Every finding on record at Tender Loving Care Home Hospice

Based on interview and record review the hospice agency failed to ensure the home medication list and the hospice agency medication list were reconciled for one of 19 sampled patients (Patient 17). This failure had the potential for inappropriate dosing, miscommunication among caregivers, and decreased physical and psychosocial well-being for Patient 17. --- Findings: A home visit for Patient 17 with the social worker was conducted on 2/12/25 at 2:25 pm. The patient resides in a board and care facility. During a record review of the home medication list, it was compared with the hospice agency medication list and it did not match. The discrepancies were as follows: Simvastatin 1 tab one time a day – not in home med list. PreserVision 1 cap by mouth two times a day – not in home med list Mutiple vitamins – 1 tab po daily – not in home med list Probiotic 2 caps daily - not in home med list Seroquel – 25mg tab – not in home med list Robitussin DM – 1-2 teaspoon by mouth every 4 hours as needed - listed in home med list not in care plan med list. During an interview on 2/13/25 at 2:20 pm, with the director for patient care services (DPCS) , the DPCS stated the medications that were not in the home medication list were discontinued. The DPCS acknowledged the agency needed to update their records to match with the home medication list. The facility policy and procedure titled ";Medication Profile" dated April 2020 indicated ";Medication profiles will be updated to reflect current medications and new and/or discontinued medication.

Based on record review and interview, the hospice agency failed to ensure planned home visits were conducted according to the hospice plan of care for three of 19 sampled patients (Patients 1, 10 and 17) when: 1. The frequency of ordered hospice aide (HA) visits for Patient 1 was not followed. 2. Patient 10s ordered HA visits during the hospice benefit/certification period of 2/29/24-5/28/24 were not documented in the medical record after 4/25/24. 3. Chaplain visit was not completed within one month for Patient 17. These failures resulted in missed visits and had the potential not to meet the needs of these patients affecting their quality of life. --- During a review of ";General Patient Details (GPD)," dated 12/17/24, the ";GPD" indicated, Patient 17 is 90 year old female, admitted 12/17/24 for Cerebral Infarction (occurs when blood flow to the brain is blocked.) During a review of ";Plan of Care (POC)," dated 12/17/24, the ";POC" indicated, ";...Chaplain one visit monthly..." During a concurrent interview and record review on 2/13/25 at 10:50 a.m. with the Director of Patient Care Services (DPCS), Patient 17s ";Clinical Record (CR)," dated 2/13/25 was reviewed. The ";CR" indicated, no chaplain visit was noted within one month. DPCS agreed, there was no visit done by the chaplain within one month. During a review of the facilitys policy and procedure titled, ";Missed Visits," dated 4/2020, indicated, ";...POLICY: Missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record." During a review of Patient 10s medical records, the ";Hospice Certification of Terminal Illness (HCTI)," dated 2/29/24, indicated in part, Patient 10 is a 92-year-old male admitted for hospice routine level of care for diagnosis of Alzheimers disease (a brain disease that causes memory loss, thinking problems and personality changes). Patient 10s hospice benefit/certification period started 2/29/24-5/28/24. The records also indicated Patient 10 was discharged from hospice on 5/28/24 as the patient no longer met the criteria for hospice eligibility. During a review of Patient 10s medical records, the ";Plan of Care (POC)" for the benefit/certification period of 2/29/24-5/28/24, indicated in part, ";Discipline... Hospice Aide... two visit(s) weekly 4 PRN (as needed) visit(s) every 7 days...." During a review of Patient 10s medical records, the ";Encounter Charting (EC - a section in the patients medical record where agency staff documents details of the home visit)" of HA visits made for the benefit/certification period of 2/9/24-5/28/24 failed to indicate documentation whether HA visits were conducted or missed after 4/25/24. During a concurrent record review and interview on 2/13/25 at 10:30 a.m., with DPCS, Patient 10s POC and EC for the benefit/certification period of 2/29/24-5/28/24 were reviewed. DPCS verified that there were no documented HA visits for Patient 10 after 4/25/24 and could not provide justification for it. During a review of the agencys policy and procedures (P&P) titled, ";The Plan of Care," dated 11/2018, the P&P indicated in part, ";POLICY... The care provided to the patient must be in accordance with the plan of care...." During a review of the agencys P&P titled, ";Missed Visits," revised 4/2020, the P&P indicated in part, ";POLICY... Missed visits will be communicated to the Interdisciplinary Group (IDG) at the IDG meeting. A missed visit will be rescheduled the same week as possible. Missed visits will be documented in the clinical record." During a review of Patient 1s electronic health record (EHR) on 2/11/25 at 3:40 pm, the EHR indicated Patient 1 has an order for a hospice aide (CHHA) for 2 visits per week and 3 visits as need per 7 days. On the week of 12/22/24 to 12/28/24 there was only one CHHA visits, no missed visit documentation was located. During an interview with the director for patient care services (DPCS) on 2/11/24 at 3:40 pm, the DPCS acknowledged the missed visit. The facility policy and procedure titled ";Missed Visits" dated 4/2020 indicates ";Missed visits will be communicated to the interdisciplinary group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in clinical record.

Based on record review and interview, the hospice agency failed to ensure nurse supervisory visits were conducted and documented in the chart for two of 19 sampled patients (Patients 7 and 9) who received hospice aide services. This failure had the potential to negatively impact the quality of care provided to these patients due to services not getting evaluated. --- Findings: During a review of Patient 7s medical records, the ";Hospice Certification of Terminal Illness (HCTI)," dated 11/1/24, indicated in part Patient 7 is an 80-year-old female who was admitted for hospice routine level of care with a primary diagnosis of cancer of the uterus. Patient 7s hospice benefit/certification period (HBCP) started 11/1/24-1/29/25. During a review of Patient 7s medical records, the ";Plan of Care (POC)" for the HBCP of 11/1/24-1/29/25, the POC indicated in part, ";Discipline... Hospice Aide...two (2) visit(s) weekly, three (3) PRN (as needed) visit(s) every 7 days..." During a review of Patient 7s medical records, the "Encounter Charting (EC - a section in the patients medical record where agency staff documents details of the home visit)" for RN supervisory visits as follow-up for HA visits made during the HBCP of 11/1/24-1/29/25, failed to indicate documentation whether RN supervisory visits were conducted or missed for the whole benefit/certification period. During a concurrent interview and record review, on 2/13/25 at 10 a.m., with the agencys Director of Patient Care Services (DPCS), Patient 7s POC and EC for the HBCP of 11/1/24-1/29/25 were reviewed. DPCS verified that no RN supervisory visits were documented in the patients medical record during this benefit/certification period and could not provide justification for it. During a review of Patient 9s medical records, the ";HCTI," dated 10/9/24, indicated in part Patient 9 is an 85-year-old male admitted for hospice routine level of care for diagnosis of Parkinsonism, Unspecified (refers to a group of conditions that cause movement-related symptoms including slowed movements, stiffness, tremors and balance issues). Patient 9s HBCP started 10/6/24-1/31/25. During a review of Patient 9s medical records, the ";POC" for the HBCP of 10/6/24-1/31/25, indicated in part, ";Discipline... Hospice Aide... two (2) visit(s) weekly two (2) PRN (as needed) visit(s) every seven (7) days...." During a review of Patient 9s, ";EC" for the HBCP of 10/6/24-1/31/25, documentation of RN (registered nurse) supervisory visits as follow-up for HA visits made for this benefit/certification period were further reviewed. There was no documentation during the month of 11/2024, that either an RN supervisory visit was conducted or missed. During a concurrent interview and record review, on 2/13/25 at 10:15 a.m., with DPCS, Patient 9's POC and EC for HBCP of 10/6/24-1/31/25 were reviewed. DPCS verified that no RN supervisory visit was documented in November during the HBCP reviewed and could not provide justification for it. During a review of the agencys P&P titled, ";Supervision," revised 11/2017, the P&P indicated in part, ";Procedure... 2) A registered nurse (or therapist, when appropriate) is available whenever homemaker-hospice aide services are provided. Homemaker-hospice aide services are supervised every fourteen (14)

Based on interview and record review, the hospice agency failed to include a visit note into the clinical record (CR) for one of 19 sampled patients (Patient 2). This failure had the potential to result in not facilitating collaboration with other healthcare professionals, not informing of treatment decisions and continuity of care. --- Findings: During a review of ";General Patient Details (GPD)," dated 1/21/25, the ";GPD" indicated, Patient 2 is 86 year old female, admitted 1/21/25 for Alzheimers Disease (type of dementia that affects memory, thinking and behavior). During a concurrent interview and record review on 2/11/25 at 3:08 p.m. with the Director of Patient Care Services (DPCS), Patient 2s ";CR," dated 2/11/25 was reviewed. The ";CR" indicated, no social worker visit was done from admission date of 1/21/25 to 2/11/25. DPCS agreed, that she did not see one, DPCS was notified by social worker that there was a visit, but a visit note was not put into the ";CR." During a review of the facilitys policy and procedure titled, ";Entries into the Clinical Record," dated 4/2020, indicated, ";6. Entries into the clinical record will be made within 24 hours of the care provided to the patient..."

Based on record review and interview, the hospice agency failed to ensure the initial admission assessments (IAA) for two of 13 sampled patients (Patients 1 and 11), were signed by the clinicians within the time frames for completion. These failures had the potential to affect the planning and delivery of care and services for Patients 1 and 11. Findings: 1) During a review of the agency's policy and procedure (P&P) titled, "Entries into the Clinical Record," revised 4/2020, the P&P indicated, "...The clinical note will include: Signature of clinician..." During a concurrent interview and record review, on 7/22/22, at 10:44 a.m., with the Clinical Coordinator (CC), Patient 1's medical record was reviewed. Patient 1's "IAA," dated 4/13/22, indicated, Patient 1's start of care (SOC) was 4/13/22 and the "IAA," was not signed by the clinician (LN 2). The CC verbalized, Patient 1's "IAA" was not signed, and it should be signed. The CC further verbalized, the "IAA" is deemed complete, when it is signed by the clinician. 2) During a concurrent interview and record review of Patient 11's records on 7/22/22, at 3:19 p.m., with the clinical coordinator (CC), Patient 11's "IAA," dated 3/17/21 was reviewed. Patient 11's "IAA" indicated, SOC was 3/17/21 and was not signed. The CC verbalized, Patient 11's "IAA" was not signed by the clinician (LN 3), and the CC further verbalized, the "IAA" should be signed, to prove it was completed.

Based on observation, interview, and record review, the hospice agency failed to ensure one of three sampled patients (Patient 1's), Norco 5-325 milligrams (mg) [pain medication] supply provided at home was the same dosage as written on the medication profile, Norco 10-325 mg. This failure had the potential to not provide adequate pain relief for Patient 1. Findings: The agency's policy and procedure (P&P) titled, "Drug Information for the Nurse," revised 4/2020, indicated, "...Medication reconciliation consists of a comparison of those medications ordered for, administered to, or dispensed to the patient while under the care of...hospice to those on the list and any discrepancies are resolved ..." During a home visit on 7/20/22, at 11:00 a.m., Patient 1's medication supplies at home were reviewed with the registered nurse (LN 1). The pain medication "Norco 5-325 milligrams (mg)" supply at home did not match the correct regimen of "Norco 10-325 mg" as listed in the current medication profile. During a concurrent interview and record review with the LN 1 on 7/20/22, at 11:00 a.m., Patient 1's medication profile was reviewed. Patient 1's medication profile indicated, " Norco 1-1 Tablet every 4 hours ORAL AS Needed 10-325 MG tablet)." The LN 1 verbalized, the "Norco 5-325 milligrams (mg)" supply at home, did not match the correct regimen of "Norco 10-325 mg" as listed in the current medication profile. The LN 1 further verbalized, the medication sheets and or medication supply should have been updated with medication order changes and it was not.

Based on record review, and interview, the hospice agency failed to ensure three of 13 sampled patients (Patients 1, 12, and 7), received hospice aide visits, as ordered by the plan of care. This failure had the potential to affect the quality of care provided to all patients serviced by the agency. Findings: 1) The agency's policy and procedure (P&P) titled, "Missed Visits," revised 4/20, indicated, "...If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit ..." During a review of Patient 1's plan of care (POC), for the certification period of 4/13/22 through 7/11/22, Patient 1's "POC" indicated, the hospice aide (HA) would visit the patient two times a week, and two times as needed, every seven days. During a concurrent interview and record review, on 7/22/22, at 12:00 p.m., Patient 1's visit log, was reviewed with the Clinical Coordinator (CC). Patient 1's visit log indicated, no hospice aide visits were made for the week of 6/12/22 to 6/18/22. The clinical coordinator (CC) verbalized, the HA was unable to visit that week due to having an illness and no arrangement has been made to replace the HA. 2) During a review of Patient 12's "POC," for the certification period of 4/24/22 through 6/22/22, Patient 12's "POC" indicated, the hospice aide (HA) would visit two times a week, and three times as needed, every seven days. During a concurrent interview and record review, on 7/22/22, at 12:20 p.m., Patient 12's visit log was reviewed with the CC. Patient 12's visit log indicated, only one of two HA visits were made for the week of 5/22/22 through 5/28/22. No further HA visits were made for the remaining 4 weeks, from 5/29/22 through 6/22/22. No documentation was located for the reason of the missed HA visit. The CC verbalized no visits for the week of 5/22/22 and from the weeks of 5/29/22 through 6/22/22. 3) A review of Patient 7's clinical record, indicates Patient 7 had an order for hospice aid (HA) for 3 visits a week, and 2 visits, as necessary, every 7 days. On the week of 12/20/21 to 12/25/21, there was only one HA visit for Patient 7. There are no documentation of any missed visits. During an interview on 7/22/22 at 3:10 PM the clinical coordinator (CC) acknowledged there was no documentation of a missed visits during that week. The agency's P&P titled, "Missed Visits," dated 4/2020, indicates, "Missed visits will be communicated to the interdisciplinary group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in clinical record."

Based on interview and record review, the facility failed to ensure a registered nurse (RN) made an on-site supervisory visit every 14 days for one of 13 sampled patients (Patient 2). This deficient practice had the potential to negatively impact the quality of care received by Patient 2, due to missed evaluations of services being provided. Findings: During a concurrent interview and record review, on 7/21/22 at 4:10 p.m., with the clinical coordinator (CC), Patient 2's clinical record was reviewed. The clinical record indicated, patient 2 had orders for home health aide (HHA) for two visits a week, and three visits, as necessary in seven days during the 5/26/22 to 8/23/22 certification period. From 5/26/22 up to the day of the inspection, there was only one documented RN supervisory visit, 7/20/22. The CC verbalized, RN supervisory visits were not located in the health records. The CC further verbalized, per federal regulations, the RN supervisory visit for HHA is every 14 days

Based on interview and record review, the Hospice Agency failed to ensure prescribed medications, for one of 13 patients (Patient 3), were made routinely available on a 24- hour basis, when as needed (PRN) and routine medications were not filled timely. These failures have the potential to delay treatment and care for Patient 3 and other patients under the care of the agency. Findings: During a review of Patient 3's clinical record and home medication list, the review indicated, Patient 3 had a doctor's order for Vimpat (anti-seizure medication) 100 milligrams (mg), 2 times a day. Patient 3's home medication list did not contain Vimpat. During an interview on 7/21/22, at 12:00 p.m., the Patient 3's significant other verbalized, since the start of care by the agency, on 7/6/22, Patient 3 had not received the Vimpat with the other medications. During an interview on 7/22/22, at 10:30 a.m., the clinical coordinator (CC) verbalized, Patient 3 has an order for Vimpat. The CC was not able to verbalize, why the Vimpat was missed during medication reconciliation (confirming a patient's home medications). During a review of the agency's policy and procedure (P&P) titled, "Drug Information For The Nurse," dated 4/2020, the P&P indicates, "Medication reconciliation consists of a comparison of those medication ordered for, administered to, or dispensed to the patient while under the care of "Agency's Name" Hospice to those on the list and any discrepancies are resolved."

Based on interview and record review, the facility failed to ensure the Physician Order for Life-Sustaining Treatment (POLST) [legal document for end of life treatment] for one of 13 sampled patients (Patient 6), was prepared and signed correctly. This agency failure had the potential for not providing care and treatment per Patient 6 or their legal guardian's directives. Findings: During a review of Patient 6's "POLST," dated 3/13/22, the "POLST" indicated, the legally recognized decision maker is a family member. On the actual "POLST," the name of the decision maker is Patient 6 (instead of the family member) and the relationship was not indicated as "self." During an interview on 7/22/22, at 3:10 p.m., the clinical coordinator (CC) verbalized, Patient 6's "POLST" had mistakes, and the mistakes were not corrected. The agency's policy and procedure (P&P) titled, "POLST Policy," dated 4/2020, the P&P indicates, "at the time of admission, the patient or legally authorized decision maker will be asked if an advance directive and POLST have been completed. They will also advise of the hospice policy and procedure regarding advance directives .... If they have not done so and continue to have a capacity for decision-making, and wish to do so, they will be offered information and assistance in completing the appropriate documents."