Every finding on record at Tru Community Care - Lafayette

Observed in Tracer Activities. The surveyor observed that the agency had not defined in writing the reassessment information it collected related to wound assessment. This issue was discussed and confirmed with organization leadership.

Observed in Patient Home. In 3 of 7 home visits conducted, the surveyor observed that the medication profile had not been accurate. In HOSHV#3 the SNF patient had narcan on profile of SNF, but narcan had not been listed on hospice profile. HOSHV#5 the surveyor observed that the patient's dose of metformin had been decreased 3 weeks prior from 1000 to 500, but this had not been reflected on patients hospice medication profile, HOSHV#6 the patient had both senna and senna plus in home medication, but only senna had been listed on hospice medication profile. The surveyor discussed and confirmed issue with the SN on each case, the administrator and the director of regulatory & quality.

Observed in Individual Tracer. In 3 of 3 patient records reviewed, in the IPU the goals were observed to be vague and not individualized. An example in review of 3 of 3 IPU patient records revealed the same goal Patient symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow. This has been validated by Administrator and the Director of Quality. Observed in Record Review. In 9 of 15 resident records reviewed, the surveyor observed that the goals for chaplain and MSW were vague, generic, repetitive and not measurable . In addition the surveyor observed that multiple nursing goals also had been vague and not measurable. Examples are: patient/caregiver will feel needs are being met as they have defined was receptive MSW goal. Repetitive chaplain goals observed had been patient /caregiver will cope with change in lifestyle, patient /caregiver will feel needs are being met as they have defined . . Examples of nursing goals that had been vague repetitive : patient's symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow. In discussion with administrator and director of regulatory and quality it was confirmed that not only was goals an issue, but one they had recently identified also. Observed in Record Review. In 3 of 3 patient records reviewed, the surveyor observed the goals to be vague and non-measurable. For example, SN: Patient/caregiver will demonstrate necessary behaviors to maintain good safety awareness andminimize the risk of falls and/or injury; Target Date: 4/10/2025.MSW: Continuity of care will be maintained as appropriate to patient/caregiver needs; Target Date: 1/14/26SN: Anxiety/agitation controlled through course of care; Target Date: 12/7/20251/14/2026. These goals are not individualized and do not clearly state the behaviors or actions to measure in order to determine success. This was reviewed and validated with the administrator of TRU Hospice.

Observed in Building Tour. The surveyor observed in supply room multiple expired items to include : Medihoney expired 1/2026, Xeroform expired1/2026,Iodine expired 10/2025, lemon glycerin swabs expired 2023. This issue was observed, discussed and confirmed with hospice unit manager and other hospice leadership. Observed in Patient Home. In 2 of 6 home visits conducted, the surveyor observed SN failed to perform hand hygiene consistent with policy. During HOSHV#2 the surveyor observed SN not complete hand hygiene between glove changes on 6 occasions while providing wound care to healing stage 4 coccyx wound and bilateral heel wounds. The surveyor also observed SN not change gloves or complete hand hygiene between moving from wounds on right foot to wounds on left foot. The patient had a foley and colostomy in place that the SN emptied. During HOSHV5 the surveyor observed the SN providing wound care to a recent mastectomy patient on oral chemo fail to perform hand hygiene consistent with policy. The surveyor observed the SN change gloves on 3 occasions without cleaning hands as required by organization policy. The issue was discussed and confirmed with organization leadership.

Observed in HR File Review. In 2 of 2 hospice aide human resource (HR) files reviewed, there was no evidence that the aide training program included all of the required elements. The training program did not address appropriate and safe techniques in personal hygiene that include bed, sponge, tub and shower bathing. This was discussed with the hospice administrator (Director of Hospice Innovation).

Observed in Patient Home. In 2 of 6 home visits conducted, The surveyor observed that the SN had not respected the patients right to privacy as evidenced by HOSHV#2 and HOSHV#5 the SN provided wound care to private areas without closing large window very near patient. The issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, discharged alive. The surveyor observed the organization had not provided a summary of care to the hospital in which the patient discharged to. This was reviewed with and confirmed by the administrator.

Observed in Tracer Activities. The surveyor observed during tour of hospice unit 9 oxygen cylinders without proper signage for empty and full tanks. This issue was discussed and confirmed with organization leadership.

Observed in Individual Tracer. In 1 of 3 IPU visits, during patient interview, husband of patient shared a concern regarding timeliness of meal service on several occasions. Discussed concern with unit manager and she confirmed that this has happened on several occasions with other patients and at different meal times. She verbalized concern to the contracted hospital dietary department and currently there has been no resolution. This was validated with Administrator, Director of Quality and Unit Manager.

Based on interviews and record reviews the agency failed to protect patient rights specifically; be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property for 2 of 2 patients (Patients #1 and #8). --- Findings include: AGENCY POLICY According to the policy titled, "Rights/Responsibility," dated, 10/5/2023 (in part): "The right to be free from mental, physical, sexual, and/or verbal abuse, neglect, or exploitation." According to the policy titled, "Scope of Services," dated, 10/5/2023 (in part): "TRU Community Care provides hospice services that are intended to meet the physical, psychosocial, practical, and spiritual needs of hospice patients and family/caregivers. The core hospice team members (registered nurse, medical social worker, physician, and Chaplain) are available to patients and family/caregivers seven (7) days a week, 24 hours a day." 1. The clinical record for Patient #1 was reviewed on 1/7/25. The patient was admitted to hospice care and services on 9/8/24, with a terminal diagnosis of Senile degeneration. The plan of care for the certification period dated 9/8/24 to 11/6/24, included orders for a skilled nurse twice a week for wound care, nurse aide twice a week for activities of daily living, medical social worker once to twice a month for psychosocial needs, and chaplain once a month for spiritual needs. He resided in an assisted living facility that was contracted with the hospice agency. a. The agency failed to protect Patient #1 from neglect. Record review showed Patient #1 had three (3) wounds; one on the right foot, left heel and on the coccyx/buttocks area. On 10/22/24 the coccyx wound was described and documented by hospice skilled nurses to be yellow-green in color and to have a foul odor, which were signs and symptoms of an infection. Further record review failed to show evidence that wound care was provided by the agency's skilled nurse twice a week as ordered by the physician. The weeks of 11/4/24 through 11/30/24 and 12/4/24 through 12/16/24, no wound care was provided to the patient by the hospice staff. There were five (5) missed wound care and dressing changes the patient did not receive from the hospice agency's skilled nurse as ordered by a physician. Review of a missed visit note created by RN (Employee #4) on 11/14/24, showed RN #4 had concerns shared with her by the patient's family about wound care frequency and the patient's repositioning frequency at which the nurse advised the family member to speak to the facility. She further documented the facility staff would do the dressing change that day. There was no evidence Employee #4 did anything about the family members' concerns. Review of a missed visit note created by RN #4 on 11/28/24 revealed RN #4 wrote, "No visit made due to Thanksgiving holiday." RN #4 documented on 12/5/24, dressing change completed by facility staff and that no visit was needed until next week. A review of the contract between Patient #1's hospice agency and the assisted living facility showed no evidence that skilled nurse wound care services were to be provided by the assisted living facility. On 12/17/24, RN #4 created a discharge summary for Patient #1, this summary failed to communicate the patient's wound characteristics, number of wounds, location of wounds and any wound care treatments that were given to the patient while under the hospice agency's care. Further review showed the agency failed to send the discharge summary to the home health agency that the patient was transferred to after discharge. On 12/21/24, Patient #1 was admitted to the hospital with the acute medical problem of septic shock suspect bacteremia due to necrotic grade 4 pressure ulcer/buttock with suspicion of sacral osteomyelitis. In non medical terms, this is a bacterial infection in the blood from the coccyx/buttock wound with a suspicion that the patient's sacral bone is also infected by bacteria. At the entrance interview with the hospice leadership team which included, Employees #1, #3, and #8 on 1/7/25 at 10:42 a.m., they were asked the definition of patient neglect. They collectively stated the following; failure to follow the plan of care, failure to provide the patient with treatment or services, missing visits, and not responding to the patient's needs. An interview with the hospice leadership team which included, Employees #1, #2, #3, and #8 occurred on 1/13/25 at 4:00 p.m. They acknowledged the agency failed to provide Patient #1 with ethical care that was in the best interest of the patient which constituted patient neglect. They also acknowledged that the contract with Patient #1's assisted living facility failed to include wound care as a contracted service, and therefore wound care should have only been provided by the hospice skilled nursing staff. They further acknowledged that the discharge summary was sent to the hospice agency physicians and that they had failed to send the patient's discharge summary to the patient's new home health agency. Additionally, the discharge summary failed to mention the patient's current state or wounds that the patient had at the time of discharge while under their care. Lastly, they acknowledged that skilled nurse, Employee #4 failed to provide Patient #1 with quality nursing care or documentation and they had plans to educate and re-train her immediately. 2. An active clinical record for Patient #8 was reviewed on 1/7/25. The patient was admitted to hospice care and services on 9/10/24, with a terminal diagnosis of Senial degeneration. The plan of care for the certification period dated 9/10/24 to 12/8/24, included orders for a skilled nurse once a week for 13 weeks, nurse aide once a week for activities of daily living, medical social worker once to twice a month for psychosocial needs, and chaplain once to twice a month for spiritual needs. He resided in an assisted living facility that was contracted with the hospice agency. a. The agency failed to provide treatment or services to Patient #8 as ordered by a physician. On 1/8/25 at 12:30 p.m., an observation of Patient #8 in their assisted living residence took place, RN #9 was there to assess the patient and to provide wound care to the right hip. Upon arrival, RN #9 stated the facility had already provided the patient's wound and dressing changes prior to her arrival and that Patient #8 was on a facility outing and would return shortly. She was asked how the assisted living facility was approved to provide wound care that was ordered for the hospice staff to perform. She proceeded to show an intervention in the patient's record that stated, "Facility to manage daily care needs." She also stated that she received wound updates from the facility nurse with each visit. She went on to say, with any hospice patient concerns she was called immediately by the assisted living staff or they called an afterhours hotline to get a hospice nurse. During this same discussion, RN #9 had given an introduction to the assisted living facility director of nursing (DON). The assisted living DON acknowledged that her staff had provided wound care for Patient # 8 and other hospice patients when it was needed and that the hospice agency had supplied wound care supplies. When asked about billing procedures and the facility contract with the agency she said, she was unsure how billing worked when her staff provided wound care instead of the hospice agency's skilled nurses. She did not know if the contract between the hospice agency and the assisted living facility covered wound care services. A review of the contract between Patient #8's hospice agency and the assisted living facility showed no evidence that skilled nurse wound care services were to be provided by the assisted living facility. Record review for Patient #8 revealed a fall on 12/29/24, resulting in a hip wound. Documentation showed the hospice agency was aware of the fall on 12/31/24 but there was no evidence of a wound assessment for infection or provision of wound care until 1/6/25. Further review showed on 1/8/25, the patient's nurse practitioner reclassified the wound as an unstageable wound with the presence of slough. At the entrance interview with the hospice leadership team which included, Employees #1, #3, and #8 on 1/7/25 at 10:42 a.m., they were asked the definition of patient neglect. They collectively stated the following; failure to follow the plan of care, failure to provide the patient with treatment or services, missing visits, and not responding to the patient's needs. An interview with the hospice leadership team which included, Employees #3 and #8 occurred on 1/14/25 at 12:00 p.m. They acknowledged that the agency delayed Patient #8 from treatment and services and that the agency should have made a visit to the patient after he had fallen to assess the patient's needs, therefore constitutes neglect. They also acknowledged that the contract with Patient #8's assisted living facility failed to include wound care as a contracted service, and therefore wound care should have only been provided by the hospice skilled nursing staff.

Observed in Record Review. Identified in 4 of 11 active patient records reviewed, the Medical Social Worker's (MSW) initial comprehensive assessment did not address funeral/burial needs. Reviewed in the records for HV#3, HV#4, HV#5, and in RR#2, there was no documentation to support that a discussion occurred, nor was there an update in the patients' profiles that indicated a funeral home or burial plan. This was reviewed and validated with the Director of Clinical Services.

Observed in Record Review. Identified during the record review, the Comprehensive Assessment was not completed within 5 calendar days. In the record review for HV#3, RR#10, and RR#12, the initial Comprehensive Spiritual Care visit did not occur until six (6) calendar days after the election of hospice care for each patient. This was reviewed and validated with the Director of Clinical Services.

Observed in Individual Tracer. In 2 of 2 home visits conducted where the Registered Nurse (RN) was completing a Comprehensive Assessment, the assessment were not completed in accordance with the organizational Policy No 2-031.1,2 - Ongoing Comprehensive Assessment - 2) The nurse will assess the patient on each ongoing comprehensive visit, for: G. Skin integreity. For example, observed in HV#3 the RN examined the patients lower extremities from the knees down including the feet, but did not examine the remaining skin integrity. Observed in HV#5, the RN did not conduct any skin assessment. This was reviewed and validated with the Director of Clinical Services.

Observed in Record Review. Identified in 4 of 11 Patient Records Reviewed, elements of a complete Plan of Care were missing. For example, in the review for HV#3, it was identified that the chaplain Plan of Care (POC) lacked Goals and Target dates. In review of the record for HV#5 it was identified that the Chaplain's Initial Plan of Care did not identify Goals or Target Dates, and has remained unchanged into the fourth (4th) benefit period. Identified in RR#2, the Registered Nurse (RN), Medical Social Worker (MSW), and Chaplain initial Plan of Care did not include Target Dates, and at the second (2nd) IDG (Interdisciplinary Group) for RR#2 the RN's updated Plan of Care did not include Goals or Target Dates; and, the MSW's updated Plan of Care did not include Goals or Target Dates. There was also no change or updates in the Plan of Care during the third (3rd) and fourth (4th) IDG meetings. Identified during RR#7, the chaplain Plan of Care lacked Goals and Target dates. This was reviewed and validated with the Director of Clinical Services.

Observed in Record Review. In 4 of 11 active patient records reviewed, the Medical Social Worker did not include Funeral/Burial needs in the Plan of Care. Reviewed in the records of HV#3, HV#4, HV#5, and RR#2, Funeral/Burial needs was not identified in the Plan of Care as a problem. This was reviewed and validated with the Director of Clinical Services.

Observed in Record Review. EP 18 Identified in 4 of 11 Patient Records Reviewed, elements of a complete Plan of Care were missing. For example, in the review for HV#3, it was identified that the chaplain Plan of Care (POC) did not include Interventions. In review of the record for HV#5 it was identified that the Chaplain’s Initial Plan of Care lacked interventions and has remained unchanged into the fourth (4th) benefit period. This was reviewed and validated with the Director of Clinical Services.

Observed in Patient Home. Observed in 2 of 2 home visits conducted, the reusable medical equipment was not being cleaned according to organizational Policy No. 9-914.1,2 Bag Technique. During HV#3, and HV#5, the clinicians cleaned all reusable medical equipment with a Wipes Plus Disinfecting Wipe supplied by the organization. Per policy, When the visit is completed, reusable equipment will be cleaned using alcohol and/or soap and water as appropriate..., A. Stethoscope, bell and diaphragm - alcohol; D. Thermometer-Alcohol swab or soap and water . . .E. Blood pressure cuff will be cleaned in accordance with the manufacturer's guidelines . . .F. Pulse Oximeter- Isopropyl alcohol. The Wipes Plus active ingredients do not include alcohol. This was reviewed and validated with the Director of Clinical Services.

Observed in Record Review. In 3 of 7 active patient records reviewed where hospice aide services were ordered, it was identified that the hospice Aide Supervisory visit did not occur every 14 days. For example, in RR#2, there were six (6) consecutive weeks of hospice aide visits made without supervision beginning approximately one (1) month after the start of care. In RR#6, the initial hospice Aide Supervisory visit occurred 21 days after the initial hospice aide visit. In RR#8, during the first benefit period, the aide supervisory visit was missed approximately 4 weeks after the start of care; and, in the second benefit period, there was a span of 6 weeks where no Aide Supervisory visit occurred; and, another missed Aide Supervisory visit approximately three weeks prior to this survey date. This was reviewed and validated with the Director of Clinical Services.

Observed in Record Review. During HV#3, the patient's caregiver shared that there were two instances when she called the organization outside of normal business hours because of the onset of new or uncontrolled symptoms being experienced by her mother. Identified in the record review for HV#3, care was not provided consistent to the patient and family needs, nor delivered with the patient needs as priority. For example, approximately five (5) weeks after the start of care date, the daughter called the triage line to report stomach ache not relieved by the morphine. There was no PRN (as needed) visit made. Four days following, the family caregiver called the Registered Nurse (RN) Case-Manager and reported nausea and generalized abdominal pain . . ., and, an episode of diarrhea x1. The RN Case-Manager documented Educated on calling triage line for prn, and I will follow-up tomorrow. There was no documentation of a follow-up call or visit made on that day or the following day. The next made was a routine, scheduled visit 5 days later. This was reviewed and validated with the Director of Clinical Services.

Observed in HR File Review. Identified during the Competencies Session, the organization has not defined competencies or implemented Competency Assessments for all positions providing care, treatment, and services to patients including Physicians, Clinical Supervisors/Managers, Medical Social Workers, and Bereavement Coordinators. This was validated by the Acting Director of Human Resources. Observed in HR File Review. Identified during the review of personnel records, it was identified that staff had not completed the training in compliance with law and regulation. Upon review of the record for HR#11-Quality and Compliance Manager, there was no evidence that the OSHA BBP or HIPAA educational requirement was met. This was validated with the Acting Director of Human Resources, and the Education Supervisor. Observed in HR File Review. Identified in 4 of 9 clinical staff personnel chats reviewed, the Annual Competency Assessment for 2020, 2021, and 2022 was not completed in accordance with Policy No. 1-008.2 - Competency Assessment-Ongoing Assessment: 1) Competency assessments will be completed at least one time per year . . .; 2) Using a Competency Skills Performance Checklist, the Supervisor will evaluate the competence in performing and rendering care . . .; and, 3) Clinical staff will make a join visit with a Clinical Supervisor annually for direct observation assessment. In HR#4-Medical Social Worker, HR#8-Bereavement Coordinator, HR#10 Registered Nurse Supervisor, and HR#12 MSW Clinical Manager there is no evidence of annual Competency Assessments completed. This was validated with the Acting Director of Human Resources. Observed in HR File Review. Identified during the review of personnel records, it was identified that staff had not participated in ongoing education and training. Upon review of the record for HR#11, it was identified that the Quality and Compliance Manager had not completed any of the required 7.5 hours of education and training for non-clinical roles. This was validated with the Acting Director of Human Resources, and the Education Supervisor. Observed in HR File Review. Identified in 2 of 9 clinical staff personnel charts reviewed, the Initial Competency Assessment was not completed in accordance with Policy No. 1-008.1- Competency Assessment: 2) Using a Competency Skills Performance Checklist, and the Orientation Checklist, the . . . will observe the new personnel performing the required skills and activities. For example, in review of HR#3, the Initial Competency Assessment checklist for the Registered Nurse was incomplete. In review of HR#9, there was no evidence of a Competency Assessment checklist being initiated for the Medical Director. This was reviewed and validated with the Director of Human Resources.

Based on interview and record review, the hospice failed to ensure patients received effective pain management and symptom control from the hospice for conditions related to the terminal illness in 1 of 3 patient records reviewed (Patients #3). --- 2. The clinical record for Patient #2 was reviewed on 10/18/22. The patient was admitted for hospice care and services on 11/21/19, with a terminal diagnosis of malignant neoplasm of the brain. Plan of care orders for the period from 9/11/21 to 11/9/21, revealed SN fifteen PRN visits for symptom management and wound care, Certified Nurse Aide (CNA) for activities of daily living (ADL) care, MSW to assess and evaluate and CH to assess and evaluate. a) The hospice failed to coordinate care to meet the patient's needs by reporting to the hospice that Patient #2 experienced frequent falls in the assisted living setting. Review of the clinical record showed the patient was living at an assisted living residence with hospice services from 11/21/19 to 9/2/21. The patient's condition declined so the patient was moved to the skilled care side of the residence on 9/2/21 to receive higher acuity care. Review of the clinical record showed that on 9/2/21 the hospice nurse received a verbal report from the staff at the assisted living facility who reported the patient fell everyday. The hospice nurse and family were not aware of the frequent falls. The note read that the assistant director of nursing (ADON) at the facility was to follow up with the lack of reporting the falls to hospice. No further documentation was found regarding the follow up with the assisted living residence and communicating with hospice staff about changes in condition of patients receiving hospice services in that setting. Registered Nurse/Case Manager (RN/CM) #6 was interviewed via telephone on 10/20/21 at 9:36 a.m. She said she was the RN/CM of the patient since the patient was admitted to hospice services. During continued interview, RN/CM #6 said the facility ADON was going to follow up with the assisted living staff as to the reason for not notifying hospice when the patient fell. She said she did not hear what they found out but continued to educate them. There was high turnover in staff so the hospice needed to go out frequently and provide education on what to report to hospice staff. She said that she felt the communication was improving but recognized it was an ongoing effort for both hospice and the assisted living staff to make it successful. b) The hospice failed to provide drugs/interventions to meet needs and failed to coordinate care to meet the patient's needs. Review of the clinical record from 9/3/21 to 9/7/21, revealed the patient was admitted to the skilled nursing facility (SNF) on 9/2/21. The patient experienced difficulty with swallowing so medications were stopped except the pain and comfort medications. This was done with the family's agreement to the plan of care ordered by the physician soon after admission to the SNF. Review of the admission to the SNF medication orders dated 9/3/21 revealed the following active medications: - Fentanyl 50 micrograms (mcg)/hour (hr) transdermal film, extended release; Apply 1 patch transdermal every 72 hours; For pain - read back and confirmed Start Date: 9/3/21 - Lorazepam 2 milligram (mg)/milliliter (ml) solution; Administer 0.5 milliliter(s) orally every 6 hours as needed for anxiety/agitation; For anxiety/agitation. Start Date: 9/3/21 - Lorazepam 2 mg/ml solution; Administer 0.5 milliliter(s) orally every 6 hours; For anxiety/agitation. Start Date: 9/3/21 - Morphine Sulfate 15 mg oral tablet; Take 3 tab(s) oral every 6 hours; For pain. Start Date: 9/3/21 Review of the admission to SNF medication orders dated 9/3/21 revealed the following discontinued medications: - Discontinue: effective 9/3/21 - Clonazepam 1 mg oral tablet; Take 1 tab(s) oral 2 times a day; For anxiety. Ordered On: 8/10/2021 - Discontinue: effective 9/3/21 - diltiazem 360 mg/24 hours oral tablet, extended release; Take 1 tab(s) orally once a day for atrial fibrillation (afib). Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - D-mannose 3/4 teaspoon (tsp) powder; Take 3/4 tsp orally 2 times a day; For Urinary Tract Health. Ordered On: 3/12/21 - Discontinue: effective 9/3/21 - Fluticasone-Salmeterol Diskus 500 microgram (mcg)-50 mcg inhalation powder; Inhale 1 puff(s) inhalation 2 times a day; for COPD. Ordered On: 5/21/21 - Discontinue: effective 9/3/21 - Furosemide 40 mg oral tablet; Take 40 milligrams orally once a day for edema. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Furosemide 40 mg oral tablet; Take 80 milligrams orally once a day (in the morning) for edema. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Gabapentin 300 mg oral capsule; Take 1 cap(s) oral 2 times a day; For nerve pain. Ordered On: 6/10/21 - Discontinue: effective 9/3/21 - Keppra 100 mg/mL oral solution; Take 5 milliliter(s) orally 2 times a day for seizures. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Lantus 100 units/mL Subcutaneous solution; Inject 20 units subcutaneously once a day for diabetes. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Levothyroxine Sodium 137 mcg (0.137 mg) oral tablet; Take 137 microgram(s) oral once a day (in the morning) for hypothyroid. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Loratadine 10 mg oral tablet; Take 10 milligrams orally once a day for allergies. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Lorazepam 0.5 mg tablet; Take 1 tab(s) orally every 6 hours as needed for anxiety or agitation. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Methadone Hydrochloride 10 mg oral tablet; Take 1 tab(s) oral 2 times a day; for pain. Ordered On: 7/6/21 - Discontinue: effective 9/3/21 - Methadone Hydrochloride 5 mg oral tablet; Take 1 tab(s) oral Daily; For pain at mid-day. Ordered On: 5/7/21 - Discontinue: effective 9/3/21 - Miralax oral powder for reconstitution; Administer 17 gm(s) orally once a day as needed for constipation. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Miralax oral powder for reconstitution; Administer 17 gm(s) orally once a day for constipation. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Morphine Sulfate 15 mg oral tablet; Take 1 tab(s) oral every one hour (Q1h) as needed for pain; For pain or shortness of breath (SOB). Ordered On: 4/28/21 - Discontinue: effective 9/3/21 - Nystatin Topical 100,000 units/grams (g) topical cream; Apply Cream application applied topically 3 times a day for yeast rash. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Olanzapine 5 mg oral tablet; Take 1 tab(s) orally once a day; For nausea. Ordered On: 3/30/21 - Discontinue: effective 9/3/21 - Omeprazole 20 mg oral delayed release capsule; Take 20 milligrams orally 2 times a day for gastrointestinal (GI) upset. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - ondansetron 8 mg oral tablet; Take 1 tab(s) orally 3 times a day for nausea. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Potassium Chloride 10 milliequivalents (mEq) oral capsule, extended release; Take 30 milliequivalent(s) orally once a day for supplement. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Prednisone 10 mg oral tablet; Take 10 milligrams orally once a day for SOB and/or pain. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - PreserVision AREDS 2 Antioxidant Multiple Vitamins and Minerals oral capsule; Take 1 cap(s) orally once a day for supplement. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Probiotic Formula (Bacillus Coagulans) oral capsule (cap); Take 1 cap(s) orally once a day for supplement. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Rolaids 550 mg-110 mg oral tablet, chewable; Chew 2-3 tab(s) oral as needed (PRN) with heartburn symptoms as needed for heartburn; PRN with heartburn symptoms. Ordered On: 5/21/21 - Discontinue: effective 9/3/21 - Sertraline Hydrochloride 100 mg oral tablet; Take 100 milligrams orally once a day for mood. Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Spiriva Respimat 10 ACT 2.5 mcg/inhalation (inh) inhalation aerosol; Inhale 2 puff(s) inhaled once a day for chronic obstructive pulmonary disease (COPD). Ordered On: 3/4/21 - Discontinue: effective 9/3/21 - Tylenol Extra Strength 500 mg oral tablet; Take 1000 milligrams orally 3 times a day for pain. Ordered On: 3/4/21 Review of the clinical record from 9/4/21 to 9/7/21, revealed that throughout this time period the family requested on several occasions to have certain medications restarted due to the fear of side effects such as seizures from suddenly stopping them. On 9/4/21, the day after the medications had been stopped, the family requested the restart of Keppra 100 mg/mL, 2 mL twice a day (b.i.d.) for seizures, Tylenol for pain or fever, Senna for constipation and prednisone 10 mg every day (QD) for fluid overload due to COPD. However, the doctor did not approve the restart of the medications because the initial evaluation by the physician had not been completed. The family requested a physician change to get the medications restarted. However, there was no documentation or orders found that indicated these medications were restarted according to the family's numerous requests. Further review showed the family also reported that the facility was not controlling the patient's pain adequately. The RN/CM reaffirmed with the nurse staff at the SNF the reason for using the medications to help manage symptoms. The RN/CM compared the orders that the hospice had versus the medications the SNF had on record. Each time the RN/CM addressed medication orders with the SNF, new orders were completed to reconcile the records. The patient was seen on 9/4/21 by a hospice nurse who reported the medication requests to the physicians and addressed uncontrolled pain and agitation symptoms. The only orders noted from 9/4/21 to 9/7/21 were the following: Physician Orders dated 9/4/21: - Ipratropium Bromide 500 mcg/2.5 mL inhalation solution; Inhale 1 unit inhalation; Four times a day. Start Date: 9/4/21 - Scopolamine 1 mg/72 hr transdermal film, extended release; Apply 1 film(s) topically every 72 hours. Start Date: 9/4/21 Physician Orders dated 9/7/21 at 11:49 a.m.: - Haloperidol 2 mg/ml solution; Administer 0.5 milligrams by mouth or under tongue every 6 hours; For terminal agitation. Start Date: 9/7/21 - Haloperidol 2 mg/ml solution; Administer 0.5 milligrams by mouth or under tongue every hour as needed for agitation; For terminal agitation. Start Date: 9/7/21 Review of the clinical record revealed that on 9/7/21 the patient was transferred to the general in-patient (GIP) facility due to uncontrolled pain and agitation symptom management. During the four days the patient was receiving care at the SNF the Keppra was not restarted as the family requested until the patient was admitted to the GIP. There were no physician orders for the restart of Prednisone as requested by the family due to fears of side effects such as fluid build up in the lungs from COPD. Order Date 9/7/21 at 10:57 p.m.: - Keppra 100 mg/mL oral solution; Take 5 milliliter(s) oral 2 times a day for seizures. Start Date: 9/7/21 - Lantus 100 units/mL Subcutaneous solution; Inject 20 units subcutaneously once a day (in the morning) for diabetes. Start Date: 9/7/21 - Senna 8.6 mg oral tablet; Take 3 tab(s) oral 2 times a day for constipation. Start Date: 9/7/21 Review of the clinical record from 9/7/21 to 9/14/21 while the patient was in GIP facility care revealed that the Keppra was discontinued on 9/10/21 due to patient refusing and increased difficulty with swallowing. The family was not in agreement and wanted it restarted although the clinical team encouraged end of life and comfort medications only. On 9/14/21, the physician and nurse assessed the patient for pain and symptom management. The physician ordered an increase of the Fentanyl patch. Physician Order dated 9/14/21 at 1:11 p.m. - Fentanyl 25 mcg/hr transdermal film, extended release; Apply 1 patch transdermal every 72 hours for pain; TOTAL DOSE = 75 mcg (25 + 50) for pain. Start Date: 9/14/2021 On 9/15/21 at 7:05 a.m., 18 hours after the Fentanyl patch was ordered by the physician, it was placed on the patient according to the nurse note. Registered Nurse/Case Manager (RN/CM) #6 was interviewed via telephone on 10/20/21 at 9:36 a.m. She said the medications were stopped because the patient was having a difficult time swallowing. The daughter was in agreement at the time but then wanted medications restarted. RN/CM stated, "It was confusing to understand what the daughter wanted because one day she wanted the medications given, then the next day she wanted them stopped. The daughter really struggled with accepting her mother's declining condition." RN/CM #6 said they had all disciplines on the team to support the daughter, providing constant education about what was happening and what to expect during the dying process. The hospice team was aware the patient's daughter had coping issues, hence the plan of care including support services for the family. The patient was not accepting of her status either so it made it difficult to know what she wanted. She said the patient had been doing good for so long then progressed quickly into decline, so it was hard for the patient and daughter to accept. RN/CM #6 said that the patient frequently refused to take medications then told the family that she was not given her medications. The patient presented with agitation and pain frequently throughout her decline, so the RN/CM was not able to determine if stopping the medications caused worsening of symptoms. She knew that the patient did not have seizure activity with stopping medications. She felt the patient had always been very anxious. She did not recall increased agitation after stopping medications since the patient presented the same prior to medications being stopped. RN/CM #6 said the patient was given heavy doses of morphine but it was not making a difference in the patient's pain relief, so it was determined to send her for GIP. While under the GIP care, the Keppra was restarted but she did not have orders for the Prednisone so it was not restarted. She said it must have been determined by the doctor that it was not necessary, however she found orders that showed it was restarted. She did not know why the daughter was not notified and confirmed there was no documentation on the restart of Keppra and other medications requested by the daughter. RN/CM #6 confirmed the Fentanyl patch ordered on 9/14/21 was started on 9/15/21. She said the physician increased the Fentanyl on 9/14/21 at 12:45 p.m. and the nurse note read that it was started on 9/15/21. She said she could not verify why it was not started on 9/14/21 but instead on the 15th. She said review of the clinical record did not reveal the reason in the medication profile. She said the GIP facility would have been responsible for placement and they did not notify her of any difficulty with obtaining the medication timely. b) The hospice failed to provide drugs/interventions to meet needs and failed to coordinate care to meet the patient's needs. Review of the clinical record from 9/7/21 to 9/14/21 while the patient was in general inpatient (GIP) facility care revealed that Keppra was discontinued on 9/10/21 due to patient refusal and increased difficulty with swallowing. The family was not in agreement and wanted it restarted although the clinical team encouraged end of life and comfort medications only. On 9/14/21, the physician and nurse assessed the patient for pain and symptom management. The physician ordered an increase of the Fentanyl patch. Physician Order dated 9/14/21 at 1:11 p.m. - Fentanyl 25 mcg/hr transdermal film, extended release; Apply 1 patch transdermal every 72 hours for pain; TOTAL DOSE = 75 mcg (25 + 50) for pain. Start Date: 9/14/21 On 9/15/21 at 7:05 a.m., 18 hours after the Fentanyl patch was ordered by the physician, it was placed on the patient according to the nurse's note. Registered Nurse/Case Manager (RN/CM) #6 was interviewed via telephone on 10/20/21 at 9:36 a.m. She said the patient was given heavy doses of morphine but it was not making a difference in the patient's pain relief so it was determined to send her for GIP. RN/CM #6 confirmed the Fentanyl patch ordered on 9/14/21 was started on 9/15/21. She said the physician increased the Fentanyl on 9/14/21 at 12:45 p.m. and the nurse note read that it was started on 9/15/21. She said she could not verify why it was not started on 9/14/21 but instead on the 15th. She said review of the clinical record did not reveal the reason in the medication profile. She said the GIP facility would have been responsible for placement and they did not notify her of any difficulty with obtaining the medication timely. c) The hospice failed to coordinate care to meet the patient's needs by ensuring durable medical equipment (DME) specifically, high flow oxygen concentrator was provided for Patient #2 when in the SNF setting. Review of the clinical record from 9/18/21 to 9/29/21, revealed the patient returned to the SNF on 9/18/21. A hospice RN assessed the patient upon admission to the SNF on 9/18/21 at 1:51 p.m. RN/CM #6 conducted an assessment on 9/20/21 at 10:58 a.m., 9/21/21 at 11:35 a.m. and 9/23/21 at 2:30 p.m. The daughter called the on-call hospice phone line to report the patient had low oxygen saturation levels and the high flow concentrator was missing. Physician Order dated 3/4/21: Oxygen Via nasal cannula device; Inhale 3.5 liters per minute inhaled Continuous as needed for shortness of breath; CPAP at night (40,20). -The physician order did not indicate that the patient utilized a high flow rate concentrator for oxygen therapy. Registered Nurse/Case Manager (RN/CM) #6 was interviewed via telephone on 10/20/21 at 9:36 a.m. She said that when a patient changed settings such as assisted living to SNF to GIP, then the nurse assessments included ensuring the facility had everything it needed to provide an appropriate level of care to the patient. She said she routinely spoke to facilities to establish needs like an oxygen concentrator and ensure it was provided. RN/CM #6 said that the ALR and SNF were frequently misplacing equipment. She said the facilities would use the equipment on other patients not realizing the equipment was owned by the hospice. She said Patient #2 had received oxygen therapy for many years. She said the patient used a high flow concentrator because at times she would use 5-10 liters of oxygen per minute (lpm). She said she was not aware until the daughter called, that the concentrator had been removed from the room. She said the SNF reported they had removed it from the patient's room because it was making a lot of noise. There was no reason given as to why they did not contact hospice to get the equipment replaced. She said the concentrator was found in a closet in the SNF. The SNF used one of their own concentrators while waiting for it to be replaced, however the SNF's concentrator was not a high flow concentrator which meant the oxygen level could not be turned up beyond 5 lpm. Findings include: AGENCY POLICY According to the policy titled, "Provision of Care to Residents of SNF/NF or ICF/IID," dated 8/29/19, in pertinent parts; "A provision that the hospice may use SNF/NF or ICF/IID nursing personnel where permitted by State law and as specified by the SNF/NF or ICF/IID to assist in the administration of prescribed therapies including in the plan of care only to the extent that the hospice would routinely use the services of a patient's family in implementing the plan of care." According to the policy titled, "Pain Management," dated 8/29/19, in pertinent parts; "The patient's right to pain management is respected and supported. Hospice clinicians plan, support and coordinate activities and resources to ensure that the pain of all patients is recognized and addressed appropriately." According to the policy titled, "Continuity of Care Between Inpatient Setting and Home," dated 8/29/19, in pertinent parts; "Continuity of care and communication will be provided for patients transferring between the home and inpatient setting for respite or general inpatient care. TRU Community Care will maintain responsibility for the provision and coordination of care during the patient's inpatient stay." 1. The clinical record for Patient #3 was reviewed on 10/18/22. The patient was admitted for hospice care and services on 9/7/22, with a terminal diagnosis of malignant neoplasm of an unspecified part of the left bronchus or lung. Plan of care orders for the period from 9/7/22 to 12/5/22, revealed skilled nursing (SN) seven PRN (as needed) visits for symptom management, medical social work (MSW) to assess and evaluate and chaplain (CH) to assess and evaluate. a) The hospice failed to provide drugs/interventions to meet Patient #3's pain management needs. Review of the clinical record showed a hospice evaluation was ordered on 9/4/22. Review of the clinical record showed the patient was originally scheduled to be discharged from the hospital on 9/5/22 at 1:03 p.m., and was to be admitted to hospice on 9/7/22. On 9/7/22, the patient was discharged from the hospital and was transported to the SNF on hospice and interim medication orders were placed at 5:11 p.m., for "5 mg/0.25ml" for morphine to be administered every three hours. On 9/7/22 at 2:51 p.m., the initial Registered Nurse (RN) assessment was completed for the Start of Care (SOC) Initial Assessment by the hospice. Review of the clinical record showed RN #5 documented the patient arrived at SNF on 9/7/22 at approximately 5:00 p.m., despite Nurse Practioner (NP) #7 ordering morphine on 9/7/22. RN #5 reported that the Director of Nursing (DON) of the SNF and the daughter wished for morphine to be administered that evening. A priority order (STAT) was placed for ";20 mg/ml, 5mg Q3 hrs PRN pain/dyspnea delivery within 4 hrs", by NP #7 for the hospice. Review of the clinical record showed that a verbal order was submitted on 9/7/22 at 8:17 p.m. by NP #7 for morphine sulfate 20 mg/ml concentrate; Administer 5 milligrams by mouth or under tongue every 3 hours as needed for pain or shortness of breath; PRN pain/dyspnea. Review of the clinical record showed on 9/8/22 at 12:25 p.m., RN #5 received notification from the DON at the SNF upon arrival to the SNF, undated time, that prior to making an RN visit with the patient, the morphine that was ordered at the time of admission was never delivered. Review of the clinical record showed RN #5 notified her supervisor and a STAT order for morphine was placed. Review of the clinical record showed RN #5 arrived at the SNF, no specific time was documented on when RN #5 arrived, and collaborated with the facility DON and the DON inquired if RN #5 had brought the morphine on her person. RN #5 explained that she was not allowed to transport medications and that the morphine was ordered STAT and should arrive soon. During an interview on 10/19/22 at 2:25 p.m., the Director of Clinical Services (DCS) stated that the hospice tried to work with their contracted facilities on what medications were allowed to be ordered and that the hospice would coordinate with the contracted facilities and ultimately the hospice was trying to make sure the patient was cared for. During continued interview the DCS stated depending on the contracted facility, medications were handled with either pharmacy utilization meetings, contracted pharmacy facilities and STAT delivery.- The DCS further stated the hospice would pay the extra fee to get medications delivered in a shorter time frame. During an interview on 10/19/22 at 3:25p.m., RN #5 stated when she arrived at the SNF on 9/8/22 and was notified that the medications for the patient had not arrived and were not administered, she notified her supervisor. RN #5 stated she spoke with the DON of the SNF and a travel RN who worked at the SNF to figure out what happened and a STAT order was placed through the hospice to get that medication delivered. Furthermore, RN #5 stated she tried to access the SNF eKit and called Rocky Mountain Senior Care who was the patient's primary care physician office to get a pain medication order as the hospice protocol would be to get an emergent pain medication order from the patient's primary care physician. RN #5 stated that the hospice was never notified by the SNF of the missed medication delivery.