior to giving the medication. On 7/12/23 at 10:12 AM, during an interview, the hospice's Advanced Registered Nurse Practitioner (ARNP) reported she has worked for the hospice since 2014. The ARNP explained her role as mainly doing visits to recertify patients for hospice services, provides support to the nurses and Clinical Manager and works under the direction of the hospice Medical Director. The ARNP reported she frequently ordered medication changes and refills for hospice patients if the patient did not have an attending physician. The ARNP reported she did not remember Patient #4, and explained she never saw the patient in person. The ARNP reported she may have ordered comfort medications for the patient, but she could not recall. The ARNP explained she worked closely with the Medical Director, talks with the Medical Director "a lot" and would prescribe medications the same as the Medical Director. The ARNP reported she would not order the use of Oxycodone and Morphine at once and she would never order any medication every 15 minutes. The ARNP further explained the medications should be ordered as needed, not any shorter than every 2 hours and not scheduled. The ARNP reported she might do a one time order if a patient was in pain, and then go back to as needed. The ARNP reported the ARNP has never ordered a medication for every 15 minutes. On 7/11/23 at 3:35 PM, during an interview, Staff V, Former Hospice RN,(dates of employment 2/15/22 to 5/9/23) confirmed she was present in the patient # 4's home and with the patient when the patient died. Staff V, Former Hospice RN, described the patient as incoherent and terminally restless when Staff V arrived to the home on 6/7/22.. Staff V, Former Hospice RN, reported she and a family member of the patient's helped the patient into bed and the family member laid down with the patient in the bed. Staff V, Former Hospice RN, reported the patient asked for Staff V to call another family member to come to the home. Staff V, Former Hospice RN, reported she ended up staying close to 8 hours that day (6/7/22). Staff V, Former Hospice RN, explained she administered hourly medications while present in the home and she contacted the hospice's ARNP for medication orders. Staff V, Former Hospice RN, explained she administered all of the patient's medications through the patient's Peg tube. Staff V, Former Hospice RN, further explained that she would flush the Peg tube with water, put medications through the Peg Tube and then flush the tube again with water after administering the medications. Staff V, Former Hospice RN, reported she gave the patient Morphine and Lorazepam together every hour, and, at one point, had to send a family member to pick up more medication from the pharmacy. When the surveyor read the visit note documentation to Staff V, Former Hospice RN, and questioned the documentation of administering Oxycodone and Lorazepam every 15 minutes, Staff V responded, "Every 15 minutes was probably how it was ordered by the Medical Director (stated the Medical Director by name) or ARNP (stated the ARNP by name)." Staff V, Former Hospice RN, explained she did not recall if she gave the patient Oxycodone or Morphine. Staff V just knew that she was giving the patient medications frequently and giving the medications as ordered. Staff V, Former Hospice RN, denied the patient ever asked her to hasten the patient's death. Staff V, Former Hospice RN, explained the patient told her weeks before the patient's death that the patient had spent the last 10 years not eating, and if the patient could go, the patient would. Staff V, Former Hospice RN, reported she educated the patient on not being the purpose of hospice to help end the patient's life. Staff V, Former Hospice RN, reported she received physician orders from both the Medical Director and ARNP for medications the day the patient died. Based on the above findings, the hospice failed to ensure hospice staff recorded and signed orders immediately and had the prescribing person sign the orders. The Administrator, Clinical Manager and Director of Integration received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on review of the clinical record, hospice policy, home visit observation, hospice personnel records and a police report, and interviews with local enforcement, family members and current and former hospice staff, the hospice failed to ensure hospice staff followed written policies and procedures for the management and disposal of controlled drugs in the patient's home for 4 of 8 sampled patients (Patient #3, #6, #7 and #8). Failure to ensure hospice staff followed written policies and procedures for the management and disposal of controlled drugs (a medication requiring government control for the manufacture, distribution and use) in the patient's home increased the risk for the diversion and inappropriate use of controlled medications. --- Review of the hospice's policy, titled Home Use and the Disposal of Controlled Substances, dated 12/2018, revealed the following: the pharmacy will dispense medications directly to the patient and will be responsible tracking the amount of medication used and length of time between renewals; the hospice registered nurse (RN) will be responsible for providing, discussing and documenting they provided and discussed the written policies and procedures on the management and disposal of controlled drugs to the patient/family; when a hospice patient no longer needs a controlled medication, the hospice RN will instruct the patient/family in the proper disposal of the drug in accordance with federal, state and local laws; the hospice RN will provide information on drug take-back and mail back programs, as well as the drug disposal container; the hospice RN, social worker or chaplain attending the patient's death will inform the family of their responsibility to dispose all of the patient's prescribed medications and will document the instruction given in a clinical note; if a family requests assistance with the disposal, the hospice employee will instruct and facilitate them with the proper disposal of the prescribed medications in the home; hospice staff will document the disposal in the record and include the medication name, dose, amount destroyed, date, location, method of destruction, witness to the destruction and the name of the person destroying the medication. On 7/10/23 at 2:00 PM, during a phone interview with the hospice's Chief Compliance Officer, she confirmed the hospice last updated their drug disposal policy in 12/2018. The Chief Compliance Officer reported all staff have access to all of the hospices policies electronically. The Director of Integration is the leader of the clinical team which is responsible for staff education. Hospice nursing staff receive training on the hospices drug disposal policy upon hire during orientation and annually through computer training. The Chief Compliance Officer reported they would provide the training records for for Staff V, Former Hospice RN. The Chief Compliance Officer denied any prior drug diversion incidents with this hospice, and reported they had no reason to suspect a drug diversion had occurred. The Chief Compliance Officer reported the hospice supplied a Drug buster (container with a chemical agent inside which makes medications unusable) to all staff. Hospice nursing staff are to destroy controlled medications with a witness in the patient's home. Review of the Hospice Admission Handbook provided by hospice staff to all patients/family or patient representatives at the time of admission to hospice revealed the handbook contained directions to the patient to follow federal guidelines in the disposal of medication, to follow drug labels and any drug inserts on the specific disposal for medication, take advantage of drug take back programs. The handbook advises that if there are no instructions on the prescription label or medication insert and no drug take back programs, the patient/family should throw the medications in the household trash after removing the medication from the original container and mixing the medication with an undesirable substance such as kitty litter or used coffee grounds and placing the mixture in a sealable bag. If the medication is a controlled substance, the hospice registered nurse (RN) will be responsible for providing, discussing and documenting they provided and discussed the written policies and procedures on the management and disposal of controlled drugs to the patient/family. When a hospice patient no longer needs a controlled medication, the hospice RN will instruct the patient/family in the proper disposal of the drug. The hospice RN, social worker or chaplain attending the patient's death will inform the family of their responsibility to dispose all of the patient's prescribed medications and will document the instruction given in a clinical note. Whenever possible, the hospice RN should schedule a home visit for the witnessed destruction for any medication left in the home. Hospice personnel will witness and instruct, not dispose of any patient medications. Hospice staff are not remove prescription medications from the patient's home. If the family refuses to allow the hospice RN witness/facilitate the disposal of medications, the nurse will document this in the record and notifies the patient's physician. 1. Review of a police report, dated 6/27/23, revealed a local law enforcement investigator found, photographed and seized the following prescription drugs/narcotics in the vehicle and garage belonging to Staff V, Former Hospice RN: 1) A red pill bottle labeled Ondansetron (a medication used to treat nausea) with the name of Patient #8 on the label and pills inside the bottle located on a shelf in the garage. 2) A brown pill bottle labeled Lorazepam Intensol (a controlled medication used to treat anxiety; controlled medications are drugs/substance that require government control for making, using handling and storage) with the name of Patient #6 and liquid inside the bottle on a higher shelf in the garage. 3) A prescription bottle labeled Protonix (a medication used to treat/prevent excess stomach acid and gastric reflux) with Patient #3's name and with pills inside the bottle located in a grocery bag on the floor of the garage. 4) A box containing Levemir "injectors" (a type of injectable insulin in a multi-dose injection pen used to treat high blood sugar levels) with Patient #7's name on the label located in the grocery bag. 5) A box containing Humalog "injectors" (a type of injectable insulin in a multi-dose injection pen used to treat high blood sugar levels) with Patient #7s name on the label and located in the grocery bag. 6) One loose Humalog injector pen and one loose Levemir injector pen from the grocery bag (no patient name identified). 7) A pill bottle labeled Hydrocodone (a type of controlled medication used to treat pain) with Patient #3's name on the label, and with an estimated number of at least 50 white pills inside the bottle out of a total number of initially 90 pills prescribed, found in the center console of the vehicle. 8) A prescription bottle labeled Tramadol (a type of controlled medication used to treat pain) with Patient #3's name on the label, and white pills inside the bottle, found in the center console of the vehicle. 9) A prescription bottle labeled Lorazepam (a type of controlled medication used to treat anxiety) with Patient #3's name on the label, and white pills inside the bottle, found in the front passenger seat of the vehicle. 10) A prescription bottle with a handwritten label "meds 9-18 nighttime ???" containing 14 miscellaneous pills (no patient identified and no location). 11) A prescription bottle with a handwritten label "Tramadol" in black ink with 10 unknown pills (no patient name identified and no location). The local law enforcement officer documented a family member (Family Member #1) of Staff V, Former Hospice RN, reported staying at Staff V's house the previous night (6/26/23) and finding the prescription medications that did not belong in the home. Family Member #1 reported they recognized the names on the prescription bottles due to Staff V, Former Hospice RN, mentioning those patients. When asked by the local law enforcement officer if Family Member #1 believed Staff V, Former Hospice RN, was selling the medications, Family Member #1 responded Staff V "might be" and prior to having separate bank accounts, Family Member #1 noticed several small increment deposits, usually 10 dollars, made into a Venmo account. On 7/6/23 at 11:38 PM, during an interview, the Local Law Enforcement Officer who wrote the police report on 6/27/23 reported the officers on the scene removed medication bottles from Staff V's, Former Hospice RN, vehicle belonging to 4 different persons. The Local Law Enforcement Officer reported when questioned about the medications, Staff V, Former Hospice RN, explained while she might not have followed the normal process for the disposal of the medications, she followed how she had been trained by her coworkers. Staff V, Former Hospice RN, reported to the Local Law Enforcement Officer that the hospice had not provided any training or drug destroying containers. According to the Local Law Enforcement Officer, Staff V, Former Hospice RN, reported a co-worker provided a drug destroying container sometime after she started working for the hospice. The Local Law Enforcement Officer reported they were unable to determine if Staff V, Former Hospice RN, had any customers for the sale of the medications. The Local Law Enforcement Officer reported Staff V, Former Hospice RN, stated the reason that Staff V had the hospice patients medication bottles was because Staff V had done the death visit for those patients and took the patient's medications. The Local Law Enforcement Officer reported Staff V, Former Hospice RN, has had two negative drug tests, one through another State Agency and one through Staff V's new employer. On 7/12/23 at 11:55 AM, during an interview, Family Member #1 (family member of Staff V, Former Hospice RN) reported not knowing about the prescription medications the police found in Staff V's car. Family Member #1 reported Staff V, Former Hospice RN, used to have a plastic bag from a local retail store in the backseat of the car full of patient medications. Family Member #1 explained that they told Staff V, Former Hospice RN, that Staff V needed to get rid of the medications, and then the bag did disappear. Family Member #1 reported Staff V, Former Hospice RN, kept random medications in the garage including pain killers. Family Member reported finding an Insulin multi-dose pen that was full on the floor of the garage. Family Member #1 did not know why Staff V, Former Hospice RN, kept the hospice patient's medications. 2. Review of the hospice's self reported incident to the State Agency and the hospice's complaint log, dated 6/28/23, included documentation that a family member (Family Member #2) of Staff V, Former Hospice RN, reported "prescription drugs were found in (Staff V's) car and garage." The hospice staff interviewed family members of Staff V's, Former Hospice RN, who provided the names of 4 patients whose prescription medications were in Staff V's possession. The hospice's Chief Compliance Officer confirmed each of the 4 patients were a former patient of Staff V, Former Hospice RN. On 7/10/23 at 2:00 PM, during a phone interview with the hospice's Chief Compliance Officer and the hospices attorney, the Chief Compliance Officer reported they originally received a call from a family member of Staff V's, Former Hospice RN, on 6/24/23, but had been unable to reach and speak with the family member until 6/28/23. Family Member #2 reported Staff V, Former Hospice RN, had been historically diverting drugs and had assisted a patient with suicide. Family Member #2 reported at that time that they had contacted the police. The police had taken photos and videos of medications found in the vehicle and the patients home. Family Member #2 discussed concerns regarding patients, and mentioned those patients by name. Family Member #2 reported Staff V, Former Hospice RN, had a bottle of Lorazepam with Patient #6s name, a bottle of Zofran 1 mg tablets with Patient #8's name on the bottle, 2 insulin multi-injection pens for Patient #8 (the family member knew the first name, but not the last name of the patient) and a half bottle full of Tramadol tablets and a full bottle of Hydrocodone tablets for Patient #3. There was also a bottle of Protonix pills. On 7/12/23 at 1:54 PM, during an interview, Family Member #2 (family member of Staff V, Former Hospice RN) confirmed being present when the police confiscated the medications from Staff V's home and reported not knowing why Staff V had kept the patient's medications. 3. Patient #3 had a hospice admission date of 4/29/22, received routine home care hospice services while residing in a private home and died at home on 5/13/23. Review of the clinical record revealed the following: a. A skilled nursing visit note, dated 5/5/22, included documentation of the first time Staff V, Former Hospice RN, provided hospice nursing services to the patient. b. The Plan of Care (POC), dated 8/27/22 to 10/25/22, included Interdisciplinary Group (IDG) orders for skilled nursing services and a medication order for Tramadol 50 milligrams 1 tablet every hours as needed for pain. c. The clinical record included documentation Staff V, Former Hospice RN, entered a medication order from the patient's physician to discontinue Tramadol on 9/9/22 (a medication found by the police in Staff V's possession). d. The POC, dated 12/25/22 to 2/22/23, included physician orders for Hydrocodone-Acetaminophen 5 mg-325 mg 1 tablet every 4 hours as needed, Lorazepam 0.5 mg 1 tablet every 2 hours as needed for anxiety and 1 tablet 2 times daily and an order for Pantoprazole (Protonix) 40 mg 1 tablet every day. e. The clinical record included documentation Staff V, Former Hospice RN, entered medication orders from the patient's physician to discontinue the Hydrocodone-Acetaminophen, Lorazepam 0.5 mg, both as needed and scheduled, and the Protonix on 1/22/23 ( medications found by the police in Staff V's possession). On 7/11/23 at 3:35 PM, during an interview, Staff V, Former Hospice RN, reported the patient's family kept the patient's medications in a kitchen cupboard. Staff V, Former Hospice RN, reported an in-home provider belonging to a different agency told Staff V the discontinued medications in the patient's home needed to be removed and the in-home provider was not allowed to transport the medications. Staff V, Former Hospice RN, reported Staff V had a "drug buster" (container with a chemical agent inside which makes medications unusable) and told the in-home provider that Staff V could dispose of the medications. Staff V, Former Hospice RN, reported being unsure of when she removed the Tramadol from the patient's home, but thought she had removed Hydrocodone-Acetaminophen, Lorazepam and Protonix from Patient #3's home sometime in April 2023. 4. Patient #6 had a hospice admission date of 10/5/22, received routine home care hospice services while residing in a private residence and died at home on 10/10/22. Review of the clinical record revealed the following: a. The POC, dated 10/5/22 to 1/2/23, included IDG orders for skilled nursing services and the following physician ordered controlled medications: Lorazepam 2 mg/ milliliter (ml) oral concentrate 0.25 ml every 2 hours as needed for anxiety/restlessness (a medication found by the police in Staff V's, Former Hospice RN, possession) and Morphine Concentrate 100 mg/5 ml give 0.25 ml by mouth or under the tongue every 2 hours as needed for moderate to severe pain. b. The skilled nursing visit note, dated 10/10/22, included documentation by Staff V, Former Hospice RN, that Staff V was not present for the patient's death. Staff V, Former Hospice RN, documented Staff V arrived at the home, pronounced the patient's death with the family was present. Staff V, Former Hospice RN, documented the family would destroy the medications and Staff V had provided the family with the phone number of an approved medication disposal site. Staff V, Former Hospice RN, documented the patient had Morphine 20 mg/ml with 27 ml left in the bottle and Lorazepam 2 mg/ml and 29.25 ml left in the bottle. On 7/11/23 at 3:35 PM, during an interview, Staff V, Former Hospice RN, confirmed she completed the patient's death visit. Staff V, Former Hospice RN, reported the patient's family was present including the patient's designated representative. Staff V, Former Hospice RN, explained one of the family member's present had some drug issues, so Staff V took the patient's medications because of the family member's drug issue. Staff V, Former Hospice RN, reported the family may have wasted the Morphine medication. Staff V thought the family may have put the Morphine down the toilet before Staff V, Former Hospice RN, arrived at the patient's home. Staff V, Former Hospice RN, explained the patient's family member/designated representative put the rest of the patient's medications down the toilet or sink and Staff V told them not to do that. On 7/11/23 at 11:12 AM, during an interview, the patients family member/designated representative, reported they thought the hospice staff took the medications with them and denied destroying the Morphine and Lorazepam. On 7/11/22 at 11:08 AM, during an interview, Staff X, Hospice Aide, reported being in the home during the death visit for Patient #6 at the same time as Staff V, Former Hospice RN. Staff X, Hospice Aide, reported she did not see Staff V, Former Hospice RN, take any medications out of the home, but Staff X reported leaving the home before Staff V. 5. Patient #7 had a hospice admission date of 8/4/22, received routine home care hospice services while residing in a private residence and died at home on 9/21/22. Review of the clinical record revealed the following: The POC, dated 8/4/22 to 11/1/22, identified the patient had a diagnosis of diabetes (a chronic condition that affects the way the blood processes blood sugar, typically resulting in high blood sugar levels), included IDG orders for skilled nursing services and physician ordered medications. The same POC did not include any orders for Levemir and Humalog insulin (medications used to treat high blood sugar levels; the medication found by the police in Staff V's, Former Hospice RN, possession). On 7/11/23 at 11:30 AM, during an interview, the patients spouse reported the patient stopped taking insulin prior to starting hospice; they thought sometime in July 2021. The patients spouse explained , ";When we first moved, I was cleaning out (the patients) old medications. The nurse said give them to me, we dispose of all this, I have a thing in my car and it eats it up." The patients spouse confirmed the nurse was Staff V, Former Hospice RN. The patients spouse reported Staff V, Former Hospice RN later told them that Staff V was not supposed to take the medications from the patient's home. The patients spouse reported, from that point on, the patient's spouse took to the medications to a local pharmacy to have the medications destroyed. On 7/11/23 at 3:35 PM, during an interview, Staff V, Former Hospice RN, explained Staff V planned to take the insulin back to the pharmacy for the patient's spouse. Staff V, Former Hospice RN, explained the pharmacy staff would not let Staff V put the insulin or needles in their drop box. Staff V, Former Hospice RN, reported she did have a discussion with the patient's spouse and, "I did tell (patient's spouse) I could not take any more insulin." When the surveyor brought up the fact that Staff V, Former Hospice RN, had already removed all of the insulin from the home, Staff V responded, "; I meant I couldnt take any other diabetic medication, like Metformin" out of their home. Staff V, Former Hospice RN, reported she did not take any more medications out of the patient's home. 6. Patient #8 had a hospice admission date of 11/20/22, received routine home care hospice services while residing in a private residence and died at home on 11/26/22. Review of the clinical record revealed the following: a. The POC, dated 11/20/22 to 2/17/23, included IDG orders for skilled nursing services. The same POC included the following medication orders: Acetaminophen suppository (medication used for pain and fever reduction); Bisacodyl suppository (medication used to treat constipation); Hyoscyamine disintegrating tablet (medication used to treat excessive mouth secretions); Lorazepam 2 mg/ml oral concentrate (medication used to treat anxiety/restlessness); Morphine Concentrate 100 mg/5 ml (medication used to treat pain and shortness of breath; and, Ondansetron disintegrating tablet (medication used to treat nausea; a medication found by the police in Staff V's, Former Hospice RN, possession). b. The skilled nursing visit note, dated 11/26/22, included documentation by Staff V, Former Hospice RN, that Staff V was not present for the patient's death. Staff V, Former Hospice RN, documented she arrived at the home, pronounced the patient's death with the family was present. Staff V, Former Hospice RN, documented the family would destroy the medications and Staff V had provided the family with the phone number of an approved medication disposal site. Staff V, Former Hospice RN, documented Staff Y, Hospice Aide, was present in the home and provided a bed bath and dressed the patient for post mortem cares. Staff V, Former Hospice RN, documented the patient had Morphine with 22.0 ml left in the bottle and Lorazepam with 22.0 ml left in the bottle. On 7/11/23 at 10:20 AM, during an interview, Staff Y, Hospice Aide, reported the family dismissed Staff Y from the home prior to Staff V, Former Hospice RN, arriving at the home. Staff Y, Hospice Aide, explained Staff Y pulled out of the patient's driveway when Staff V, Former Hospice RN, pulled in. On 7/11/23 at 12:40 PM, during an interview, the patient's spouse reported Staff V, Former Hospice RN, did take some medications out of the house on the same day the patient died. The patient's spouse reported Staff V, Former Hospice RN, told the spouse that Staff V was going to destroy the medications. The patient's spouse reported being unsure what medications Staff V, Former Hospice RN, took with her. On 7/11/23 at 3:35 PM, during an interview, Staff V, Former Hospice RN, explained she was on-call the day the patient died. Staff V, Former Hospice RN, explained when she went into the home, the patient's spouse handed Staff V a bag with the patient's medications inside the bag. Staff V, Former Hospice RN, reported the patient's spouse told Staff V, "I need you to get everything out of here because my (identified a specific family member) is a drug addict." Staff V, Former Hospice RN, reported the patient's spouse handed Staff V the medicated suppositories, and Staff V threw them away. Staff V, Former Hospice RN, explained that if the medication had a patient name on it, Staff V would put the medication on a shelf in Staff V's garage, or Staff V would dispose of the medication in the drug buster container in Staff V's garage if and when Staff V's spouse moved their truck which blocked access to the drug buster container. Staff V, Former Hospice RN, reported Staff V would take empty prescription bottles to a drop box at a local pharmacy when Staff V could get there. During the same interview, Staff V, Former Hospice RN, reported the hospice had provided little to no education to Staff V in regards to the hospice's medication and controlled drug disposal policies. Staff V, Former Hospice RN, reported Staff was given a 64 ounce drug buster container when Staff V started. Staff V, Former Hospice RN, stated, "The boss did not do any training." Staff V, Former Hospice RN, explained when someone died, if the pharmacy was not open and the family requested it, Staff V would put the patient's medications in the drug buster container. Staff V, Former Hospice RN, reported Staff V did not read the hospice's policy on the disposal of controlled substances. Staff V, Former Hospice RN, explained Staff V had 5 business days to complete training on the computer, and they were out in the field with Staff M, Former Manager of Clinical Services, described as Staff V's "boss" at the time, Staff V denied completing the orientation checklist within the 30 days required. . Staff V, Former Hospice RN, explained Staff O, Former Clinical Services Manager, called Staff V into the office and asked Staff V where Staff V's orientation checklist was located. Staff V, Former Hospice RN, reported to Staff O, Former Clinical Services Manager, that the previous Clinical Services Manager had not completed the orientation checklist, so both Staff V and Staff O went initialed each of the training areas on the checklist and signed Staff V's completion of the orientation training that same day (11/30/22). Staff V, Former Hospice RN, explained they did not really review the areas of training and the initialing and signing of the form was just a technicality. During the same interview, when asked what education Staff V, Former Hospice RN, provided to patients and their families on drug disposal, Staff V reported when Staff V, admitted patients, which was not often, Staff V would tell the family to go to the local pharmacy or local police department to dispose of the patient's medications. Staff V, Former Hospice RN, reported mostly providing education to the families of patients at death visits. Staff V, Former Hospice RN, reported Staff V never read the hospice's admission packet Hospice Admission Handbook with the patients and families. Staff V, Former Hospice RN, explained when Staff V admitted the patients to hospice, one of the hospice's Care Transition Coordinators would be with Staff V, and Care Transition Coordinators would review the Hospice Admission Handbook and admission packet with the patients and families while they all sat together. Staff V, Former Hospice RN, reported Staff V would give family members the 1-800 number to call for medication disposal if the patient died and information on pharmacy disposal boxes. Staff V, Former Hospice RN, reported on multiple occasions, during death visits with families, the family members would be highly emotional and the family members would "say things like will you please take this out of my house, thats when I would take the medications out of the house to drug buster." Staff V, Former Hospice RN, stated, "I moved the drug buster from my car from the backseat to a shelf in my garage and then I would bring whatever medications I needed to dispose and then dispose of them. In the winter months, I could not fit between the truck and the shelf (in the garage), so I could only dispose of them (patient's medications) when his truck was pulled out. Staff V, Former Hospice RN, reported that if Staff V could not dispose of a patient's medications right away, Staff V put the medications in plastic bags on the garage shelf. On 7/11/23 at 4:18 PM, during an interview, the Director of Integration reported that the Care Transition Coordinators do not review the hospices admission packet with the patients. The admission nurse or social worker reviews the contents of the admission packet including the drug disposal policy. On 7/12/23 at 11:01 AM, during an interview, Staff T, Care Transition Coordinator, reported she started working for the hospice in November 2021. Staff T, Care Transition Coordinator, reported she does sit in on admission visit with a nurse on occasion. Staff T, Care Transition Coordinator, explained she does an initial meeting with patient/family when the hospice gets a referral and she just does the first steps of the referral process. Staff T, Care Transition Coordinator, explained the hospice nurse is responsible for reviewing the admission packet and signing consents with patient. Staff T, Care Transition Coordinator, reported she would never talk about the hospice's drug disposal policy with a patient or family. On 7/12/23 at 11:29 AM, during an interview, Staff R, Care Transition Coordinator, reported working for the hospice since 8/29/22. Staff R, Care Transition Coordinator, described her role as the hospice's liaison for marketing and reported responsibilities include sharing information on programs the hospice provides and providing "hospice 101 education" to potential hospice patients and families. Staff R, Care Transition Coordinator, reported she has, on occasion, sat in on an admission visit with a nurse, but explained she is just there to help answer questions and to be a familiar face. Staff R, Care Transition Coordinator, reported the nurse reviews the admission packet and reviews the drug disposal policy with the patient and family. On 7/12/23 at 11:45 AM, during an interview, Staff S, Care Transition Coordinator, reported she has been with hospice a little over 2 years. Staff S, Care Transition Coordinator, reported she does go out an admission visit with nurse. Staff S, Care Transition Coordinator, explained the nurse reviews the admission packet with family including drug disposal policy. 7. Patient #4 had a hospice admission date of 4/14/22, received routine home care hospice services while residing in a private residence until 5/24/22, then received continuous (services provided daily, up to 8 hours per day) hospice services at home from 5/25/22 until the patient's death at the patient's home on 6/7/22. Review of the clinical revealed the following: The comprehensive assessment completed at the start of care by Staff V, Former Hospice RN, dated 4/14/22, included documentation that Staff V discussed the hospice's policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and family (Staff V had stated in Staff V's interview that she did not know the hospice's policy for disposal of controlled drugs and they had never reviewed this with a patient/family). 8. Review of the hospice's drug management and disposal procedures and education provided to staff, and specifically Staff V, Former Hospice RN, revealed the following: a. On 7/5/23 at 4:15 PM, during an interview, the Director of Integration reported the hospice provided education to staff upon hire and at staff meetings regarding the hospices drug disposal policy for controlled medications. The hospice staff are not to remove medications from the home or take medications to the home. The hospice uses either a 24 hour pharmacy or a courier to deliver the medications to the patients. Hospice staff are to witness the destruction of the medications and document the destruction of the medication when the patient dies or if the patients physician discontinues the medication. b. On 7/6/23 at 10:12 AM, during a home visit observation, Staff D, RN, assessed Patient #1 (a current hospice patient receiving hospice services while residing in a private residence) and asked the patient about pain. The patients spouse then asked Staff D, RN, to remove discontinued medications from the home, and tried to hand the medications to Staff D. Staff D, RN, responded that she could not remove the medications, but she could assist the patient with destroying the medications with a ";drug buster" (a container with a chemical agent used to destroy medications and make them unusable). The surveyor observed one of the medications the patients spouse wanted to destroy was Hydrocodone-Acetaminophen tablets, a controlled medication. Staff D, RN, reported the hospice staff do not take or remove medications from the patients homes. Staff D, RN, reported she uses the drug buster to waste medications and document the waste of the medications in the patients record. c. On 7/6/23 at 11:07 AM, during an interview, Staff G, RN, reported she has worked for the hospice for the last 2 years, but only since April 2023 at this hospice's office. Staff G, RN, reported shr discussed medication changes with the patient and/or family prior to any changes to ensure the patient/family are in agreement. Staff G, RN, reported she discussed the drug disposal policy with patients and/or caregivers on admission, with any medication changes and with the death of the patients if the patients are in a private home setting. Staff G, RN, explained she document the discussion of the drug disposal policy with the family in the clinical record. Staff G, RN, reported she does not bring any or remove any medications from a patients home. She brings the drug buster into the patients home and the family witnesses what medication she destroy and how much, or the family destroys the medication and the nurse witnesses the destruction. The nurse documents the medication and amount destroyed in the patients clinical record. The hospice provides education regarding the drug disposal policy. Staff G, RN, reported not having knowledge of another nurse taking medications from a patients home. d. On 7/6/23 at 11:15 AM, during an interview, Staff H, RN, reported she has worked for the hospice for 3 and half years. Staff H, RN, reviews the drug disposal policy for controlled medications upon admission with the patient/family, with the discontinuation of medications and with the death of the patient. Staff H, RN, reported she never take medications out of a patients home. Staff H, RN, reported she use a drug buster or coffee grounds to dispose of the medications. Staff H, RN, reported she witness the medications destroyed by the family, if possible, and document the destruction of the medications. Staff H, RN, reported the hospice provided education on drug disposal when hired and ongoing. Staff H, RN, reported not having knowledge of another nurse taking medications from a patients home. e. On 7/12/23 at 11:07 AM Staff I, RN, reported she has worked for the hospice since September 2022. Staff I, RN reported the hospice RN reviews the hospice's admission packet, which includes the Hospice Admission Handbook with the drug disposal policy, with patient and family. The Care Transition Coordinators do go to some of admissions, but never do the admission packet with patient and family Staff I, RN reported she has never had a patient or family tell Staff I that a nurse was removing meds from the patient's home. Staff I, RN, reported she has never removed medications from a patient's home. Staff I, RN, explained the hospice nurses have medication buster containers with activated charcoal inside the container and they bring the drug buster container into the patient's home. Staff I, RN, reported that she witness the family wasting the medication if the medication to be wasted is a controlled medication. Staff I, RN, reported receiving education from the hospice when she started with the hospice and also just recently on the hospice's drug disposal policy. f. On 7/12/23 at 11:42 AM, during an interview, Staff J, RN, reported working for the hospice for a little over a month. Staff J, RN, explained she was still in orientation had a "shadow" (a hospice nurse that goes with and observes them performing home visits). Staff J, RN, reported receiving education on the hospice's drug disposal policy. Staff J, RN, explained the nurse is not to take medications out of the home and the family are to dispose of them. g. On 7/10/23 at 3:20 PM, during an interview, the Director of Integration confirmed that they are responsible for ensuring the training of hospice staff during orientation and ongoing. The Director of Integration provided documentation of Staff V's, Former Hospice RN, training in the hospices policy on the disposal of medications, including controlled medications, dated 11/30/22, as part of the hospices orientation process. The Director of Integration reported hospice staff were not allowed to work independently in the field until they completed the hospices orientation, and staff typically completed the orientation within 30 days after hire. The Director of Integration reported she would look to see if there was a documented training on the controlled drug disposal policy prior to 11/30/22. The Director of Integration did provide a copy of a computer training, dated complete by Staff V, Former Hospice RN, on 2/17/22 for training on medical waste disposal. 1) On 7/10/23 at 4:45 PM, the Director of Integration provided documentation of the content of the computer training that Staff V, Former Hospice RN, took on 2/17/22. Review of the training documentation, titled Medical Waste Disposal in the Home, revealed the training included education provided to staff regarding the disposal of medications in the patients home. This education included directions to follow the hospices policy on management and disposal of medications and State and Federal laws, education on documentation and tracking process for the disposal of any medications, and education on the disposal of medications in the patients home by a process that prohibits the retrieval or ingestion by anyone, such as diluting drugs with coffee grounds or kitty litter. 2) On 7/11/23 at 8:15 AM, during an interview, the Administrator reported the person responsible, Staff O, Former Clinical Services Manager, for signing off on the training Staff V, Former Hospice RN, received on 11/30/22 no longer worked for the hospice. The Administrator reported the former Clinical Manager had been new to their role at that time and had completed a performance review with Staff V, Former Hospice RN, to determine competency. The Administrator reported the Director of Integration was still looking for documentation of Staff V's, Former Hospice RN, completed orientation documentation prior to 11/30/22. 3) On 7/12/23 at 10:26 AM, during an interview, Staff M, Former Manager of Clinical Services, reported Staff M would have instructed Staff V, Former Hospice RN, to utilize a drug buster container to dispose of medications in the patient's home. The instruction would have included for the Family or patient's representative to destroy the medications with the container after instructing the family on how to use the container. Staff M, Former Manager of Clinical Services, did not recall an incident with Staff V, Former Hospice RN, having a patients insulin in Staff V's possession and asking Staff M what should be done with it. 4) On 7/12/23 at 10:32 AM, during an interview, Staff N, Former Hospice Administer, remembered Staff V, Former Hospice RN, and being a part of Staff V's orientation. Staff N, explained she not only oversaw Staff V's, Former Hospice RN, but Staff N also went out in field doing home visits with patients and Staff V. Staff N, reported not being able to remember the specifics on training Staff V, Former Hospice RN, but the hospice has a set orientation training and all staff receive the same training. The training includes a months worth of orientation with another nurse, 1 to 2 weeks observing a nurse, and then doing the visit with another nurse observing. During the training, the nurses will do each type of visit 3 times, including admit and death visits, with the nurse in orientation observing the first, and possibly the second visit, and then performing the third visit. Staff N, reported being sure Staff V, Former Hospice RN, completed the orientation, as Staff N stated, " I would not have let ( Staff V) out in the field otherwise. Staff N, Former Hospice Administer, explained admission visits with patients would have included drug disposal education to the patient and family by getting out the hospice admission packet and going through the Hospice Admission Handbook in detail. Staff N, Former Hospice Administer, explained the nurse that does the admission visit should always take out drug buster to patients so they have one. Staff N, explained the Care Transition Coordinators are a marketing team and they are not allowed to have the patient's sign consents, or explain the admission packet. 5) On 7/12/23 at 11:34 AM, during an interview, Staff O, Former Clinical Services Manager from late July 2022 to December 2022, reported she was responsible for overseeing new staff orientation and ensure the completion of the new staff orientation checklist. Staff O, Former Clinical Services Manager, explained they did complete an orientation checklist form for Staff V, Former Hospice RN, on 11/30/22, but as an annual evaluation, not an initial training. Staff O, Former Clinical Services Manager, reported on 11/30/22, Staff O went through each of the training areas on the form with Staff V, Former Hospice RN, by talking through the training areas before initialing and signing off at the end with Staff V. Staff O, Former Clinical Services Manager, remembers she discussed attendance as an area of concern with Staff V, Former Hospice RN, at the time of the annual performance review. Staff V, Former Hospice RN, reported the review with Staff V, Former Hospice RN, included a review of the hospice drug disposal policy and Staff V being able to competently state that she was to take the drug buster into the patient homes and dispose of medications at the patients home. Staff O, Former Clinical Services Manager, does not remember an incident involving Staff V, Former Hospice RN, with having patients medications in Staff V's possession. 6) On 7/12/23 at 12:07 PM, during an interview, Staff P, RN, reported she has worked for the hospice for almost 7 years. Staff P, RN, reported that she did not remember the specifics of training Staff V, Former Hospice RN, but she knew she did several routine visits with Staff V. Staff P, RN, could not say for sure if she did training with Staff V, Former Hospice RN, on how to do an admission visit, or if she provided training to Staff V on providing and discussing the drug disposal policy with patients and families on admission to the hospice. Staff P, RN, explained if the nurse was doing a death visit or the patient had a medication discontinued, the nurse provides education on drug disposal to the patient/family, and if the medication is a controlled medication, then she assists the patient/family with destroying the medication in the drug buster. Staff P, RN, reported she does not take medications out of the home and would have educated any nurse in training to bring the drug buster into the home to destroy the medication. Staff P, RN, reported she had not ever heard of a nurse with the hospice taking a patients medications out of the home. The hospice failed to ensure all hospice staff followed the hospice's written policies and procedures for the management and disposal of controlled drugs. The Administrator, Clinical Manager and Director of Integration received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to maintain documentation in the patient's clinical record as evidence that patients/caregiver received a copy of the hospice policy concerning the disposition of controlled medications and hospice staff discussed this policy with the patient/caregiver for 1 of 1 sampled patients (Patient #7) who received routine home care while living in a private home and had physician ordered controlled medications, not on admission, but some time after the patient's admission to hospice. Failure to ensure patients and/or caregivers received adequate education on the use and disposition of controlled (medication whose manufacture, distribution, possession and use are controlled by the government) increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. --- Review of the hospice's policy, titled Home Use and the Disposal of Controlled Substances, dated 12/2018, revealed the following: the pharmacy will dispense medications directly to the patient and will be responsible tracking the amount of medication used and length of time between renewals; the hospice registered nurse (RN) will be responsible for providing, discussing and documenting they provided and discussed the written policies and procedures on the management and disposal of controlled drugs to the patient/family; when a hospice patient no longer needs a controlled medication, the hospice RN will instruct the patient/family in the proper disposal of the drug in accordance with federal, state and local laws; the hospice RN will provide information on drug take-back and mail back programs, as well as the drug disposal container; the hospice RN, social worker or chaplain attending the patient's death will inform the family of their responsibility to dispose all of the patient's prescribed medications and will document the instruction given in a clinical note; if a family requests assistance with the disposal, the hospice employee will instruct and facilitate them with the proper disposal of the prescribed medications in the home; hospice staff will document the disposal in the record and include the medication name, dose, amount destroyed, date, location, method of destruction, witness to the destruction and the name of the person destroying the medication. Review of the Hospice Admission Handbook provided by hospice staff to all patients/family or patient representatives at the time of admission to hospice revealed the handbook contained directions to the patient to follow federal guidelines in the disposal of medication, to follow drug labels and any drug inserts on the specific disposal for medication, take advantage of drug take back programs. The handbook advises that if there are no instructions on the prescription label or medication insert and no drug take back programs, the patient/family should throw the medications in the household trash after removing the medication from the original container and mixing the medication with an undesirable substance such as kitty litter or used coffee grounds and placing the mixture in a sealable bag. If the medication is a controlled substance, the hospice registered nurse (RN) will be responsible for providing, discussing and documenting they provided and discussed the written policies and procedures on the management and disposal of controlled drugs to the patient/family. When a hospice patient no longer needs a controlled medication, the hospice RN will instruct the patient/family in the proper disposal of the drug. The hospice RN, social worker or chaplain attending the patient's death will inform the family of their responsibility to dispose all of the patient's prescribed medications and will document the instruction given in a clinical note. Whenever possible, the hospice RN should schedule a home visit for the witnessed destruction for any medication left in the home. Hospice personnel will witness and instruct, not dispose of any patient medications. Hospice staff are not remove prescription medications from the patient's home. If the family refuses to allow the hospice RN witness/facilitate the disposal of medications, the nurse will document this in the record and notifies the patient's physician. Patient #7 had a hospice admission date of 8/4/22, received routine home care hospice services while residing in a private residence and died at home on 9/21/22. Review of the clinical record revealed the following: a. The POC, dated 8/4/22 to 11/1/22, included IDG orders for skilled nursing services and physician ordered medications, but lacked an order for a controlled medication. b. A clinical coordination note, dated 9/10/22, included documentation the patient's family requested medications for the patient for comfort, restlessness and pain. c. A physician order given by the hospice's Medical Director, dated 9/10/2022, included an order for Lorazepam Intensol and Morphine Concentrate, both controlled medications (the patient was not on a controlled medication prior to 9/10/22). d. The subsequent skilled nursing visit note completed by Staff AA, Former Hospice RN, dated 9/12/2022, included documentation the patient had received "comfort medications that day", but lacked any documentation the nurse provided the patient/caregiver with information and education on the disposal of controlled medications on this date. On 7/5/23 at 4:15 PM, during an interview, the Director of Integration reported the hospice provided education to staff upon hire and at staff meetings regarding the hospices drug disposal policy for controlled medications. On 7/6/23 at 11:07 AM, during an interview, Staff G, RN, reported she discussed the drug disposal policy with patients and/or caregivers on admission, with any medication changes and with the death of the patient/family if the patient was in a private home setting. On 7/6/23 at 11:15 AM, during an interview, Staff H, RN, reported she reviews the drug disposal policy for controlled medications upon admission with the patient/family, with the discontinuation of medications and with the death of the patient. On 7/11/23 at 3:35 PM, during an interview, Staff V, Former Hospice RN, reported when Staff V, admitted patients, she would tell the family to go to the local pharmacy or local police department to dispose of the patient's medications. Staff V, Former Hospice RN, reported mostly providing education to the families of patients at death visits. Staff V, Former Hospice RN, reported she never read the hospice's admission packet or Hospice Admission Handbook with the patients and families. The Administrator, Clinical Manager and Director of Integration received the above findings and hospice staff provided no further information prior to the end of the survey.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a criminal history, dependent adult abuse or child abuse record checks for 1 of 3 sampled registered nurses sampled (Staff I, Registered Nurse). Failure to complete criminal history, dependent adult and child abuse record checks as required by State regulation, increased the potential risk of harm to agency patients from staff who had direct patient contact. --- Staff I, Registered Nurse (RN), had hire date of 9/19/22. Staff I's personnel file included documentation of completed criminal history, dependent adult and child abuse record checks, dated 8/17/22, 33 days prior to Staff I's start date. On 7/12/23 at 2:47 PM, during an interview, the Clinical Manager confirmed the hire date for Staff I, RN, was 9/19/22. The Director of Integration reported she would check to see if Staff Is personnel file had another background check (criminal history, dependent adult and child abuse record checks). On 7/13/23 at 10:22 AM, during an interview, the Director of Integration reported an inability to find the completion of a background check for Staff I, RN, within 30 days of hire. Hospice staff failed to complete criminal history, dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring. The Administrator, Clinical Manager and Director of Integration received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, facility medication administration record review, patient representative interview and hospice staff interview, the hospice failed to ensure the hospice Interdisciplinary Group members collaborated and communicated to ensure hospice staff maintained responsibility for directing, coordinating and supervising the care and services provided to patients living in a facility, either assisted living facility or nursing facility (nursing home) (see L0554). --- This systemic practice resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel promoted and supported the safe, comprehensive and effective delivery of medication to their hospice patients.

Based on clinical record review, hospice policy review, facility medication administration record review, patient representative interview and hospice staff interview, the hospice failed to ensure the hospice Interdisciplinary Group (IDG) members collaborated and communicated to ensure hospice staff maintained responsibility for directing, coordinating and supervising the care and services provided to patients living in a facility, either assisted living facility or nursing facility (nursing home) for 5 of 5 sampled patients (Patients #1, #2, #3, #4 and #5). Failure of the hospice team members coordinate and collaborate services and communicate patient medications effectively increased the risk that patients did not receive the medications needed in order to effectively manage symptoms and maintain the highest possible level of quality of life for the patients. Findings include: --- Review of the hospice policy, titled Interdisciplinary Group Membership and Responsibilities, dated 12/2018, revealed the IDG will collaborate with the patient's attending physician to develop an individualized Plan of Care (POC). Review of the hospice policy, titled IDG Coordination of Care, dated 12/2018, identified the IDG will retain professional management responsibilities for the provision of services. The hospice will utilize a case management system to guide an IDG to provide comprehensive, coordinated health care to patients and families/caregivers serviced by the hospice. The IDG, in collaboration with the attending physician, will conduct assessments, develop and update the POC, and review the effectiveness of care at a minimum of every 15 calendar days. The attending physician will receive a copy of the IDG meeting every 2 weeks. On 3/28/23 at 9:58 AM, during an interview, the Administrator reported the coordination between hospice staff and nursing homes and ALFs depends on who the patient chose as their attending physician. Typically, the hospice staff get orders from the attending physician. The Administrator reported a lot of the assisted living and/or nursing facilities also have a nurse practitioner (NP) who write the patient's orders. For some medications, like comfort meds, the facility will go through the hospice Medical Director (MD). If the hospice MD writes the order, the hospice nurse will fax the signed order to the facility. The hospice nurses will contact the primary provider to get orders. Once the hospice nursing staff receives the signed physician order, they will do a medication reconciliation. The hospice nurses should be looking for medication changes once a week at the facilities. Hospice staff review each patient medications in the IDG meeting. In review of the medical records, the hospice IDG was not reviewing the current medications ordered for each hospice patients. On 3/28/23 at 10:11 AM, during an interview, the Medical Director (MD) explained the coordination of care between the hospice and the nursing home and ALFs are the responsibility of the hospice nurse . The hospice nurse goes onsite to see the patient. The nurse discusses with the patient and determine if the patient selects their primary care physician (PCP) or MD to direct their hospice care. During the initial assessment, the nurse reviews the medications with the Hospice MD and determines the need for the medications and hospice services. The hospice nurse calls the MD if there are any concerns. The hospice will work with the PCP and MD to set the patient up with pain or comfort meds if needed. If the patient has a PCP, the MD will tell the nurse to call PCP if the nurse want to change medications. The MD explained the hospice are consultants when working with the PCP. 1. Patient #1 had a hospice admission date of 11/8/22 and received routine home care hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. The POC, dated 2/6/23 to 5/6/23, identified the patient had a primary diagnosis of Alzheimers disease with late onset and had an attending physician that was not associated with the hospice. b. The IDG meetings, dated 2/16/23, 3/2/23 and 3/16/23, included documentation of a medication review completed by the IDG members based on the medications orders approved by the hospice. On 3/22/23 at 10:10 AM, during a home visit observation for Patient #1, with Staff B, Registered Nurse (RN), the surveyor observed Staff B complete an assessment on the patient. The patient displayed forgetfulness of where one of the patients socks went. The patient did not know the year. The patient denied any pain. Staff B, RN, talked with the Assisted Living facilitys caregiver on duty to get an update on the patients condition and to let the facility know the results of Staff Bs assessment. In an interview, during the same home visit observation, the surveyor asked if the Assisted Living Facility (ALF) Staff could provide a copy of the patients Medication Administration Record for the month of March 2023. Staff B, RN, reported she was not sure if the facility medication list matched what the hospice had ordered. Staff B, RN, went on to explain the Hospice did not know if there had been any medication changes and Staff B added the patient frequently refused medications. The Assisted Living Facility Staff reported the cancellation of all morning medications except a blood pressure medication and Miralax (medication used to treat constipation) and reported the patient only took Metoprolol, Levothyroxine and Sertraline in the afternoon. The Assisted Living Staff reported the discontinuation of the Hydrocodone-Acetaminophen and reported the patient only had Tylenol as needed for pain. Staff B, RN, reported this was due to the patient denying that the patient had any pain at every visit. Based on review of the hospices medication orders for Patient #1, identified in the Interdisciplinary Group (IDG) meeting, dated 3/16/23, and review of the assisted living facility (ALF) Medication Administration Record (MAR) for March 2023, the surveyor identified the following medication discrepancies: a. The hospice had an order for Acetaminophen 325 milligrams (mg) every 4 hours as needed and 325 mg 2 tabs twice per day since 11/8/22. The ALF MAR had an order for Acetaminophen 325 mg 2 tabs every 6 hours as needed since 2/22/23. b. The hospice had an order for Hydrocodone 5 mg-Acetaminophen 325 mg 1 tab daily and Hydrocodone 5 mg-Acetaminophen 325 mg 2 tabs every 4 hours prn since 11/8/22. The ALF MAR did not include either of these orders. c. The ALF MAR had an order for Metoprolol Succinate 200 mg 1 tab daily with an 11/30/22 start date. The hospice did not have this order. d. The ALF MAR had an order for Miralax 17 grams in 4-8 ounces of juice twice daily with an 11/30/22 start date. The hospice did not have this order. e. The ALF MAR had an order for Loperamide 2 mg capsule 1 cap by mouth every 6 hours as needed for diarrhea. The hospice did not have this order. f. The ALF MAR had an order for Senexon S 1 tab by mouth twice daily as needed with a start date of 2/22/23. The hospice did not have this order. g. The ALF MAR had an order for Milk of Magnesia suspension 1200 mg/15ml 30 ml by mouth daily as needed for constipation with a start date of 11/30/22. The hospice did not have this order. On 3/22/23 at 2:28 PM, during an interview, the assisted living facility Regional Wellness Director reported Patient #1's attending physician discontinued both Hydrocodone orders on 2/16/23. On 3/27/23 at 11:35 AM, during an interview, the Durable Power of Attorney (DPOA) and the DPOAs spouse reported the assisted living staff or Staff B, Hospice RN, reported the medication changes to them. The DPOA explained that the hospice nurse called them weekly with an update. The IDG meetings failed to include a collaborative and comprehensive list of the patient's medications due to a lack of coordination and communication between the ALF staff and the hospice IDG. 2. Patient #2 had a hospice admission date of 7/27/22 and received routine home care hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. The POC, dated 1/23/23 to 3/23/23, identified a primary diagnosis of cerebral atherosclerosis and had an attending physician that was not associated with the hospice. b. The IDG meetings, dated 2/2/23, 2/16/23, 3/2/23 and 3/16/23, included documentation of a medication review completed by the IDG members based on the medications orders approved by the hospice. Review of the hospices current medication list and the assisted living facility MAR for March 2023 identified the following medication discrepancies: a. The assisted living facility (ALF) had an order for Valproic Acid (Depakote) 250 mg/5 ml, give 5 ml by mouth twice per day with a 11/28/22 start date. The hospice had an order for Depakote 250 mg/ml, give 2.5 ml by mouth twice a day with a 11/21/22 start date. b. The hospice had an order for Tylenol liquid 325 mg/5 ml, give 10 ml by mouth 4 times a day with a 11/21/22 start date. The ALF MAR did not include an order for Tylenol. c. The hospice had an order for Lorazepam Intensol 2 mg/ml oral concentrate, give 0.25 ml by mouth every 4 hours as needed for anxiety with a 7/27/22 start date. The ALF MAR did not include this order. d. The hospice had an order for Miralax 17 grams oral powder 1 packet daily with a 7/27/22 start date. The ALF MAR did not include this order. e. The hospice had an order for Haloperidol Lactate 5 mg/ml injection solution, give 1 mg intramuscularly daily as needed for agitation and a 3/1/23 start date. The ALF MAR had the same order with a 3/8/23 start date, but time limited for 14 days and a second one time order on 3/25/23 for the same medication. f. Both the hospice and ALF MAR included an order for Haloperidol Lactate 2 mg/ml oral concentrate, give 0.75 ml orally three times a day and a start date of 11/21/22. The hospice had an additional order for Haloperidol Lactate 2 mg/ml oral concentrate, give 0.25 ml orally 2 times per day with a 7/27/22 start date. The ALF MAR did not include the order for 0.25 ml orally 2 times per day. On 3/27/23 at 11:25 AM, during an interview, the Patient's Representative reported the hospice staff communicated through phone calls, texts and emails. The Patient Representative explained the hospice staff contact them after visiting with the patient. For medication changes, the Patient Representative reported the assisted living staff contacted him/her not the hospice. On 3/27/23 at 2:41 PM, during an interview, Staff C, RN, reported when the hospice obtain an order, she gives the order to the nurse in charge that day at the assisted living facility. Staff C, RN, explained she talks with assisted living staff at the time of a visit, to both get and give updates on the patient. Staff C, RN, reported she also talks with the facilitys director of nursing. Staff C, RN, obtains orders from either the hospices Medical Director or the hospices nurse practitioner (NP) even though the patient has an attending healthcare practitioner identified. Staff C, RN, explained if the facility obtains the order, the hospice does not find out about medication changes until the hospice nurse does a visit there and happens to talk to the right person that knows about the medication change. Staff C, RN, reported being aware that there have been medication changes made without the hospice knowledge. Staff C, RN, reported she reviews the facilitys MAR at least once every couple months; ";probably not as often as I should." Staff C, RN, reported the patients primary care physician is supposed to get a copy of the IDG meeting after each meeting. The IDG meetings failed to include a collaborative and comprehensive list of the patient's medications due to a lack of coordination and communication between the ALF staff and the hospice IDG. 3. Patient #3 had a hospice admission date of 7/1/22 and received routine home care hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. The POC, dated 2/26/23 to 4/26/23, identified the patient had a primary diagnosis of Alzheimers disease with late onset and had an attending physician that was not associated with the hospice. b. The IDG meetings, dated 2/9/23, 2/23/23 and 3/9/23, included documentation of a medication review completed by the IDG members based on the medications orders approved by the hospice. Review of the hospices current medication list and the ALFs MAR for March 2023 identified the following medication discrepancy: The hospice has an order for Neosporin topical ointment, apply topically to right forearm skin tear daily and as needed with a start date of 2/17/23. The ALF MAR had an order to discontinue the Neosporin on 3/3/23, but the hospice did not have an order to discontinue. On 3/27/23 at 11:20 AM, during a phone interview, the DPOA reported the hospice included the DPOA in the care planning process and notified the DPOA of any changes to medications or services. The DPOA explained that all the hospice staff contacted the DPOA about every little thing, the hospice sent out a satisfaction survey every 2 weeks. On 3/27/23 at 2:16 PM, during an interview, Staff F, RN, reported she communicates with the assistant DON and on duty nurse at the assisted living facility. They discuss any changes of the patients and if there are any concerns. Staff F, RN, reported the most recent medication change involved an order for an antifungal. Staff F, RN, called the hospices nurse practitioner to get an order to treat the fungal infection. Staff F, RN, reported if she gets a medication order change, she writes the order, send it to the pharmacy, give the facility a copy and let the DON and on duty nurse know. Staff F, RN, reported she checks the patients medications once a month to see if there are any changes. Staff F, RN, reports any medication changes every 2 weeks to the IDG, but was unsure how communication occurs with the primary care physician regarding IDG meetings. The IDG meetings failed to include a collaborative and comprehensive list of the patient's medications due to a lack of coordination and communication between the assisted living facility staff and the hospice IDG. 4. Patient #4 had a hospice admission date of 1/27/23, received routine home care hospice services while residing in an assisted living facility and died on 2/9/23. Review of the clinical record revealed the following: a. The POC, dated 1/27/23 to 4/26/23, identified a primary diagnosis of Alzheimers disease with late onset and identified the attending physician as the Medical Director. b. The IDG meetings, dated 2/2/23 and 2/16/23, included documentation of a medication review completed by the IDG members based on the medications orders approved by the hospice. c. The IDG meetings, dated 2/16/23, 3/2/23 and 3/16/23, included documentation of a medication review completed by the IDG members based on the medications orders approved by the hospice. Review of the hospices last medication list for the patient, dated 2/16/23, and the ALFs MAR for 1/27/23 to 2/9/23 identified the following medication discrepancy: The hospice had a medication order for Nitroglycerin 0.4 mg sublingual tablet, 1 tab every 5 minutes times 3 doses as needed for angina and notify the physician with a start date of 1/27/23. The ALF MAR included an order to discontinue the medication on 2/1/23, but the hospice did not have an order to discontinue. 3/23/23 at 9:32 AM, during a phone interview, the DPOA for Patient #4, the hospice kept the DPOA informed and involved. 3/27/23 at 2:51 PM, during an interview, Staff C, RN, explained all medication orders for Patient #4 went through the hospices Medical Director, as the POA chose the Medical Director to be the patients attending physician. Staff C, RN, reported no problems with medication orders since all orders went through the hospice and the Medical Director. The IDG meetings failed to include a collaborative and comprehensive list of the patient's medications due to a lack of coordination and communication between the assisted living facility staff and the hospice IDG. 5. Patient #5 had a hospice admission date of 1/28/23, received routine home care hospice services while residing in a nursing home and died on 2/13/23. Review of the clinical record revealed the following: a. The POC, dated 1/28/23 to 4/27/23, identified a primary diagnosis of congestive heart failure and had an attending physician that was not associated with the hospice. b. The IDG meetings, dated 2/2/23 and 2/16/23, included documentation of a medication review completed by the IDG members based on the medications orders approved by the hospice. Review of the hospices last medication list for the patient, dated 2/16/23, and the nursing homes MAR for 1/28/23 to 2/13/23 identified the following medication discrepancies: a. The nursing home MAR had an order for Amiodarone 200 mg tablet, 1 tablet by mouth daily with a start date of 1/25/23 and an end date of 2/13/23. The nursing homes MAR included documentation that the patient continued to receive the medication through 2/13/23. The hospice had an order to discontinue the medication on 2/10/23. b. The nursing home MAR had an order for Bumetanide 2 mg tablet, 1 tablet by mouth daily with a start date of 1/16/23 and an end date of 2/13/23. The nursing homes MAR included documentation that the patient continued to receive the medication through 2/13/23. The hospice had an order to discontinue the medication on 2/10/23. c. The nursing home MAR had an order for Lactobacillus 1 tablet by mouth daily with a start date of 2/7/23 and an end date of 2/13/23. The hospice did not have an order for this medication. d. The nursing home MAR had an order for Mirtazapine 30 mg tablet, 1 tablet by mouth daily at bedtime with a start date of 1/25/23 and an end date of 2/13/23. The nursing homes MAR included documentation that the patient continued to receive the medication until 2/12/23 (the patient died prior to the bedtime dose on 2/13/23). The hospice had an order to discontinue the medication on 2/10/23. e. The nursing home MAR had an order for Montelukast 10 mg tablet, 1 tablet by mouth daily with a start date of 1/16/23 and an end date of 2/13/23. The nursing homes MAR included documentation that the patient continued to receive the medication through 2/13/23. The hospice had an order to discontinue the medication on 2/10/23. f. The nursing home MAR had an order for Pantoprazole 40 mg tablet, 1 tablet by mouth daily with a start date of 1/16/23 and an end date of 2/13/23. The nursing homes MAR included documentation that the patient continued to receive the medication through 2/13/23. The hospice had an order to discontinue the medication on 2/10/23. g. The nursing home MAR had an order for Miralax 17 gram oral powder mix, 17 grams in 4 to 8 ounces of liquid by mouth daily with a start date of 1/16/23 and an end date of 2/13/23. The nursing homes MAR included documentation that the patient continued to receive the medication through 2/13/23. The hospice had an order to discontinue the medication on 2/10/23. h. The nursing home MAR had an order for Potassium Chloride extended release 10 milliequivalents capsule, 1 capsule by mouth daily with a start date of 1/31/23 and an end date of 2/13/23. The nursing homes MAR included documentation that the patient continued to receive the medication through 2/13/23. The hospice had an order for Potassium Chloride extended release 10 milliequivalents capsule, 2 capsules by mouth twice per day with a start date of 1/28/23 and an order to discontinue the medication on 2/10/23. i. The nursing home MAR had an order for Senna Plus 8.6 mg- 50 mg tablet, 1 tablet by mouth twice daily with a start date of 1/16/23 and an end date of 2/13/23. The nursing homes MAR included documentation that the patient continued to receive the medication through 2/13/23. The hospice had an order to discontinue the medication on 2/10/23. j. The nursing home MAR had an order for Sertraline 50 mg tablet, 1 tablet by mouth daily with a start date of 1/16/23 and an end date of 2/13/23. The nursing homes MAR included documentation that the patient continued to receive the medication through 2/13/23. The hospice had an order to discontinue the medication on 2/10/23. k. The nursing home MAR had an order for Synthroid 225 micrograms (mcg) (a 25 mcg tablet plus a 200 mcg tablet), by mouth daily with a start date of 1/16/23 and an end date of 2/13/23. The nursing homes MAR included documentation that the patient continued to receive the medication through 2/13/23. The hospice had an order for Synthroid 200 mcg tablet, 1 tablet by mouth daily with a start date of 1/28/23 and an order to discontinue the medication on 2/10/23. l. The nursing home MAR had an order for Trazodone 50 mg tablet, 1 tablet by mouth at bedtime with a start date of 1/28/23 and a discontinue date of 2/2/23. The hospice had an order to start the medication on 1/28/23, and did not have an order to discontinue the medication. m. The nursing home MAR had an order for Vitamin D3 5000 unit capsule, 1 capsule by mouth daily with a start date of 1/31/23 and an end date of 2/13/23. The nursing homes MAR included documentation that the patient continued to receive the medication through 2/13/23. The hospice did not have an order for this medication. n. The skilled nursing visit note, dated 2/10/23 at 8:06 AM to 9:27 AM, included documentation the hospice nurse updated the primary facility nurse on the patients plan of care, but lacked any documentation the hospice nurse discussed the discontinuation of the patients routine medications. A second skilled nursing visit, dated 2/10/23, lacked any documentation of coordination with the facility staff regarding the medication changes. o. The skilled nursing visit note, dated 2/11/23, included documentation that the hospice nurse updated the patients medication profile and reported no changes to the patients plan of care and completed communication with facility staff and family. On 3/28/23 at 11:12 AM, during an interview, the Manager of Accreditation, reported for Patient #5, the hospice staff faxed orders to change Morphine and Lorazepam doses/frequency on 2/10/23 at 9:31 AM and faxed the orders to discontinue most of the patients medications on 2/10/23 at 11:40 AM to the facility. Review of the hospices faxed orders for Patient #5 revealed the following: 1) A faxed order, dated 2/10/23 at 9:31 AM, included orders to change Lorazepam 2 mg/ml oral concentrate, from giving 0.25 ml every 4 hours as needed to every 2 hours as needed and to change Morphine concentrate 100 mg/ 5 ml, from giving 0.25 ml every 4 hours as needed to every 2 hours as needed. 2) A faxed order, dated 2/10/23 at 11:40 AM, included orders to discontinue Amiodarone, Bumetanide, Miralax, Mirtazapine, Montelukast, Pantoprazole, Potassium Chloride extended release 10 MEQ 2 capsules 2 times per day, Senna Plus, Sertraline and Synthroid 200 mcg daily. Patient #5s nursing home MAR reflected the change in orders related to the Lorazepam and Morphine, but did not reflect the change in orders to discontinue medications related to the fax sent at 11:40 AM on 2/10/23. Review of Patient #5s clinical record revealed the hospice provided skilled nursing services 2 times on 2/10/23, and 1 time per day on 2/11/23, 2/12/23 and 2/13/23. On 3/27/23 at 1:58 PM, during an interview, Staff E, RN reported coordination with the facilities depended on the needs of the patient. For coordination of orders including medications, Staff E, RN, reported it depended on the facility and the patient's primary healthcare provider. Staff E, RN, reported she goes through the patients primary physician to get and change orders. The hospice faxes the order to the facility. Occasionally, the facility staff will initiate some orders and Staff E, RN, will be unaware of the order changes. Almost every visit, Staff E, RN talks with the DON, facility Social Worker and MDS coordinator. Staff E, RN, reported the hospice also attend the patients care conferences at the nursing home. Staff E, RN, explained it was the RNs responsibility to inform the IDG of changes, such as any meds added or discontinued. Staff E, RN, reported she reviews meds during IDG with the Medical Director and Administrator. The IDG meetings failed to include a collaborative and comprehensive list of the patient's medications due to a lack of coordination and communication between the nursing home and the hospice IDG. The above information was reviewed with Administrator and the Manager of Accreditation. No additional information provided prior to the end of the survey.