Every finding on record at Tnmo Healthcare, LLC

Upon patient record review 1 of 19 records (Patient #7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #7: The patient was admitted on 9/8/23. The record indicated that the spiritual assessment was completed on 9/14/24.

Upon patient record review 1 of 19 records (Patient #14) did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #14: There was not evidence of a spiritual assessment.

Upon patient record review, 3 of 19 records (Patient #4,#5,#6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #4: The certification of terminal illness and nurse documentation indicated that the patient was on oxygen at 5L/min. There was not evidence that oxygen was in the medication profile. Corrected on site. Patient #5: The record indicated duplicate orders for Hydrocodone5 - Acetaminophen325 q6h prn pain, dated 3/8/24 and 4/19/24. Corrected on site. Upon home visit, Nystatin powder was on the medication profile at the SNF but not on the hospice medication profile. Bisacodyl supp was on the hospice medical record but not the facility MAR. Corrected on site. Patient #6: Lidocaine patch was on the medication profile at the SNF but not on the hospice medication profile. Acidophilus was on the hospice medical record but not the facility MAR. Corrected on site.

Upon patient record review, 3 of 19 records (Patient #1,#7,#14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1: The patient was admitted on 2/17/24. The record indicated that the bereavement assessment was completed on 2/23/24. Patient #7: The patient was admitted on 9/8/23. The record indicated that the bereavement assessment was completed on 9/14/23. Patient #14: The patient was admitted on 2/19/24. The record indicated that the bereavement assessment was completed on 2/26/24.

Upon patient record review, 1 of 19 records (Patient #13) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #13: The visit frequency on the initial plan of care for the social worker and the spiritual care counselor was 1 prn. There was not evidence of a routine visit frequency.

Upon patient record review, 4 of 19 records (Patient #4,#5,#6,#8) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #4: The certification of terminal illness and nurse documentation indicated that the patient was on oxygen at 5L/min. There was not evidence of an order for oxygen. Corrected on site. Patient #5: Upon home visit, Nystatin powder was on the medication profile at the SNF but the hospice record did not contain order. Corrected on site. Patient #6: Lidocaine patch was on the medication profile at the SNF but the hospice record did not contain order. Corrected on site. Patient #8: An order dated 5/2/24 indicated to insert a 16F Foley with a 10cc balloon. There was not evidence that the order included when to change the catheter and if and when to flush the catheter. Corrected on site.

Upon patient record review, 1 of 19 records (Patient #8) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and notes the patient's progress towards outcome/goals from the plan of care. Patient #8: The record indicated on 5/2/24 that a 16F Foley with a 10cc balloon was inserted. There was not evidence that the revised plan of care included information from the patient's updated assessment and noted the patient's progress towards outcome/goals in regards to the catheter. Corrected on site.

Upon client record review, 1 of 19 records (Patient #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #13: The visit frequency for the spiritual care counselor was 2 every 2m2, 2m1, 1m1 and 2 prn. The record indicated that an evaluation was conducted on 2/24/24, with subsequent routine visits on 3/14/24, 3/28/24, 4/8/24, 4/23/24, and 5/6/24. In addition, the record contained an order, dated 2/22/24 for care of the pleural drainage system insertion site; Clean catheter site and surrounding area with alcohol swab. Apply split sponge around catheter. Cover with gauze pad and cover with occlusive dressing. There was not evidence of dressing changes.

Upon observation, 1 of 4 visits (Patient #8) did not demonstrate evidence that the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #8, Aide: After washing and cleaning her hands, this staff member used the patient towel hanging in the patient's bathroom to dry her hands.

Upon patient record review 1 of 19 records (Patient #1) did not have evidence of documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #1: The aide visit frequency was 2x/week and on 4/1/24, the aide visit orders indicated to have 2 aides complete care. There was not evidence that 2 aides completed the aide tasks on 4/26/24.

Upon patient record review 2 of 19 records (Patient #4,#9) did not have evidence of documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #4: There was not evidence of an aide supervisory visit between 2/27/24 and 3/21/24. Patient #9: There was not evidence of an aide supervisory visit between 4/5/24 and 4/22/24.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Documents indicate that the volunteer usage percent for the year 2023 was 1.24% for the provider.

Upon patient client record review, 4 of 19 records (Patient #1,#2,#3,#6) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #1: The benefit election statement, dated 2/17/24 indicated that the patient/caregiver wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was not evidence that this document was furnished. Patient #2: The benefit election statement, dated 3/8/24 indicated that the patient/caregiver wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was not evidence that this document was furnished. Patient #3: The benefit election statement, dated 9/15/23 indicated that the patient/caregiver wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was not evidence that this document was furnished until 9/21/24. Patient #6: The benefit election statement, dated 3/12/24 indicated that the patient/caregiver wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was not evidence that this document was furnished. A second document indicated a request was made on 3/22/24 but the document was not furnished until 3/27/24

Upon patient client record review, 1 of 19 records (Patient #15) did not evidence that each patient record contains physician orders. Patient #15: The patient was discharged on 11/9/23 as the patient was no longer appropriate for hospice. There was not evidence of an order from the Medical Director to discharge the patient.

Upon patient client record review, 1 of 19 records (Patient #7) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #7: The record indicated that an LPN supervisory visit was conducted on 4/3/24. There was not evidence that an LPN provided care to this patient. In addition, the question for aide supervision, asking if the aide plan of care was updated and the nurse documentation indicated, 'yes.' There was not evidence that an aide had provided care to this patient.

Upon client record review, 1 of 19 records (Patient #15) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested

Upon client record review, 1 of 19 records (Patient #15) did not have evidence that the discharge summary includes all required information. Patient #15: There was not evidence of a summary of the patient's stay, including treatments, symptoms and pain management.

Upon client record review, 3 of 19 records (Patient #4,#5,#6) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #4: The record contained a wound care order dated 2/24/24, for wound care to a stage II left heel wound daily. Cleanse with wound cleanser and allow to dry. Apply Santyl to areas of slough. Cover and secure with bordered foam. Wound care to be performed by hospice nurse or facility nurse. There was an update to the wound care on 4/25/24 which still indicted that the hospice nurse or the facility nurse could provide the wound care. The order did not specifically indicate which provider was to perform the wound care. Corrected on site. Patient #5: The record contained a wound care order dated 2/20/24, to cleanse back, buttock, and peri area with NS wound cleanser and cover with calmoseptine BID and prn to be performed by facility staff or hospice nurse. The order did not specifically indicate which provider was to perform the wound care. Patient #6: There were wound care orders dated 3/18/24 for a DTI to the right heel, and on 4/4/24 to the right lateral elbow. Both orders indicated for the facility nurse or the hospice nurse to provide the wound care without specifically indicating which provider was to perform the wound care. Corrected on site.

Based on policy review, record review, grievance file review, and interview, the hospice failed to enure patients received effective pain management and symptom control for conditions related to the terminal illness (L512). The effect of the deficient practice resulted in a finding of immediate jeopardy for two patients (Patient/Records #4 & #5) and has the potential to affect all patients served by the agency.

Based on agency policy review, clinical record review, and interviews, the agency failed to ensure that patients received effective pain management and symptom control for conditions related to the terminal illness and related conditions in two of five records reviewed (Records/Patients #4 & #5). This deficient practice has the potential to affect the pain and symptom management of all of the agency's patients. Findings included: Review of the "Kindred at Home- Hospice Division" hospice policy titled "Patient Bill of Rights 2-002", last updated November 2020 showed the patient bill of rights defines that the patient has the right to effective pain management. Review of the "Kindred at Home- Hospice Division" hospice policy titled "Interdisciplinary group plan of care 4-031", last updated November 2020 showed in part the following: - The hospice interdisciplinary group will retain professional management responsibilities for the provision of services and will insure that services are furnished in a safe and effective manner; and - It's the responsibility of the case manager to facilitate communication about changes in the patient's status between interdisciplinary group members and the patient's physician if any. Review of the "Kindred at Home- Hospice Division" hospice policy titled "Pain Assessment 4-046", last updated November 2020 showed: - The pain assessment occurs during the initial assessment and ongoing basis. The nurse will complete a pain assessment to identify pain; and - Pain assessment to include history, location, intensity, quality, onset, duration, patterns, medication regimen and effectiveness. Record/Patient #4: Review of the hospice record showed that the patient was admitted to Avalon Hospice on 10/25/2021 with cancer of the bladder. The patient had heart disease, COPD (chronic obstructive pulmonary disease), and kidney disease. Review of the hospice complaint log showed that on 12/08/2021 at 9:47 AM, a hospice manager received a complaint from the patient's primary caregiver. The description section of the complaint log showed "Patient (caregiver) reports that nurse stated (he/she) would order medication for shortness of breath during (his/her) visit on Monday. Patient (caregiver) then spoke with the nurse on Tuesday and nurse reported (he/she) would address the medication. Patient's (caregiver) reports patient was uncomfortable all night and (the caregiver) ended up texting their family doctor him/herself for medications to address the issue". During an interview with the patient's primary caregiver/family on 12/22/2021 at 2:00 PM, he/she stated the following: - The patient has COPD (chronic obstructive pulmonary disease), and has needed a nebulizer for treatment of the COPD in the past. The patient had a nebulizer machine in the house, but no medications for it; - On 12/06/2021 he/she informed the registered nurse (RN-B) that the patient was coughing intermittently, and caused shortness of breath; - On 12/07/2021 he/she again told the hospice nurse (RN-B) by phone that at night the patient has coughing episodes and was short of breath, needed medications; and - The night of 12/07/2021 (the patient) was" bad short of breath with cough and was miserable". He/she ended up calling the previous family physician him/herself to get medications for the patient. During an interview on 12/22/2021 with RN-B, he/she stated the following: - The patient's family asked for medications for the patient's cough on 12/06/2021. The patient did not appear to be in any distress on the 12/06/2021 visit; - The family again asked on 12/07/2021 for medications for cough and shortness of breath. "I cannot recall if I called" (the physician) for orders; - He/she did not follow-up on the family's request, "I dropped the ball"; - The branch clinical manager talked to me after the incident, "I know now" to follow-up; and - The patient's respiratory status has declined, the patient is now on oxygen and uses nebulizer treatments regularly. Review of the nurse visit note on 12/06/2021 by RN-B showed: - The patient had a "cough and abnormal breath sounds"; - The patient had a "productive" cough; and - The nurse documented that the caregiver "would like me to speak to the patient's Combivent, or nebulizer treatment". Review of all clinical records showed no hospice visit was performed by a nurse 12/07/2021 through 12/09/2021. Review of the plan of care interim orders showed three respiratory treatment orders were added 12/08/2021 at 2:51 PM as follows by registered nurse (RN-C): - "Solumedrol dose pack" (a steroid: the order was incomplete for strength, route, frequency and duration); - Tesslon Perles (cough suppressant: the order was incomplete for strength, route, frequency); - Duoneb (nebulizer: the order was incomplete for strength, route, frequency). Review of a "coordination note report" by RN-C on 12/08/2021 (untimed) showed "Spoke with patient's (family/caregiver) who reported patient was up all night coughing. Family contacted doctor and received orders for solumedrol dose pack and Tesslon Perles". The findings were reviewed with the hospice branch manager on 12/22/2021 at 11:06 AM; no additional information was provided by the survey exit. The branch manager stated that he/she was new to the position, the previous branch manager had resigned the position. Record/Patient #5: The patient was admitted to hospice on 11/01/2021 with a terminal diagnosis of esophageal cancer. The patient was on hospice services until his/her death the morning of 11/09/2021. Review of the patient's hospice plan of care showed that the nurse would observe and assess for altered comfort, anxiety. "The nurse will assess for need of medication, medication changes, and patient/caregiver education". Review of the hospice complaint log showed that on 11/02/2021 at 4:51 PM that a hospice manager received a complaint from the patient's primary caregiver. The description section of the complaint log showed "(caregiver) called again to complain that patient has been waiting all day for pain medications." A follow-up comment showed that the hospice had spoke with the patient's caregiver three times the evening of 11/02/2021 and that the pain medications ordered were sent to the wrong pharmacy. Review of the initial hospice nursing visit dated 11/01/2021 showed the following: - The patient's pain is described as mild (no numerical rating); - The patient was prescribed oxycodone (narcotic analgesic) 5 mg every six hours as needed for pain and lorazepam 0.5 mg tablets, 1-2 tablets as needed for shortness of breath or anxiety; and - The patient had taken oxycodone and Ativan for several years. Review of the hospice nursing visit dated 11/02/2021 at 1:23 PM showed the following: - The pain assessment showed the patient had pain all of the time. The patient's pain at the beginning of the visit was rated an 8, the best the patient's pain had been was a 3, and the highest was an 8 (on a 0-10 high scale) in the past 24 hours. During the visit, the nurse provided education on liquid morphine (it should be noted that there were no orders in the chart for the medication and no documentation of physician communication requesting the medication); * There was no documentation of the LPN (licensed practical nurse) reporting the patient's increased pain (from the initial assessment) to the Interdisciplinary Group (IDG); Review of the hospice call log and case communication notes showed the following: - At an undetermined time on 11/02/2021, the patient's caregiver called to ask about the prescription for liquid morphine: * The nurse checked with the physician and the clinical manager and confirmed that the order for liquid morphine had been signed; * The nurse then called the patient's caregiver and told him/her that the script had been sent to the pharmacy; * The patient's caregiver asked the nurse if, for some reason the pharmacy couldn't fill the prescription, would the agency be able to get it filled somewhere else that would be open later in the day; * The on-call nurse advised the patient's caregiver that he/she would have to check with the pharmacy to see how long it would take for the script to get filled, and check with the pharmacy to see if they would transfer the script; * According to the communication note, untimed on 11/02/2021 the caregiver stated, "I have been waiting all day on this, we may need to leave this company." Then caregiver hung up the phone on the hospice nurse. Call logs from the hospice answering service show that the patient's caregiver called three times on 11/02/2021 as follows: - On 11/02/2021 at 5:15 PM reporting that the medication was still not at the pharmacy; - On 11/02/2021 at 6:33 PM reporting that the medication had not been called into the pharmacy; - On 11/02/2021 at 7:16 PM calling again to report the medication had not been called into the pharmacy. Call logs from the hospice answering service show on 11/02/2021 at 7:43 PM a call from the (pharmacy-B) requesting billing information for the medication. (It should be noted that according to the agency complaint record, the original prescription had been sent to the wrong pharmacy). Review of the hospice nursing visit dated 11/03/2021 at 10:21 AM showed: - The visit documentation failed to contain an assessment of the patient's pain rating and character of pain (as described in the agency's pain management policy); - The family was concerned that the patient had not had a bowel movement and administered Miralax without an order: - The family requested the oxycodone dose be increased to every four hours instead of every six hours (interim physician order was obtained for the increase); Review of the answering service records showed: - On 11/03/202 at 8:41 PM the family called the answering service to report that the patient had stomach pain and his abdomen was hard; and - A registered nurse visit was made with an enema administered. Review of the hospice nursing visit dated 11/04/2021 at 12:00 PM showed the nurse failed to asses the patient's pain, including any pain rating; *The patient was, "still constipated," and the family had administered fleets; and Miralax, senna, and Gas-X. Small bowel movement noted; - Interim order received for Miralax, Fleets enema, and Fleet glycerin suppository. Review of the hospice nursing visit dated 11/5/2021 showed: - The patient was lying in bed grimacing and complaining of being uncomfortable; - The nurse administered a fleet enema with results; - The patient complained of muscle pain and diclofenac cream was ordered for hips and shoulders; - The patient reported no appetite and had not had solid food for two days; and - Interim orders were received to increase oxycodone to 5-10 mg every four hours as needed (PRN) for pain, and diclofenac cream to affected area four times per day PRN for pain relief. Call logs from the hospice answering service showed on 11/6/2021 at 10:39 AM. The caregiver called the answering service requesting an increase or an additional pain medication to keep patient comfortable. The current dose of oxycodone 10 mg every four hours was not working. The patient remains in distress with shoulder and neck pain. The Voltaren cream not an option because the patient is allergic to ACE inhibitors and pharmacy did not fill the medication. (it should be noted that no allergies to ACE inhibitors are on the patient's record). RN visit was advised. Review of a 11/06/2021 PRN hospice nursing visit at 5:17 PM (~five hours after the hospice answering service advised a visit for uncontrolled pain) showed that: - The family/caregiver had requested extended release morphine that morning and an order had been received to give 15 mg twice a day; - The family/caregiver had not administered the extended release morphine at the time of the nursing visit; - The documentation failed to contain a pain assessment including pain rating and character; - The patient was still using the oxycodone for pain management; - The patient used Aspercreme (Lidocaine) four times a day for topical pain control; - The patient did not tolerate Ativan, it caused hallucinations, Buspar 10 mg ordered BID; and - An interim order at 5:17 PM to increase nursing visit to daily was written during this visit. Review of an untimed case communication note from 11/06/2021 showed that the nurse called and spoke with the patient's caregiver. The caregiver reported that the patient had been moaning out for a few hours and believes (the patient) is suffering. Caregiver states he/she had been giving the medications as ordered. During the call, the caregiver reported that the patient just began to rest. The nurse instructed the caregiver to call if any further needs. Review of the plan of care interim orders showed on 11/07/2021 at 10:14 AM orders were entered for a fentanyl patch (narcotic pain patch) 100 mcg/hr, change every 48 hours. Review of the case communication showed on 11/07/2021 at 11:36 AM the caregiver/family called the office asking when the nurse would arrive for a visit. Review of the call log showed on 11/07/2021 at 1:09 PM the caregiver called answering/triage service and stated that they were still waiting on the nurse, that the patient was in pain and (the caregiver) was wanting to know the maximum amount of pain medication that could be given. The answering/triage staff member reviewed the medication profile with the caregiver. * Oxycodone 5-10 mg every four hours as needed for pain; * Extended release morphine 15 mg twice a day; * Lorazepam 0.5 mg every four hours for anxiety, which the family voiced concern over past issues with breathing when using the medication; and * A nursing visit was scheduled. Review of a nursing visit on 11/07/2021 at 2:04 PM showed the following: - The patient's pain was rated at an 8 at the time of the visit, with the pain rated 5 at best, and a rating of 9/10 at worse; - The caregiver reported that the patient was having increased pain and shortness of breath; and * The physician was notified and orders were received to increase the extended release morphine to every 8 hours and oxycodone to 15 mg every two hours as needed for pain; and * The family stated they would just like the patient to be comfortable. Review of a 11/07/2021 nursing visit at 3:20 PM showed: - The visit documentation does not contain a pain assessment including pain rating or character; - Fentanyl patch was applied per family request (~five hours after the physician order); - The family was asking for a backup option for pain medication since patient wasn't swallowing; * The hospice physician was notified and stated patient needs to wear the fentanyl patch at least 24 hours to see effectiveness and patient can utilize oxycodone up to 15 mg every two hours and liquid morphine (it should be noted that there is not an order in the record for this medication) PRN for emergency. Review of the call log on 11/07/2021 at 11:00 PM showed that the caregiver called the answering/triage service reporting that he/she feels that the patient is suffering, moaning and crying. They have been giving the oxycodone 15 mg every two hours and the extended release morphine 15 mg every 8 hours routinely. The answering/triage service documented that the medication is not effective and a nursing visit advised for uncontrolled pain. It should be noted that review of all available clinical records showed no further documentation or visits after the reports of uncontrolled pain by the caregiver/family on 11/07/2021 at 11:00 PM . Review of the the answering/triage service log on 11/08/2021 at 6:19 AM. showed the caregiver/family reported pain medication was not effective and would like a visits as soon as possible. The caregiver reported he/she had given all medications including morphine (extended release) ER, Oxycodone 15 mg, and Ativan 30 minutes ago, and the medications were not working. Review of a nursing visit 11/08/2021 at 7:17 AM (seven hours after the report of uncontrolled pain and recommendation from the answering/triage service advising a nursing visit.) showed: - There was no pain assessment documented including rating or character of pain; and - The nurse contacted the physician about pain control issues; The patient passed away on 11/09/2021 at approximately 2:00 AM. During an interview on 12/22/2021 at 4:00 PM, the administrator stated that: - There are variances in the orders for lorazepam and oxygen; - For the LPN visit dated 11/02/2021, there is not documentation to show that the LPN reported the patient's increased pain to the RN; - Generally the staff communicate emergent symptoms during the morning, "Stand Up Meeting," but the meeting notes failed to contain documentation of the patient's increased pain; - The nursing visits on 11/04/2021, 11/06/2021, and 11/08/2021 failed to contain documentation of a pain assessment per agency policy including but not limited to the patient's numerical pain rating and character of pain; and - On 11/08/2021, they would expect the patient to receive pain medication for management of uncontrolled pain in less than 5 hours. During an interview with the patient's primary caregiver on 12/22/2021 at 10:02 AM, he/she stated the following: - The delivery/management of medications and DME (durable medical equipment) was a problem. They were told that they would get medications and equipment within 2-3 hours, but in reality it was 12-24 hours before meds would be gotten; - It was frustrating watching his/her parent suffer; - The patient was taking oxycodone (prescribed from the oncologist) for several years for pain control. The hospice changed the medication to morphine; - He/she stated she spoke with the administrator several times about concerns; - The night the patient passed away, the suction machine broke. The patient was frothing at the mouth. The suction machine stopped working about two hours before the patient passed. The family called the equipment company and the DME employee was getting ready to come, but the patient passed away in the interim; - "We just watched (the patient) suffer, they told us 'anything you need, we can get in 2-3 hours' but that was not true"; - On the first and second day after admission to hospice, they weren't very responsive, we were blind-sided by the whole "Hospice" thing, but by the time (the patient) was admitted to Avalon, he/she was starting to decline; - The pain was awful, (the patient) was unable to clearly communicate, but was restless and uncomfortable, and was able to cry out in pain; and - The hospice never offered continuous care or general inpatient care when the pain was uncontrolled. In conclusion the patient was admitted to hospice on 11/01/2021 with a terminal diagnosis of esophageal cancer. The patient was on hospice services until his/her death the morning of 11/09/2021. The patient had severe pain throughout the 8 day episode of care. Pain medication delivery was delayed at least once because the prescription was sent to the wrong pharmacy. The daughter called the answering service daily to report uncontrolled pain. The agency staff made changes to the plan of care, but did not achieve pain management. After the caregiver reported pain at six nurse visits and the family/caregiver called the hospice office and after hours triage 10 additional times regarding pain, the hospice never offered continuous care or general inpatient care for the uncontrolled pain.