Every finding on record at Three Rivers Consulting & Management, LLC

Based on record review and interview, the IDG failed to include medical supplies and appliances necessary to meet the needs of the patient on the POC for three (#5, #12, #13) of nineteen (#1 -#19) records reviewed. --- Review of clinical records for Patient's #5, #12 and #13 failed to provide evidence on the POC of Oxygen and related supplies as identified on the Medication Profile and SN Visit Notes for each patient. Review of Agency policy #9.12.1 titled, "IDG: Care Planning Process" states at Procedure item #8: An individualized written plan of care is developed for each patient: Medical supplies and appliances necessary to meet the needs of the patient". During an interview on 08/30/23 at 9:00 AM, the Director of Operations stated the IDG failed to include medical supplies and appliances on the POC as required for Patient's #5, #12 and #13.

Based on record review and interviews the RN failed to conduct on site supervision of the Hospice Aide every 14 days as required for two (#9 and #12) of fourteen (#1- #4, #9- #12 and #14 - #19) records reviewed with orders for Hospice Aide services. --- Patient #9 Review of clinical record #9 for certification periods 06/13/23 - 10/09/23 revealed a primary diagnosis of Congestive Heart Failure and orders for Hospice Aide services five times a week for eight weeks. Review of RN Visit Notes indicated an on-site Supervisory Visit by the RN was conducted on 08/02/23 and next on 08/17/23 (1 day late). Patient #12 Review of clinical record #12 for certification periods 06/10/23 - 07/17/23 revealed a primary diagnosis of Atherosclerotic Heart Disease and orders for Hospice Aide services five times a week for eight weeks. Review of RN Visit Notes indicated an on-site Supervisory Visit by the RN was conducted on 08/02/23 and next on 08/17/23 (1 day late). During an interview on 08/30/23 at 9:00 AM, the Director of Operations stated the RN failed to conduct Supervisory Hospice Aide visits as required for Patients #9 and #12.

Based on record review and interview, the hospice failed to ensure effective anxiety management was provided for one (Patient #1) of six patients. --- Patient #1 A review of the plan of care dated 05/07/23 to 08/04/23 showed a primary diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung and documented a skilled nurse frequency of seven times a week for four weeks. The plan of care documented a physician's order for Diazepam 5 milligrams per milliliter oral concentrate, to give 1-2 milliliters sublingually every 4 hours as needed for anxiety. A skilled nurse initial assessment dated 05/07/23 at 3:20 pm, documented the patient was "very anxious" upon arrival. The patient was sitting up to wanting to lie down and documented the skilled nurse believed it was "terminal anxiety". The skilled nurse administered 0.5 milliliters of Diazepam (not the ordered dosage). A skilled nurse assessment dated 05/07/23 at 1:20 am [sic], documented the patient was "very very anxious" with an anxiety score of 8. The skilled nurse assessment documented the patient would lie down for a few minutes then "pop right back up" and unable to be consoled. The patient's spouse administered Diazepam but had difficulty due the patient fighting, swinging her arms and spitting the medication out (time unspecified). The patient continued to get up and down. The spouse administered the patient her pain medication, but the patient once again began fighting, swinging her arms and spitting out the medication (time unspecified). The skilled nurse documented she then contacted the physician and was ordered to administer the liquid medications rectally. The spouse then stood the patient and held her while the nurse administered the Diazepam rectally with part of the medication running out of the patient's rectum. The patient then rested for 30 minutes then the "same cycle started over." The skilled nurse then documented the spouse told the skilled nurse to go home and get some rest since there was nothing more that could be done "med wise". The skilled nurse documented the "spouse demanded another nurse come out first thing in the morning with the skilled nurse informing him one will be out as soon as the physician signs for new meds and the pharmacy gets them ready." A skilled nurse care shift note dated 05/08/23, documented the following: At 8:45 am, anxiety score of 10. At 9:00 am, upon arrival patient is "very restless and agitated." Patient inconsolable and "very restless." At 9:45 am, anxiety score of 8. At 10:00 am, continues to be "very restless and agitated", awaiting arrival of medications from pharmacy. At 11:00 am, injectable medications administered. At 12:00 pm, "still very restless, only resting 15-30 seconds at a time." At 12:30 pm, another dose of injectable medication was administered. At 1:00 pm, resting for longer periods of time, "nearly 45-55 seconds at a time." At 1:30 pm, anxiety score of 4 At 3:00 pm, anxiety score of 1 On 06/06/23 at 12:40 pm, Staff A stated: 1. the skilled nurse should not have left the patient as documented on the skilled nurse assessment dated 05/07/23 at 1:20 am, (reported as 05/08/23 at 2:00 am); 2. the patient and family had no skilled nurse assistance with "terminal anxiety" from 05/08/23 at 2:00 am until 05/8/23 at 11:00 am; 3. there is no documentation of any anxiety medications administered while a skilled nurse was present on 05/08/23 at 8:45 am until 11:00 am; 4. the physician should have been notified the rectal medication administration was ineffective; and 5. the anxiety for Patient #1 was not managed from 05/07/23 at 11:00 pm to 05/08/23 at 12:00 pm.

Based on record review and interview, the hospice failed to ensure an accurate bereavement risk assessment for one (Patient #1) of six patients. --- Patient #1 An initial psychosocial assessment dated 05/07/23 at 3:20 pm, documented the patient's spouse was not coping well, was drinking alcohol to cope, throwing things and acting out verbally (not aggressive towards staff). An initial spiritual assessment dated 05/09/23 at 8:30 am, documented the patient's spouse was very stressed and not coping well. On 06/06/23 at 11:00 am, a request was made for a list of bereaved patients. A list was obtained at 11:35 am. The list documented the patient's family as a "low risk" for bereavement issues. On 06/06/23 at 12:10 pm, Staff A stated the bereavement risk on the list of bereavement patients was incorrect and should have reflected the poor coping issues documented in the initial psychosocial and spiritual assessments.

Based on record review and interview, the hospice failed to ensure the ordered dosage for an anxiety medication was provided in accordance with the plan of care frequency for one (Patient #1) of six patients. --- Patient #1 A review of the plan of care dated 05/07/23 to 08/04/23 showed an order for Diazepam 5 milligrams per milliliter (liquid concentrate) to administer 1-2 milliliters sublingually as needed for anxiety. An initial skilled nurse assessment showed an order for Diazepam 5 milligrams per milliliter (liquid concentrate) to administer 1-2 milliliters sublingually as needed for anxiety. The initial assessment documented the skilled nurse administered 0.5 milliliters of Diazepam for terminal anxiety. On 06/06/23 at 12:15 pm, Staff A stated the orders for Diazepam were not followed.

Based on record review and interview, the hospice failed to ensure skilled nursing services met the needs of the patient for the management of anxiety for one (Patient #1) of six patients. --- Patient #1 A review of the plan of care dated 05/07/23 to 08/04/23 showed a primary diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung and documented a skilled nurse frequency of seven times a week for four weeks. The plan of care documented a physician's order for Diazepam 5 milligrams per milliliter oral concentrate, to give 1-2 milliliters sublingually every 4 hours as needed for anxiety. A skilled nurse initial assessment dated 05/07/23 at 3:20 pm, documented the patient was "very anxious" upon arrival. The patient was sitting up to wanting to lie down and documented the skilled nurse believed it was "terminal anxiety". The skilled nurse administered 0.5 milliliters of Diazepam (not the ordered dosage). A skilled nurse assessment dated 05/07/23 at 1:20 am [sic], documented the patient was "very very anxious" with an anxiety score of 8. The skilled nurse assessment documented the patient would lie down for a few minutes then "pop right back up" and unable to be consoled. The patient spouse was documented as smelling of alcohol. The patient's spouse administered Diazepam but had difficulty due the patient fighting, swinging her arms and spitting the medication out (time unspecified). The patient continued to get up and down. The spouse administered the patient her pain medication, but the patient once again began fighting, swinging her arms and spitting out the medication (time unspecified). The skilled nurse documented she then contacted the physician and was ordered to administer the liquid medications rectally. The spouse then stood the patient and held her while the nurse administered the Diazepam rectally with part of the medication running out of the patient's rectum. The patient then rested for 30 minutes then the "same cycle started over." The skilled nurse then documented the spouse told the skilled nurse to go home and get some rest since there was nothing more that could be done "med wise". The skilled nurse documented the "spouse demanded another nurse come out first thing in the morning with the skilled nurse informing him on will be out as soon as the physician signs for new meds and the pharmacy gets them ready." A skilled nurse care shift note dated 05/08/23, documented the following: At 8:45 am, anxiety score of 10. At 9:00 am, upon arrival patient is "very restless and agitated." Patient inconsolable and "very restless." At 9:45 am, anxiety score of 8. At 10:00 am, continues to be "very restless and agitated", awaiting arrival of medications from pharmacy. At 11:00 am, injectable medications administered. At 12:00 pm, "still very restless, only resting 15-30 seconds at a time." At 12:30 pm, another dose of injectable medication was administered. At 1:00 pm, resting for longer periods of time, "nearly 45-55 seconds at a time." At 1:30 pm, anxiety score of 4 At 3:00 pm, anxiety score of 1 On 06/06/23 at 12:40 pm, Staff A stated: 1. the skilled nurse should not have left with the spouse smelling of alcohol as documented on the skilled nurse assessment dated 05/07/23 at 1:20 am, (reported as 05/08/23 at 2:00 am); 2. the patient and family had no skilled nurse assistance with "terminal anxiety" from 05/08/23 at 2:00 am until 05/8/23 at 11:00 am; 3. there is no documentation of any anxiety medications administered with a skilled nurse present on 05/08/23 at 8:45 am until 11:00 am; 4. the physician should have been notified the rectal medication administration was ineffective; 5. the skilled nurse should not have allowed the patient spouse to administer medications if he smelled like alcohol; and 6. the anxiety for Patient #1 was not managed from 05/07/23 at 11:00 pm to 05/08/23 at 12:00 pm.