Every finding on record at Universal Hospice, Inc

Based on interview and record review, the home health agency failed to conduct an assessment of the health status in accordance with the patient's plan of care (POC) for one of three sampled patients (Patient 8). The HHA failed to assess the patient's whole body system, on the location of edema (swelling). This deficinet practice had a potential to miss changes on the patient over all health status and lack of treatment to meet the patient's care goals. Findings: On 5/26/22, a review of Patient 8's electronic clinical record indicated a hospice care date of 2/23/22, with a terminal diagnoses of chronic combined systolic and diastolic heart failure, and cardiac amyloidosis ( non as a stiff heart syndrome occurs when amyloid deposits take the place as normal heart muscle and may affect the way electrical signals move through the heart) A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 2/23/22 to 5/23/22, indicated Patient 8's terminal diagnosis was Chronic combined systolic and Diastolic Heart Failure, and Cardiac Amyloidosis ( non as a stiff heart syndrome occurs when amyloid deposits take the place as normal heart muscle and may affect the way electrical signals move through the heart). A review of the initial, Nursing Assessment, visit by the RN, dated 2/23/22, indicated Patient 8 had functional limitation of endurance. Patient 8 has an oxygen concentrator and requires O2 continuously at 2-5 liters per minute (LPM) and as needed as needed (PRN). The Skilled Nurse (SN) documented Patient 8 has pitting edema at the level of 2 (the pressure leaves an indention of 3-4 mm that rebounds in 15 seconds). The assessment as to the location of the edema was not identified. There was no assessment of the patient caregiver knowledge or training to assist the patient daily personnal and needs when the hospice nurse is not visiting the patient. A review of the, "Initial orders and Plan of Care," dated 11/8/2021, indicated the Skilled Nurse (SN) visit frequency for Patient 1 was once a week and two visits as needed for symptom management, O2 at two LPM as needed and for the SN to check O2 saturation (sat) PRN for shortness of breath (SOB)-call Medical Doctor (MD) for O2 sat less than 88%, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/caregiver care plan/intervention in collaboration with interdisciplinary team (IDT). "Initial orders and Plan of Care." A review of Patient 11's electronic clinical record, indicated a start of hospice care date was 8/13/21, with terminal diagnoses of , with a terminal diagnosis of Chronic combined systolic and Diastolic Heart Failure.(Unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the '"Physician's Certification Hospice Benefit, '' for the 1st 90 -day period, from 8/13/21 to 11/10/21, indicated Patient 11's terminal diagnosis was Heart Failure, Unspecified. There was no documented evidence the hospice attending physician communicated with the primary physician, to certify that Patient 11 had a life expectancy of six months or less if the terminal illness runs it normal course. A review of the initial, Nursing Assessment, visit by the RN, dated 8/3/21, indicated Patient 11 had functional limitation of endurance, and that patient 8 has an oxygen concentrator and requires O2 continuous and as needed as needed (PRN), at 2-5 liters per minute (LPM) . There was no assessment of the patient caregiver. The Skilled Nurse (SN) documented patient 8 has pitting edema at the level of 2, however, did not document the location of the pitting edema. A review of the "Initial orders and Plan of Care," dated 8/3/2021, indicated the SN visit frequency for Patient 2 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the social worker to visit once a month to assess, evaluation. The chaplain was instructed to visit once a month to assess and evaluate. It also indicated that volunteer services were "Declined". During an interview with the Director of Nurses on 5/27/22, at 12pm, she stated the comprehensive assessment should be complete. A review of the agency's policy and procedure on Comprehensive Assessment revised April 2021, stipulates, " A physical assessment, including blood pressure, temperature, pulse, respiration, skin and other relevant data related to pertinent physical findings and the patient's terminal illness."

Based on observation, interview, and record review, the hospice failed to maintain an accurate, current medication profile for two of three sampled patients (Patient 1 and Patient 2). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. Findings: a. A review of Patient 1's Patient Profile indicated, a start of care (SOC) date of 9/27/20, with a diagnosis which included hypertensive chronic kidney disease (kidney failure). A review of Patient 1's Plan of Care (POC), for the re-certification period from 5/20/22 to 7/18/22, indicated an order for skilled nurse (SN) to visit 1 time a week and 3 additional visits per week as needed for nine weeks. On 5/25/22, at 12:00 p.m., a home visit was conducted at Patient 1's residence with the Licensed Vocational Nurse (LVN 1). Patient 1 was observed lying on her bed. A caregiver was at the patient's bedside. The LVN proceeded to render care. On 5/25/22, at 12:28 p.m., the LVN asked the caregiver to show all the medications the patient was taking. The LVN was observed looking at the medication bottles for the following medications: 1. Atorvastatin (for cholesterol)20 mg (milligrams, unit of measurement) 1 tablet by mouth every day at bedtime. 2. Nitrofuratoin (antibiotic to prevent infection) 100 mg 1 capsule by mouth every day at bedtime. 3. Metroprolol (to treat high blood pressure) 25 mg tablet 1 tablet by mouth every day. 4. Cranberry with Vitamin C 450-125 mg by mouth twice a day. 5. Furosemide (a diuretic, to get rid of excess fluid)20 mg tablet 1 tablet by mouth every day. 6. Losartan 25 mg 1 tablet by mouth every day for systolic blood pressure greater than 150. 7. Lorazepam (relieves anxiety) 1mg under the tongue every 4 hours as needed for agitation. 8. Levothyroxine (for low thyroid) 75 mcg (micrograms, unit of measurement) 2 tablets by mouth every day. 9. Latanoprost (helps prevent loss of eyesight) 0.005% 1 drop both eyes every night. 10. Timolol 0.5% (helps prevent loss of eyesight) 1 drop both eyes every day. 11. Albuterol (to help breathe easier) 0.5 mg every 4 hours as needed for wheezing, coughing. The LVN did not have a medication list or any other reference to refer to when reviewing the medications. A review of Patient 1's record titled, "Current Treatment/Medication/DME List", printed 5/25/22, indicated 12 medications listed, not observed and reviewed during the home visit. These were: 1. Melatonin 5 mg 1 tablet by mouth every night. 2. Phenergan DM Syrup 5 ml by mouth every 4 hours as needed for cough. 3. Ceftin 250 mg 1 tablet by mouth every 12 hours for 7 days. 4. Levsin 0.125 mg 1 tablet under the tongue every 3 hours as needed for increased secretions. 5. Aspirin 81 mg EC DR 1 tablet by mouth every day. 6. Azopt 1% opth susp 1% 1 drop each eye three times a day. 7. Dulcolax 10 mg 1 suppository rectally daily for constipation. 8. Effer-K 20 mEq 1 tablet by mouth every 3 days. 9. Polyethylene glycol 17 gm (grams) 1 capful by mouth daily for constipation. 10. Stool softner 100 mg liquid gel 100 mg 1 capsule by mouth twice daily. 11. Tramadol 50 mg 1 tablet by mouth every 6 hours as needed for pain. 12. Propyl Glycol 0.6% 1 drop both eyes daily as needed for dry eye. b. A review of Patient 2's Patient Profile indicated, a start of care (SOC) date of 9/24/21, with a diagnosis of down syndrome (a genetic disorder associated with physical growth delays, mild to moderate intellectual disability, and characteristic facial features). A review of Patient 2's Plan of Care (POC), for the re-certification period from 5/12/22 to 7/10/22, indicated an order for skilled nurse (SN) to visit 1 time a week and 3 additional visits per week as needed for nine weeks. On 5/25/22, at 1:30 p.m., a home visit was conducted at Patient 2's residence with the Licensed Vocational Nurse (LVN 1). Patient 2 was observed lying on her bed. Patient 2's mother was at her bedside. The LVN proceeded to render care. During the home visit, the LVN did not review the medications Patient 2 was taking. During an interview on 5/25/22, at 1:50 p.m., the LVN stated "nothing has changed" when asked if she had reviewed the medications during the visit. The LVN stated "there hasn't been any changes. Its repetitive, my documentation". During an interview on 5/27/22, at 12:07 p.m., the Director of Patient Care Services (DPCS) stated nurses were expected to review the medications patients are taking, every visit. The DPCS stated reviewing medications patients take every visit is important because the nurse needs to make sure they have enough supply, nothing is expired, make sure patients are not using medication that is not prescribed because medication doses can change and to be sure patients are taking the right medication. A review of the HA's policy and procedure titled, "Medication Profile", revised April 2021, indicated "Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications."

Based on interview and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for Interdisciplinary group, care planning, and coordination of services, as follows: 1. Failed to ensure the interdisciplinary group (team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), in consultation with the patient's attending physician prepare a written plan of care for four of 11 sample patients, (Patient 1, Patient 2, Patient 6, Patient 9). (Refer to G537) 2. Failed to ensure a social worker and a chaplain were included in the interdisciplinary group (team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) for three of 11 sampled patients, (Patient 1, Patient 2, and Patient 6). (Refer to G541) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with Federal regulations for Interdisciplinary group, care planning, and coordination of services.

Based on observation, interview, and record review, the hospice agency failed to ensure medications were administered in accordance with the plan of care (POC) for 1 of 3 sampled patients (Patient 2). The hospice agency failed to follow the POC, when the Licensed Vocational Nurse (LVN), administered medication for pain, for the patient's chest congestion (the accumulation of mucus in the lungs and lower bronchi (breathing tubes). The hospice agency failed to ensure the LVN, verify the patient's POC while preparing the medication and before administration. The LVN failed to document the medication administration. This failure has the potential to result in medication errors and adverse actions that could affect the health and safety of the patient. Findings: A review of Patient 2's Patient Profile indicated, a start of care (SOC) date of 9/24/21, with a diagnosis of down syndrome (a genetic disorder associated with physical growth delays, mild to moderate intellectual disability, and characteristic facial features). On 5/25/22, at 1:30 p.m., a home visit was conducted at Patient 2's residence with the Licensed Vocational Nurse (LVN 1). Patient 2 was observed lying on her bed with her eyes closed. Patient 2's family member and primary caregiver was at her bedside. On 5/25/22, at 1:33 p.m., LVN 1 was observed checking Patient 2s vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation, and pain). LVN 1 stated Patient 2's oxygen saturation (the percentage of oxygen in the blood) was 79 %. LVN 1 stated the reason the oxygen saturation was low was due to Patient 2's "congestion". On 5/25/22, at 1:36 p.m., the LVN 1 called Registered Nurse (RN) and left text message to notify the patient's physician to notify and get an order for the patient's congestion. On 5/25/22, at 1:42 p.m., during an observation, the LVN removed Morphine Sulfate (a medication used to treat pain) from the comfort kit and told the patient's family member, "I am going to give her morphine to help her breathing. It helped last time". The LVN withdrew 0.25 ml (milliliters) using a syringe and administered the medication under the patient's tongue. The morphine sulfate bottle label was observed and read "Morphine Sulfate 20 mg/ml 5mg/0.25 ml oral/sublingual every 4 hours as needed for pain". LVN 1 did not have a medication profile or the plan of care while preparing and administering the medication. On 5/25/22, at 2:00 p.m., during an interview, LVN 1 stated, the reason she administered Morphine Sulfate was for Patient 2's cough, and not for pain. LVN 1 stated, "I noticed Morphine actually relieves or helps the cough. When I give them a small dose, it helps them breathe easier. I know the label legally has to say pain, but it works as a miracle for breathing. I know that it works for breathing." On 5/27/22, at 10:15 a.m., during an interview with the Director of Patient Care Services (DPCS), stated she had not felt the need to supervise medication administration practices because most of the nursing staff communicate with her if they have questions about giving a medication. The DPCS stated the nurses were expected to review the patient's medication being given against the doctor's order in the plan of care. The DPCS stated nurses were expected to review the "5 rights of medication administration: right person, right medication, right dose, right purpose (what the medication is for)." The DPCS stated Morphine Sulfate has to administer to patient for respiratory distress or pain. On 5/27/22 at 10:30 a.m., during an interview and concurrent record review of Patient's 2 record titled, "Current treatment/medication/DME list" the DPCS stated "It is not specified here", Morphine Sulfate to be used for congestion, cough or respiratory distress. The DPCS stated "As far as, it is an unwritten policy, we can give it for respiratory distress even through the order doesn't say so. Because my thing is, I don't want the patient to be in pain and gasping for air." The DPCS stated the LVN should have called her to get a doctor's order. The DPCS stated "if I was there, I would have not given it for nasal congestion." On 5/27/22, at 12:25 p.m., during an interview and reviewed Patient 2's medical record, the DPCS, stated there was no documentation Morphine Sulfate was administered to Patient 2. The DPCS stated, there was no documentation of doctor notification or RN notification of Patient 2's congestion and need to have an order to treat congestion. A review of Patient 2's record titled "POC/IDG Review", dated 5/11/22, did not indicate interventions on how to manage Patient 2's congestion or need for medication management to address Patient 2's congestion. A review of Patient 2's record titled "Current treatment/medication/DME list", indicated an order for the following medication but was not administered to the patient's congestion. "Albuterol Inhalation Solution 0.083% 1 vial inhalant via nebulizer every 6 hours as needed for wheezing, shortness of breath, congestion ...Levsin 0.125 mg 1 tablet by mouth or sublingual every 3 hours as needed for increased secretions, indication congestion. A review of the HA's policy procedure titled "Identification of medication for administration", revised April 2021, indicated "Procedure 1. Prior to medication administration, the nurse will be familiar with the patient's medical history and will review present medication regimen, including allergies to foods and drugs. 2. The nurse will review the written physician's orders prior to medication administration. 3. It will be the nurse's responsibility to be knowledgeable of the medication to be administered, including indications ..." A review of the HA's policy and procedure titled "Administration and documentation of medications", revised April 2021, indicated "Licensed nursing personnel will administer and document only those medications which have been ordered by the physician, as part of the plan of care and have been approved for safe administration and monitoring during a hospice visit." A review of the HA's policy and procedure titled "Care of the dying patient", revised April 2021, indicated "Procedure 1. At the start of care, and on an ongoing basis, hospice personnel will assess the patient and family/caregiver unit for: ...D. Presence of secondary symptoms and response to treatment ...2. An individualized plan of care will be developed in cooperation with the patient and family, attending physician, and interdisciplinary group members, which facilitates: ...C. Prevention of secondary symptoms ...3. With each patient visit, the hospice nurse will follow the plan of care and assess the need for changes/updates and will document accordingly."

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the patient's symptoms of congestion was assessed and the symptoms were managed with medication in accordance with the plan of care for 1 of 3 sampled patients (Patient 2). This failure resulted in Patient 2 not receiving medication and treatment indicated for the symptoms being experienced. Findings: A review of Patient 2's Patient Profile indicated, a start of care (SOC) date of 9/24/21, with a diagnosis of down syndrome (a genetic disorder associated with physical growth delays, mild to moderate intellectual disability, and characteristic facial features). On 5/25/22, at 1:30 p.m., a home visit was conducted at Patient 2's residence with the Licensed Vocational Nurse (LVN). Patient 2 was observed lying on her bed with her eyes closed. The LVN proceeded to render care. On 5/25/22, at 1:33 p.m. the LVN was observed checking Patient 2s vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation, and pain). The LVN stated Patient 2's oxygen saturation (the percentage of oxygen in the blood) was 79 %. The LVN stated the reason the oxygen saturation was low was due to Patient 2's "congestion". On 5/25/22, at 1:42 p.m., the LVN removed Morphine Sulfate (a medication used to treat pain) from the comfort kit (a prescribed set of medications that are kept in a patient's home to treat any distressing symptoms as quickly as possible) and stated to patient's family member, "I am going to give her morphine to help her breathing. It helped last time". The LVN withdrew 0.25 ml (milliliters) using a syringe and administered the medication under the patient's tongue. On 5/25/22, at 2:00 p.m. the LVN stated the reason she administered Morphine Sulfate was for Patient 2's cough. The LVN stated "no, she was not in pain. I gave it to her for the cough. I have noticed Morphine actually relieves or helps the cough. When I give them a small dose, it helps them breathe easier. I know the label legally has to say pain, but it works as a miracle for breathing. I know that it works for breathing." A review of Patient 2's record titled "POC Summary", printed on 5/25/22, indicated "8. Medications: ... Albuterol Inhalation Solution 0.083% 1 vial inhalant via nebulizer every 6 hours as needed for wheezing, shortness of breath, congestion ...Levsin 0.125 mg 1 tablet by mouth or sublingual every 3 hours as needed for increased secretions, indication congestion ...Morphine Sulfate 20 mg/ml 5mg/0.25 ml oral/sublingual every 4 hours as needed for pain ..." A review of the HA's policy and procedure titled "Administration and documentation of medications", revised April 2021, indicated "Licensed nursing personnel will administer and document only those medications which have been ordered by the physician, as part of the plan of care and have been approved for safe administration and monitoring during a hospice visit." A review of the HA's policy procedure titled "Identification of medication for administration", revised April 2021, indicated "Procedure 1. Prior to medication administration, the nurse will be familiar with the patient's medical history and will review present medication regimen, including allergies to foods and drugs. 2. The nurse will review the written physician's orders prior to medication administration. 3. It will be the nurse's responsibility to be knowledgeable of the medication to be administered, including indications ..."

Based on observation, interview, and record review, the HA failed to ensure the patient's medications were not expired, and were available for immediate use, to meet the patient's needs and comfort, for 1 of 3 sampled patients (Patient 1). This failure placed Patient 1 at risk for receiving expired medications for symptom management. Findings: A review of Patient 1's Patient Profile indicated, a start of care (SOC) date of 9/27/20, with a diagnosis which included hypertensive chronic kidney disease (kidney failure, involves a gradual loss of kidney function that filter wastes in the blood). On 5/25/22, at 12:00 p.m., a home visit was conducted at Patient 1's residence with the Licensed Vocational Nurse (LVN). Patient 1 was observed lying on her bed. A caregiver was at the patient's bedside. The LVN proceeded to render care. On 5/25/22, at 12:31 p.m., an observation of the comfort kit (a series of medications used to manage pain and other symptoms during the end of life) indicated a label which read "Comfort Kit, open when directed by hospice (Morphine, Lorazepam, Bisacodyl, Hyoscyamine, Acetaminophen, Odanestron ODT, Docusate). Exp Date: Sept 2021". The comfort kit contained the following medications: 1. Morphine Sulfate 20 mg(unit of measurement) sublingual 0.25 ml (unit of volume) every 4 hours as needed for pain. Expiration date: 9/21. 2. Acetaminophen 650 mg 1 suppository every 4 hours as needed for mild pain. Expiration date: 9/21. 3. Bisacodyl 10 mg suppository rectal every day as needed for constipation. Expiration date: 9/21. 4. Docusate Sodium 100 mg 1 capsule by mouth daily as needed for constipation. Expiration date: 9/21. 5. Zofran 4 mg 1 tablet by mouth or sublingual every 6 hours as needed for nausea/vomiting. Expiration date: 9/21. 6. Lorazepam 1 mg tablet by mouth or sublingual every 4 hours as needed for anxiety. Expiration date: 9/21. On 5/25/22, at 12:32 p.m. the LVN was asked for the expiration date on the comfort kit and stated "I have to order another one. Its expired. It says September 2021." On 5/27/22, at 12:07 p.m., the Director of Patient Care Services (DPCS) stated nurses were expected to review the medications patients are taking, every visit. The DPCS stated reviewing medications patients take every visit is important because the nurse needs to make sure they have enough supply, nothing is expired ..." A review of the HA's policy and procedure titled "Care of the dying patient", revised April 2021, indicated " ...2. An individualized plan of care will be developed in cooperation with the patient and family/caregiver, attending physician, and interdisciplinary group members, which facilitates: ...B. Pain management (control or alleviation) according to physician orders, which may include analgesia (pain medication) ..."

Based on interview and record review, the hospice agency failed to ensure volunteer service program was maintained and was offered /provided to the patients for one of 11 sampled patients (Patient 9). This deficient practice prevented the patients from receiving benefit from the volunteer program. Findings: A review of Patient 9's admission record indicated the patient was admitted to the hospice agency on 3/16/2022, with primary diagnosis of Aortic Valve Disorder. A review of Patient 9's "Initial orders and Plan of Care" dated 3/16/2022, indicated the SN visit frequency was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention, in collaboration with interdisciplinary team (IDT). The "Initial orders and Plan of Care" indicated, the volunteer was "Declined". On 5/27/2022, at 3:50 p.m., during an interview with the Don , stated she , the volunteer services had been suspended since Covid 19 outbreak, so the volunteer service had not been explained and offered to all the patients/family. A review of the agency's policy of "Volunteer Services" revised on the year of 2017 indicated the hospice will provide volunteer services under the direction of a volunteer coordinator and with the assistance of trained volunteers.