Every finding on record at United Palliative & Hospice Care Inc

Based on record review, observations, and interviews, the administrator failed to be responsible for the day-to-day operations for 1 of 7 discharged patients (#7) whose records were reviewed in that: The Administrator failed to ensure that the patient was properly assessed for hospice eligibility. This failure placed the patient at risk of not getting the correct care needed. --- Findings include: Record review of the undated agency policy titled "Eligibility and Election of the Medicare Hospice Benefit" read in part; "...(i) At the time of referral, eligibility criteria will be reviewed to determine if the patient will be admitted to hospice...(ii) if the hospice determines the admission is not appropriate and /or the patient is not eligible for hospice, either upon referral or after the initial visit, the patients physician, and referral source will be notified..." Record review of the undated agency policy titled "Patient Assessments" read in part; "...(ii) The hospice will conduct and document in writing a patient-specific comprehensive assessment that identifies the patients need for hospice care and services, and the patients need for physical, psychosocial, emotional, and spiritual care..." Patient #7 Record review of the plan of care for certification period 3/8/2023 to 9/3/2023 showed a start of care date of 3/8/2023 and diagnosis of Senile Degeneration of brain. The plan of care was signed by RN A on 3/8/2023 and by MD #1 on 3/14/2023. Record review of the RN hospice discharge data collection only - showed a no visit made note, dated 04/03/2023 and signed by the Alternate Administrator/ADON read in part: ";Patient moved out of service area. Unable to make contact or communicats [sic] with patient or care givers." Record review of the referral sheet showed a referral date of 03/08/2023 and the referral contact was Group Home Owner #1. Record review of the History & Physical and Face-to-Face note dated 2/23/23 that was electronically signed by the hospice NP reads in part: ";a 28 year old female, was seen and evaluated in his [sic] private residential to continue hospice care [there was no evidence that she was in hospice before]. She has complicated diagnoses of Senile Degeneration of Brain Comorbidities, chronic pain, bipolar disorder, localized edema, anxiety and migraine. Past medical history: Senile Degeneration of Brain Comorbidities, chronic pain, bipolar disorder, localized edema, anxiety and migraine. [Patient #7], a 28 female was examined with a terminal diagnosis of Degenerative disease of nervous system, unspecified. Other: (secondary, comorbidities) involve Chronic Pain, Bipolar Disorder, Localized Edema, anxiety and Migraine. Recently hospitalized for extreme agitation, psychosis, and suicidal ideation. Symptoms related to hospice diagnosis include unorganized thoughts, paranoia, increased confusion, SOB, with mild to moderate exertion, generalized pain and distress with activity. Caregiver was concerned about increased tenderness & stiffness to joints, tremors, muscle spasms, poor concentration. She needed assistance with ADLs. KPS remained 40% [a score of 40% is Disabled; requires special care and assistance], FAST remained 7E, inability to smile. She sleeps for 12.5+ hours in 24 hours a day this period. She remained at very risk for falls. Severe limitations with active and passive ROM/ADLs. No acute neurological deficits. The plan is to continue with comfort measures and to educate patient, caregivers, and family members about disease processes and expected signs and symptoms. Her quality of life is poor. The patient is a good candidate for hospice services and hospice appropriate." Record review of the RN hospice start of care assessment dated 03/08/2023 signed by RN A documented the following: - Eligibility criteria and for reason for admission: RN 1 documented ";senile degeneration of brain." - The patient should meet all of the following neurological disorder criteria: RN 1 documented ";Palliative performance scale (PPS) score of 40% or less [a score of 40% means Mainly in Bed. Unable to do most activity. Extensive disease], functional decline to dependence in most or all ADLs/requiring major assistance with all ADLS in prior 12 months, impaired memory, cognition, or consciousness. - Narrative: RN 1 documented ";Patient #7 is a 28 year old Caucasian female admitted to [this hospice] with terminal diagnosis of senile degeneration of brain comorbidities Chronic Pain, Bipolar Disorder, Localized Edema, anxiety and Migraine. Pt was awake, alert and oriented X 3 [person, place, time]. Pt is able to make needs known. Pt. was recently hospitalized due to increase anxiety, depression, and suicidal ideation. Pt has increased numbness, pain and weakness in bilateral lower extremities. Pt has complained of pain level 8 in lower back and bilateral lower extremities. Pt decreased nutritional intake. RT MAC 40, KPS 50% [A score of 50% Requires considerable assistance and frequent medical care]. Patient needs assistance with ADLS. PT sleeps 6 hours daily. PT eligible for service. MD was notified and orders were obtained. Plan of care established by the interdisciplinary group member in collaboration with the patient and caregiver towards providing end of life care. Record review of the Hospice CTI verbal order dated 3/8/23 read in part: ";I certify that the patient has a terminal diagnosis of senile degeneration of brain and prognosis is six months or less if the disease runs its normal course." Further review of the physician narrative read in part: ";28 year old Caucasian female admitted to [this hospice] with terminal diagnosis of degenerative disease of nervous unspecified. Comorbidities chronic pain, bipolar disorder, anxiety, and migraine. Pt was awake, alert, and oriented x 3. Pt is able to make needs known. Bilateral lungs sounds diminished. Pt has shortness of breath with moderate exertion. Pt has irregular heart rate with bilateral lower extremities +1 edema. Pt was recently hospitalized due to increased anxiety, depression and suicidal ideation. Skilled nursing performed psychiatric assessment and no sign of suicidal ideation noted. Pt has increased numbness, pain and weakness in bilateral lower extremities. Patient complained of pain level 8 in lower back and bilateral lower extremities. Pt has hyperactive abdominal bowel sounds. Pt has decreased nutritional intake. RT MAC 40, KPS 50%, Pt is continent of bowel and has occasional incontinent of bladder due to urgency and frequency. TUG Test is 15 seconds. Pt has bilateral lower extremities pain and unsteady gait. Pt is at high risk for fall. Pt needs assistance with ADLs. Pt sleeps 6 hours daily. Due to history and report obtained, certification is indicated. Attestation: I confirm that I composed the narrative above and that it is based on my review of the patients medical record and/or examination of the patient." The verbal order was signed by the Administrator/DON on 03/08/2023 and by MD #1 on 05/02/2023. Further review of the clinical record showed the last visit Patient #7 received was from RN B on 3/22/23. Review of a client coordination note report dated 03/30/2023 entered by RN B read in part: ";Pt left the group home." Review of a second client coordination note report dated 05/03/2023 entered by the Administrator/DON read in part: ";Per RN B missed visit due to patient moving out of service area." During an interview on 05/04/23 at 10:00 am with Family Member #1, he was asked why Patient #7 was on hospice services. Family Member #1 stated that he didnt know Patient #7 was on hospice services. Family Member #1 was asked if Patient #7 had senile degeneration of the brain and Family Member #1 stated that Patient#7 didnt have senile degeneration of the brain and she didnt need hospice. Family Member #1 stated that Patient #7s had mental problems, schizoaffective disorder, and substance abuse. Family Member #1 was asked if Patient #7 was able to walk, feed herself, bathe and do her activities of daily living and Family Member #1 stated that she was capable of doing all her activities of daily living. Family Member #1 stated that at this time Patient #7 was in jail. Family Member #1 stated that due to Patient #7s mental disorder she got in trouble and she had been in jail for about 2 weeks. During an interview on 05/04/23 at 10:11 a.m. with Family Member #2, she was asked if Patient #7 had a diagnosis of senile degeneration of the brain and Family Member #2 denied that Patient #7 had senile degeneration of the brain. Family Member #2 stated that Patient #7 had Schizoaffective disorder and substance abuse. Family Member #2 stated that Patient #7 was in jail, after she was released from jail, she was going to rehab and then live with her (Family member #2). Family Member #2 was asked if Patient #2 was capable of doing her activities of daily living like walking, bathing, feeding herself, etc. Family Member #2 stated that Patient #7 was capable of doing all her activities of daily living. Family Member #2 stated that she was not aware that Patient #7 was on hospice services. Family Member #2 stated that Patient #7 was never on hospice services before and denied that Patient #7 had a terminal diagnosis. Family Member #2 stated that if Patient #7 was on hospice, ";then that was a scam." During interview on 05/04/23 at 2:35 p.m. with MD #1, he was asked if he did a face-to-face assessment to Patient #7 and MD #1 stated ";no, that is not standard of care." MD #1 stated that the NP did the face-to-face assessment, the RN did the initial assessment, they took data from the patient and then they sent it to him. From there, he approved hospice services and gave verbal order to start hospice services. MD #1 was informed that per family members, they denied that Patient #7 had senile degeneration of brain or other terminal diagnosis, and they said that Patient #7 had Schizoaffective disorder and substance abuse. MD #1 stated that Schizoaffective disorder and substance abuse can cause senile degeneration of the brain. During interview on 05/04/23 at 4:13 p.m. with RN A, she was asked for the criteria for hospice eligibility for Patient #7 and RN A stated that it was based on the diagnosis. RN A was asked how she got the diagnosis of senile degeneration of the brain and RN A stated that she didnt have access to the system at this time and she had to call the surveyor later. During a follow up interview on 05/04/23 at 6:13 p.m. with RN A, she stated that the correct terminal diagnosis for Patient #7 was degenerative disease of the nervous system. RN A stated that it was a mistake from her part, a typo and she made a correction of the diagnosis on 03/10/2023. RN A was asked for the criteria for hospice eligibility for Patient #7 and she said that its was based on the diagnosis. RN A stated that the diagnosis was given to her from the hospice and ";I dont give diagnosis." RN A stated that prior to conducting the start of care assessment, the NP assessed the patient and completed the H & P. RN A was asked if Patient #7 was capable of doing her ADLs and RN A stated ";I dont stay with her all day. I know she need it assistance with some ADLs." RN A was asked for the ADLs that Patient #7 need it assistance and RN A stated ";I dont remember specifically and I didnt document it." On 05/05/23 at 10:40 a.m., the hospice provided a client coordination note report dated 05/04/23 that was entered by RN A that read in part: ";Diagnosis correction per physician order. Pt diagnosis is degenerative disease of nervous system. "; At this time the hospice also provided a physicians order #9289, dated 3/10/23 that showed a diagnosis of degenerative disease of nervous system with onset or exacerbation date of 3/8/23. The order was electronically signed by RN A but was missing physician signature. During interview on 05/04/23 at 4:55 p.m. with Group Homeowner #1, she was asked why she referred Patient #7 to hospice services. Group Homeowner #1 stated that Patient #7 asked about the services, there was another patient in the group home that was receiving his medications through the hospice and Patient #7 wanted the same services. Group Homeowner #1 stated that she didnt know who qualified for hospice services, she gave the hospice information to Patient #7 and the patient called the hospice. Group Homeowner #1 stated that Patient#7 lived in her group home for about a month, she left the group home because she didnt like the curfew hours of the group home. Group Homeowner #1 stated that Patient #7 had personal issues with street drug use, issues with the curfew time, was in and out of the group home with the boyfriend, and she didnt follow the rules. Group Homeowner #1 was asked if Patient #7 was capable of doing her activities of daily living like walking, bathing, feeding herself, and Group Homeowner #1 stated that some days Patient #7 didnt want to bathe or get out of bed, but it was due to her mental problems [depression] but she was capable of doing all her activities. Group Homeowner #1 was asked if Patient #7 used any assistive device for walking and she said ";no." Group Homeowner #1 was asked if Patient #7 had speech problems and she said ";no, she was very verbal." Group Homeowner #1 was asked about Patient #7s medical diagnoses and Group Homeowner #1 stated that she didnt know anything about her diagnoses. Group Homeowner #1 stated that Patient #7 didnt have power of attorney and she signed her own consent for hospice services. Group Homeowner #1 stated that Patient #7 moved out of the group home at the end of March, and she didnt know where she moved. During interview on 05/05/23 at 11:32 a.m. with RN B, she stated that she made 2 regular visits to Patient #7. RN B stated that on the third visit, the group home informed that Patient #7 moved out and they didnt know where she moved out. RN B stated that she called Patient #7, but the calls didnt go through, and she was nowhere to be found. RN B was asked if Patient #7 was capable of doing her ADLs and RN B stated that Patient #7 was capable of doing her ADLs and she was ambulatory without using an assisting device. During interview on 05/05/23 at 12:20 p.m. with the hospice NP, he was asked how he got the terminal diagnosis of senile degeneration of the brain. NP stated that the diagnosis was already in the system [hospice system]. NP was informed that according to clinical record reviews it showed he was the first hospice staff that assessed the patient and NP stated ";the diagnosis was already in the system." NP was asked if Patient #7 met the criteria for hospice and NP stated that Patient #7 had senile degeneration of the brain, he did an assessment and Patient #7 was very confused, disorganized and was not taking her medications. NP was asked if these findings met the criteria for hospice eligibility and NP stated ";its hard to determine that in one day. We have the first certification period, the nurse goes to assess the patient weekly, we discuss findings in the IDGs, if patient is not declining then we discharge. Its a process. First period we monitor closely." NP was asked if Patient #7 was in hospice service before since the face-to-face showed ";to continue hospice service." NP stated ";that I dont know. I have a template that I use, maybe was an error." During interview on 05/05/23 at 1:09 p.m. with the Alternate Administrator/ADON, she was asked where the hospice got the terminal diagnosis for Patient #7. The Alternate Administrator/ADON stated that the Intake person enters that information in the system. At this time the Alternate Administrator/ADON called the Intake Personnel, and she was asked where she got the diagnosis for Patient #7. Intake Personnel stated that she entered the wrong diagnosis in the system but she got the diagnosis from the hospice NP. The Intake Personnel was informed that per NP stated that the diagnosis was already in the system. Intake Personnel stated ";[NP] gave me the diagnosis, I dont know why he would say that. I only entered the wrong code." During a follow up interview on 05/05/23 at 4:05 p.m. with the Alternate Administrator/ADON, she was asked for the hospice procedure to determine patient eligibility for hospice services. The Alternate Administrator/ADON stated that the criteria for hospice eligibility its based on the diagnosis, H & P, medications, assessment and they compared the patient activities of 6 or 3 months ago to present to see how the patient had declined.

It is required that the hospice follow up with patients/families to determine needs in the event that care is interrupted during or due to an emergency. This standard was not met as evidenced by a review of clinical medical records, observation, and an interview. In 3 of 3 (100%) records with observation visits, it was revealed the patient/family did not receive a copy of the hospice’s emergency preparedness program packet. [Record #s 80441; 78437; 38225]. A review of admission packets available in patients’ homes and an interview of caregivers confirmed a copy of the hospice’s emergency preparedness program packet was not provided to the patient or family or patient’s legal representative(s). A review of the general patient admission packet revealed a copy of the hospice’s emergency preparedness program packet is not provided to the patient or family or patient’s legal representative(s). During an interview on 1/21/2022, the Alternate Administrator/ADCS confirmed this finding.

It is required that the patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This standard was not met as evidenced by a review of clinical records. In 13 of 13 (100%) records reviewed it was revealed the patient was not informed of the hospice coverage and right to request patient notification of hospice non-covered items, services, and drugs. The hospice election statement contains the right to elect or decline to receive the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” by initialing and dating on either the elect or decline option. This section of the election statement was not completed [Record #s 38225; 63198; 62232; 66523; 76525; 24471; 80441; 84788; 28887; 91296; 84257; 16552; and 78437]. During an interview on 1/21/2022, the Alternate Administrator/ADCS confirmed this finding.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan no less frequently than every 15 calendar days. This standard was not met as evidenced by a review of plans of care, IDG meeting documentation, and interviews. 8 of 8 (100%) clinical records with current active patients do not contain physician-signed plan of care orders every 15 days during the period reviewed of September 1, 2021, to January 20, 2022. Documentation of sign-in records on paper and electronically in clinical records supports IDG meetings with plan of care reviews occurring every 2 weeks. Documentation of clinical records revealed plan of care orders are not signed by the physician every 15 days. A review of clinical records revealed the last physician signed plan of care as listed below: Record #38225 Patient admitted on 2/11/2020. Most recent plan of care order is dated 9/24/21. Record# 63198 Patient admitted on 11/5/2021. Most recent plan of care order is dated 11/5/21. Record #66523 Patient admitted on 8/14/2021. The most recent plan of care order is dated 8/14/2021. Record #76525 Patient admitted on 11/12/2020. The most recent plan of care order is dated 11/12/21. Record #80041 Patient admitted on 2/11/2020. The most recent plan of care order is dated 9/24/21. Record #84788 Patient admitted on 3/4/2021. The most recent plan of care order is dated 10/11/21. Record #28887 Patient admitted on 11/15/2021. The most recent plan of care order is dated 10/8/21, identified as the referral date. Record #91296 Patient admitted on 7/5/2021. The most recent plan of care order is dated 12/17/21. During an interview on 1/21/2022, the Alternate Administrator/ADCS confirmed this finding.

It is required that medical social services are provided per the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 13 (15%) clinical records reviewed with social work (SW) visits it was revealed the SW did not provide services as ordered on the plan of care. Record #38225; The plan of care dated 9/24/2021 includes orders for SW visits, however a review of the plan of care revealed there are no problems, interventions, or goals related to SW services on the plan of care. Frequency orders as of 9/24/2021 state SW visit to occur 1/month for a duration of 1/ month and prn visits. A review of the record revealed visits occur routinely 2 times each month 9/8/21, 9/22/21, 10/13/21, 10/27/21, 11/10/21, 11/24/21, 1/8/22, and 1/22/22. Record #78437; Frequency orders as of 10/6/2021 state SW visit to occur 1/month with 2 prn visits per month. A review of the record revealed visits occur routinely 2 times each month; 10/2/21, 10/16/21, 11/10/21, 11/24,21, 12/2/21, and 12/16/21. During an interview on 1/21/2022, the Alternate Administrator/ADCS confirmed this finding.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; and is consistent with the hospice aide training. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This CONDITION was not met as evidenced by review of clinical records, interview of agency management, and interview which revealed that the agency failed to ensure written patient care instructions for a hospice aide (L625) and failed to ensure the hospice aides follow the established Aide Plan of Care (L626). The cumulative effect of these deficiencies could place the patient in jeopardy for a safety risk or for a lack of quality care.

It is required that Hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and an interview. 2 of 8 (25%) clinical records reviewed with aide services revealed the plan of care did not contain planned interventions of providing aide services. Record #38225 The plan of care order dated 9/24/2021 does not contain planned interventions for aide services. The aide provides services following an aide plan of care ordered on 12/2/2021. Record #80411 The plan of care order dated 9/24/2021 does not contain planned interventions for aide services. The aide provides services following an aide plan of care ordered on 12/2/2021. During an interview on 1/21/2022, the Alternate Administrator/ADCS confirmed this finding.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care This standard was not met as evidenced by a review of clinical records and an interview. 2 of 13 (15%) clinical records reviewed with aide visits was revealed the plan of care was not implemented as ordered. Record #78437; The plan of care order dated 12/3/21 states aide frequency orders as 6/week. The aide plan of care dated 12/17/21 states 5/week. It was revealed during record review that aide visits are occurring 5/week with visits occurring for the week of 12/16/21 -12/6, 12/7, 12/8, 12/9, 12/10; week of 12/13/21 - 12/13, 12/14, 12/15, 12/16, 12/17; week of 12/20/21- 12/20, 12/21, 12/22, 12, 23, 12/24, week of 12/27/21 (in compliance with an order for 4 times this week) 12/27, 12/28, 12/29, 12/30, week of 1/3/22 – 1/3, ¼, 1/5, 1/6, 1/7; week of 1/10/22 – 1/10, 1/11, 1/12, 1/13, 1/14; and week of 1/17/22 – 1/17, 1/18, 1/19, 1/20, 1/21. Record # 80441 The plan of care order dated 12//2/2021 states aide frequency orders as 5/week. It was revealed during record review that visits the week of 12/27/21 occurred 4 times on 12/27, 12/28, 12/29, and 12/30. A 5th visit did not occur. There was no documentation to support why the visit did not occur. Record #38225 The plan of care order dated 12/2/2021 states aide frequency orders as 5/week. It was revealed during record review that visits the week of 12/27/21 occurred 4 times on 12/27, 12/28, 12/29, and 12/30. A 5th visit did not occur. There was no documentation to support why the visit did not occur. Additionally, during an observation visit, on 1/20/2022, with the patient and hospice aide it was observed the hospice aide did not complete a shampoo as ordered to be completed on every visit in the aide plan of care dated 1/19/2022. During an interview with the aide, the aide stated shampoos are provided on Fridays. During an interview on 1/21/2022, the Alternate Administrator/ADCS confirmed this finding.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient and considers current subjective and objective medical findings when making this determination. This standard was not met as evidenced by a review of clinical records and an interview. In 6 of 9 (66%) of recertification's requiring a f2f visit, it was revealed that the f2f visit documentation had the wrong certification dates on the f2f certification dates. Record #38225: Face to Face visit by the NP was completed on 11/21/2021 for the wrong certification period of 10/3/21 to 12/1/2021. Record #66523: Face to Face visit by the NP was completed on 11/01/21 for the wrong certification period of 8/14/21 to 1/11/2021. Record #76525: Face to Face visit by the NP was completed on 1/4/2022 for the wrong certification period of 11/12/21 to 1/10/2022. Record #80441: Face to Face visit by the NP was completed on 11/21/2021 for the wrong certification period of 10/3/21 to 12/1/2021. Record #84788: Face to Face visit by the NP was completed on 12/20/21 for the wrong certification period of 10/30/21 to 12/28/21. Record #91296: Face to Face visit by the NP was completed on 12/20/2021 for the wrong certification period of 10/3/21 to 12/31/21 During an interview on 1/21/2022, the Alternate Administrator/ADCS confirmed this finding.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by a review of clinical records and an interview. 4 of 6 (66%) clinical records with patients entering the 3rd or beyond benefit period did not contain current subjective and objective medical findings when making this determination. Record #38225: Recertification dates of 10/3/21 to 12/1/2021. The face-to-face visit by the NP was completed on 9/28/21, the medical director completed and signed the written recertification order on 9/13/2021, prior to having current subjective and objective medical findings from the f2f clinical findings. Record #66523: Recertification dates of 01/11/2022 to 3/1/2022. The face-to-face visit by the NP was completed on 1/10/22, the medical director completed and signed the written recertification order on 12/31/2021, prior to having current subjective and objective medical findings from the f2f clinical findings. Record #76525: Recertification dates of 01/11/2022 to 3/1/2022. The face-to-face visit by the NP was completed on 1/4/22, the medical director completed and signed the written recertification order on 12/31/2021, prior to having current subjective and objective medical findings from the f2f clinical findings. Record #80441: Recertification dates of 12/29/21 to 2/26/22 The face-to-face visit by the NP was completed on 12/20/21, the medical director completed and signed the written recertification order on 12/17/2021, prior to having current subjective and objective medical findings from the f2f clinical findings. During an interview on 1/21/2022, the Alternate Administrator/ADCS confirmed this finding.

It is required that each patient’s record includes, at a minimum signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records and an interview. 12 of 13 (100%) clinical records reviewed of patients who elected the hospice benefit revealed the name of the hospice was not identified on the election form. [Record #s 38225; 63198; 62232; 66523; 76525; 24471; 80441; 84788; 28887; 91296; 84257; and78437]. During an interview on 1/21/2022, the Alternate Administrator/ADCS confirmed this finding and agreed the election of benefit hospice form did not identify this hospice by name on the form.

It is required that Drugs and biologicals related to the palliation and management of the terminal illness and related conditions are: Identified in the plan of care; Provided to a patient while under the care of the hospice. This standard was not met as evidenced by the review of policies and procedures, clinical records, home visit observations and interviews with patients/caregivers, and interview which revealed issues with the agency's compliance with identifying the person(s) authorized by the IDG/IDT to administer drugs and biologics (L692); issues with ensuring that drugs and biologicals related to the palliation and management of the terminal illness and related conditions are identified in the plan of care. (L687), and ensuring that a copy of the hospice written policies and procedures on the management and disposal of controlled drugs was provided to the patient or patient representative and family (L695). The cumulative effect of these deficiencies could negatively impact the ability to provide and support safe patient care practices in the home setting.

It is required that drugs and biologicals related to the palliation and management of the terminal illness and related conditions are identified in the plan of care. This standard was not met as evidenced by a review of clinical records, observation and interviews. In 1 of 1 (100%) RN observation visits, it was revealed that drugs and biologicals related to the palliation and management of the terminal illness and related conditions are not identified in the plan of care. Record #80441: The patient resides in a group home. During an observation visit with the RN on 1/20/2022 the group home administrator provided the surveyor with a copy of the patient’s medication profile and during an interview stated the medication profile contains all the medications the patient receives. A review of the patient hospice medication profile revealed not all drugs are identified in the hospice plan of care accurately or are not present. The hospice medication profile states the patient receives Levothyroxine 125mcgs, the group home medication profile states the patient receives Levothyroxine 100 mcgs. The hospice medication profile states the patient receives Carb/LEVO 10-100mg, the group home medication profile states the patient receives Carb/LEVO 25-100mgs. The hospice medication profile states the patient receives Trazadone 25mgs, the group home medication profile states the patient receives Seroquel 25mgs. The hospice medication profile states the patient receives Pataday, Ophthalmic Solution 0.1% 1 Gtt BID, prn; Bromfed DM oral Syrup 30-2-10 mg/5ml 1tsp, q 4hours prn; and Bisac-Evac Rectal Suppository 10 mg. 1 QD, prn. These medications are not present on the group home medication profile. During an interview on 1/20/2022, the Alternate Administrator/ADCS confirmed this finding.

It is required that the plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. If the patient and/or family cannot administer drugs or biologicals, it is noted in the plan of care, as well as how it is addressed by the IDG. This standard was not met as evidenced by clinical record review and an interview. In 13 of 13 (100%) clinical records reviewed of patients who reside at home, it was revealed the records did not contain the IDG determination of the ability of the patient/family to safely self-administer drugs and biologicals to the patient in the home. [Record #s 38225; 63198; 62232; 66523; 76525; 24471; 80441; 84788; 28887; 91296; 84257; 16552; and78437]. During an interview on 1/21/2022, the Alternate Administrator/ADCS confirmed this finding.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by a review of clinical medical records, observation and an interview. In 3 of 3 (100%) records with observation visits, it was revealed the patient/family did not receive a copy of the hospice’s written policies and procedures for the management and disposal of controlled medication [Record #s 80441; 78437; 38225]. A review of admission packets available in patients’ homes and an interview of caregivers confirmed a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications was not provided to the patient or family or patient’s legal representative(s). A review of the general patient admission packet revealed a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is not provided to the patient or family or patient’s legal representative(s). During an interview on 1/21/2022, the Alternate Administrator/ADCS confirmed this finding.