Every finding on record at Visiting Nurse Health System

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medications. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure the drug profile was updated. Home Visit 1: The patient elected the hospice benefit on 05/03/2022 with a terminal diagnosis of severe protein-calorie malnutrition. The patient resided in a skilled nursing facility [SNF]. During the home visit observation with the Hospice Aide (staff 2), a medication review was completed by comparing the hospice medication profile with the medication administration record [MAR] from the SNF. The SNF MAR included Bisacodyl 10MG suppository every 72 hours as needed for constipation and Acetaminophen suppository 650MG every 24 hours as needed for pain or fever greater than 100.5 degrees Fahrenheit. The hospice plan of care dated 05/03/2024 and medication profile did not include Bisacodyl and Acetaminophen suppository. Home Visit 3: The patient elected the hospice benefit on 10/21/2023 with a terminal diagnosis of senile degeneration of the brain. The patient resided in a SNF. During the home visit observation with the Medical Social Worker (staff 3), a medication review was completed by comparing the hospice medication profile with the MAR from the SNF. The SNF MAR included Metoprolol succinate Extended-Release 50MG tablet. The hospice plan of care dated 04/18/2024 and medication profile did not include Metoprolol. Home Visit 4: The patient elected the hospice benefit on 03/17/2024 with a terminal diagnosis of Parkinson’s disease. The patient resided in a SNF. During the home visit observation with the Chaplain (staff 4), a medication review was completed by comparing the hospice medication profile with the MAR from the SNF. The SNF MAR included Acetaminophen 325MG tablet, Dilaudid oral liquid 1MG/1ML, Ipratropium-albuterol inhaled solution 0.5-2.5 (3) MG/3ML every 12 hours as needed for shortness of breath/cough/difficulty breathing/abnormal breath sounds, and Sinemet 25MG-100MG tablet. The hospice plan of care dated 04/18/2024 and medication profile did not include Acetaminophen, Dilaudid, Ipratropium-albuterol, and Sinemet. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed the plans of care and medication profiles had not been updated to include medications given by the skilled nursing facility staff.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG [interdisciplinary group] in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure the hospice care and services provided to patients and families followed the individualized plan of care established by the IDG. Clinical Record 3: The patient elected the hospice benefit on 10/21/2023 with a terminal diagnosis of senile degeneration of the brain. The initial plan of care dated 10/21/2023 and updated on 11/21/2023, 12/05/2023, and 12/20/2023 included the order for “Hospice nurse to perform wound care to laceration on right lateral ankle… change every day and PRN (as needed).” The updated plan of care dated 01/03/2024 did not include the daily wound care order. The clinical record contained no documented evidence that the hospice nurse completed daily visits and performed wound care to the right lateral ankle as ordered from 10/22/2023 through 01/03/2024. Clinical Record 17: The patient elected the hospice benefit on 09/30/2023. The patient died at home on 11/08/2023. The bereavement plan of care dated 11/15/2023 included an intervention for the Bereavement Coordinator to make monthly phone calls. The clinical record contained no documented evidence that the Bereavement Coordinator completed the telephone call with the bereaved in December 2023 or documentation of why the call was not made. Clinical Record 18: The patient elected the hospice benefit on 09/30/2023. The patient died at home on 11/08/2023. The bereavement plan of care included an intervention for the bereavement coordinator to make monthly phone calls. The clinical record contained no documented evidence that the Bereavement Coordinator completed the telephone call with the bereaved in December 2023 or documentation of why the call was not made. Clinical Record 19: The patient elected the hospice benefit on 03/09/2023. The patient died at home on 06/12/2023. The bereavement plan of care dated 06/14/2023 included an intervention for grief-related mailings at two (2) weeks, three (3) months, and nine (9) months after death and telephone calls from the Bereavement Coordinator one (1) and six (6) months after the patient’s death. Although the Bereavement Care Lead provided a spreadsheet tracking bereavement services and a personal notebook documenting the services were provided, the clinical record contained no documented evidence that the mailings and telephone calls identified in the bereavement plan of care had been completed. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed the hospice nurse had not completed daily visits and provided wound care as ordered on the initial and updated plans of care. The leaders also confirmed that the clinical records did not include documentation to indicate the bereavement plan of care was followed.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 7 of 19 (37%) clinical records reviewed, the agency did not ensure the individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 05/03/2022 with a terminal diagnosis of severe protein-calorie malnutrition. The initial nursing comprehensive assessment dated 05/03/2022 included documentation that the patient was a fall risk with a fall risk score of nine out of ten. The assessment also described the patient as bedbound, non-ambulatory, incontinent of bowel and bladder, and cachectic with a comorbid condition of severe protein-calorie malnutrition. The initial plan of care dated 05/03/2022 did not include patient and family goals and planned interventions associated with the fall and skin integrity risks identified in the comprehensive assessment. Clinical Record 5: The patient elected the hospice benefit on 02/10/2024 with a terminal diagnosis of Parkinson’s disease. The initial nursing comprehensive assessment dated 02/10/2024 included documentation that the patient’s blood sugar was checked daily. The initial plan of care dated 02/10/2024 included the goal, “Blood glucose levels… managed according to MD (Doctor of Medicine) parameters.” The plan of care dated 02/10/2024 through 05/09/2024, did not contain measurable outcomes and planned interventions associated with diabetes and the need for daily glucose monitoring. Clinical Record 6: The patient elected the hospice benefit on 03/30/2024 with a terminal diagnosis of end stage heart failure. The initial nursing comprehensive assessment dated 03/30/2024 included documentation that the patient had an internal cardiac defibrillator and pacemaker in place and was receiving hyperbaric treatment for a pressure ulcer on the left inner ankle. The initial plan of care dated 03/30/2024 did not include patient and family goals and planned interventions associated with the internal cardiac defibrillator and wound identified in the comprehensive assessment. Clinical Record 10: The patient elected the hospice benefit on 09/15/2023 with a terminal diagnosis of Alzheimer’s disease. The initial nursing comprehensive assessment dated 09/15/2023 included documentation that the patient had a history of recurrent aspiration pneumonia and received four (4) cans of 1.5CAL (calorie) Jevity, a nutritional supplement, and prescribed medications each day through a gastrostomy tube. The initial plan of care dated 09/15/2023 did not include patient and family goals and planned interventions associated with the patient’s risk for aspiration, care of the gastrostomy site, and maintaining gastrostomy tube patency. Clinical Record 13: The patient elected the hospice benefit on 11/04/2023 with a terminal diagnosis of malignant neoplasm of the colon. The initial nursing comprehensive assessment dated 11/04/2023 included documentation that the patient had a terminal diagnosis of malignant neoplasm of the colon, a history of constipation, and a one (1) year history of seizures requiring scheduled Keppra [medication for seizures] 1000MG daily. The initial plan of care dated 11/04/2023 did not include patient and family goals and planned interventions associated with constipation and seizure risks identified in the comprehensive assessment. Clinical Record 14: The patient elected the hospice benefit on 08/26/2023 with a terminal diagnosis of cerebral infarction. The initial nursing comprehensive assessment dated 08/26/2023 included documented that the patient had a history of aspiration pneumonia, received Osmolite 1.5CAL (calorie), a nutritional supplement, and prescribed medications through a gastrostomy tube, and had a tracheostomy tube (size 6.0) in place to aid breathing. The plan of care dated 08/26/2023 did not include patient and family goals and planned interventions associated with the patient’s risk for aspiration, gastrostomy site care and management, and tracheostomy site care and management. Clinical Record 15: The patient elected the hospice benefit on 05/12/2023 with a terminal diagnosis of cerebral infarct. The initial nursing comprehensive assessment dated 05/12/2023 included documentation that the caregiver performed blood sugar checks before meals and bedtime (AC and HS) and administered insulin as ordered. The initial plan of care dated 05/12/2023 included the goal, “Blood glucose levels… managed according to MD parameters.” The plans of care, effective 05/12/2023 and reviewed and updated no less frequently than every 15 days through the discharge date of 03/06/2024, did not contain measurable outcomes and planned interventions associated with diabetes management and the need for AC and HS glucose monitoring. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed the written plans of care did not include patient and family goals and planned interventions for problems identified during the initial comprehensive assessments including the risks associated with falls, skin integrity, seizures, and aspiration, the care and management of gastrostomy and tracheostomy sites, and glucose monitoring.

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 9 (11%) clinical records reviewed with Licensed Practical Nurse (LPN) services provided, the agency did not ensure the Registered Nurse (RN) supervised the LPN services as required by agency policy. Agency policy No. 1-031 RESPONSIBILITIES/SUPERVISION OF CLINICAL SERVICES, no date, stated in part, "A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services." Clinical Record 6: The plan of care dated 03/30/2024 included an order for the Skilled Nurse (SN) to provide nursing visits at a frequency of two visits per week. Clinical record review revealed the LPN completed one skilled nurse visit per week since 03/30/2024. The clinical record contained no documented evidence that the RN completed monthly LPN supervisory visit for April 2024, as of the date of record review on 05/10/2024. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed that an LPN supervisory visit was not completed monthly, per the agency’s policy, for the clinical record identified. Leaders also confirmed that “monthly,” referred to in the “Responsibilities/Supervision of Clinical Services” policy, was recognized by the agency as a calendar month.

It is required that the bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) clinical records reviewed with bereavement services provided, the agency did not ensure that the bereavement plan of care included the frequency of service delivery. Clinical Record 17: The patient elected the hospice benefit on 02/21/2024. The patient died at the skilled nursing facility on 02/29/2024. The identified bereaved were determined to be at low risk for complicated grief by the Interdisciplinary Group (IDG) and a “low risk” bereavement plan of care was developed by the Bereavement Coordinator, in collaboration with the IDG on 03/13/2024. The bereavement plan of care included interventions to provide supplemental materials (kid pack, camp packet, etc.), in-person grief session with Bereavement Coordinator, in-services/consultation with employer, coworkers, support system, and connect bereaved with community resources. The plan of care did not include frequencies in which the supplemental materials, grief sessions, in-services, and community resource connections would be performed. Clinical Record 18: The patient elected the hospice benefit on 09/30/2023. The patient died at home on 11/08/2023. The identified bereaved were assessed to be at high risk for complicated grief by the IDG and a “high risk” bereavement plan of care was developed by the Bereavement Coordinator, in collaboration with the IDG on 11/15/2023. The bereavement plan of care included interventions to provide supplemental materials as needed (kid pack, camp packet, etc.), in-person grief session with Bereavement Coordinator, in-services/consultation with employer, coworkers, support system, grief education, and address complex grief issue. The plan of care did not include frequencies in which the supplemental materials, grief sessions, in-services, education, and complex grief would be performed. Clinical Record 19: The patient elected the hospice benefit on 03/09/2023. The patient died at home on 06/12/2023. The identified bereaved were assessed to be at moderate risk for complicated grief by the IDG. A “moderate risk” bereavement plan of care was developed by the Bereavement Coordinator, in collaboration with the IDG on 06/14/2023. The bereavement plan of care included interventions to provide supplemental materials as needed (kid pack, camp packet, etc.), in-person grief session with Bereavement Coordinator, in-services/consultation with employer, coworkers, support system, grief education, and address complex grief issue. The plan of care did not include frequencies in which the supplemental materials, grief sessions, in-services, education, and complex grief would be performed and addressed. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed that the bereavement plans of care did not include frequencies for all services to be provided.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) 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 clinical record review and interview. In 4 of 13 (31%) clinical records reviewed with hospice aide services provided, the agency did not ensure that the Registered Nurse prepared specific written patient care instructions for the aide to follow. Clinical Record 3: The patient elected the hospice benefit on 10/21/2023 with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed the initial nursing assessment dated 10/21/2023 included documentation that the patient had a fall risk score of ten out of ten indicating the patient was at risk for falls, and the patient had sustained a right hip fracture from a fall before electing hospice services. The hospice aide care plan assignment dated 10/21/2023 and updated on 04/25/2024 assigned the aide the tasks: seated shower, transfer from bed/chair, transfer from chair/bed, and use of gait belt. The aide care plan did not include information to alert the aide to the patient's high fall risk. Clinical Record 4: The patient elected the hospice benefit on 03/17/2024 with a terminal diagnosis of Parkinson’s disease. Clinical record review revealed the initial nursing assessment dated 03/17/2024 included documentation that the patient had a fall risk score of eight out of ten indicating the patient was at risk for falls. The aide care plan assignment dated 03/17/2024 and updated on 04/20/2024 assigned the aide to provide the patient with a seated shower at each visit. The aide care plan did not include information to alert the aide of the patient’s fall risk or safety measures to be taken. Clinical Record 6: The patient elected the hospice benefit on 03/30/2024 with a terminal diagnosis of end stage heart failure. Clinical record review revealed the initial nursing assessment dated 03/30/2024 included documentation that the patient had an internal cardiac defibrillator with a pacemaker as well as a fall risk score of nine out of ten indicating the patient was at risk for falls. The hospice aide care plan assignment dated 03/30/2024 and updated on 05/08/2024 included instructions for the aide to provide a seated shower and ensure the patient used a rollator walker when ambulating. The care plan did not alert the aide to the patient’s internal defibrillator and the risk of falls or safety measures to be taken. Clinical Record 13: The patient elected the hospice benefit on 11/04/2023 with a terminal diagnosis of end stage heart failure. Clinical record review revealed the nursing assessment completed on 11/04/2023 included documentation that the patient had a secondary diagnosis of metastatic cancer to the brain, a history of seizures, and a fall risk score of seven out of ten indicating the patient was at risk for falls. The initial aide care plan dated 11/04/2023 and updated aide care plan dated 01/15/2024 included instructions for the aide to provide the patient with a standing shower. The aide care plan did not alert the aide to the patient’s risk for seizures and falls or safety measures to be taken. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed that the Registered Nurse did not alert the aide to possible patient and staff risks associated with falls, seizures, and the internal cardiac defibrillator.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a Registered Nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide reported changes in the patient's care needs to the Registered Nurse as they related to changes needed in the plan of care. Clinical Record 9: The patient elected the hospice benefit on 07/04/2023. Clinical record review revealed the hospice aide completed visits on 03/20/2024, 03/22/2024, 03/29/2024, and 05/08/2024 and documented that mouth care was not completed as instructed because the patient was “unable to tolerate.” The clinical record contained no documented evidence that the hospice aide reported a change in the patient’s medical needs to the Registered Nurse. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed the clinical record did not contain documented evidence that the hospice aide reported changes in the patient’s ability to tolerate mouth care during the identified visits to the Registered Nurse.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse completed and documented an on-site visit to assess the quality of care and services provided by the hospice aide no less frequently than every 14 days. Clinical Record 3: The plan of care order dated 04/18/2024 through 06/16/2024 included an order for hospice aide visit frequency of two visits per week. Clinical record review revealed the hospice aide was providing visits as ordered. The Registered Nurse (RN) documented an on-site supervisory visit was completed on 04/18/2024. The next on-site supervisory visit by the RN was documented on 05/07/2024, a total of 19 days after the 04/18/2024 visit and 5 days outstanding. Clinical Record 4: The plan of care order dated 03/17/2024 through 06/14/2024 included an order for hospice aide visit frequency of two visits per week. Clinical record review revealed the hospice aide was providing visits as ordered. The RN documented an on-site supervisory visit was completed on 04/15/2024. The next on-site supervisory visit by the RN was documented on 05/07/2024, a total of 22 days after the 04/15/2024 visit and 7 days outstanding. Clinical Record 6: The plan of care order dated 03/30/2024 through 06/27/2024 included an order for hospice aide visit frequency of two visits per week. Clinical record review revealed the hospice aide was providing visits as ordered. There was no documented evidence in the clinical record that the RN had completed an on-site supervisory visit between the start of hospice aide services on 04/03/2024 and the last RN visit dated 05/04/2024, a total of 31 days. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed aide supervisory assessments were not documented by the RN as completed every 14 days.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by document review, clinical record review, observation, and interview. In 5 of 19 (26%) clinical records reviewed, the agency did not ensure the clinical record contained physician orders for care and services provided. Agency policy No. 1-003 PHYSICIAN ORDERS AND PARTICIPATION IN PLAN OF CARE, (Rev 4.0 Jan 2024), stated in part, "Physician ... orders will be individualized, based on patient's needs, and include: ...Treatments and/or procedures needed, including type, frequency, duration, and goals." Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 05/03/2022 with a terminal diagnosis of severe protein-calorie malnutrition. The patient resided in a skilled nursing facility [SNF]. During the home visit observation with the Hospice Aide (staff 2), a treatment review was completed by comparing the hospice plan of care with the treatment record from the SNF. The SNF treatment record included 2.0CAL (calorie) Supplement 120ML twice a day. The hospice plan of care dated 04/22/2024 did not include an order for 2.0CAL Supplement. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 10/21/2023 with a terminal diagnosis of senile degeneration of the brain. The patient resided in a SNF. During the home visit observation with the Medical Social Worker (staff 3), a treatment review was completed by comparing the hospice plan of care with the treatment record from the SNF. The SNF treatment record included orders for the patient to have a pureed texture/honey consistency diet, and knee-high compression stockings to the right lower extremity. The hospice plan of care dated 04/18/2024 did not include an order for pureed texture/honey consistency diet, and knee-high compression stockings to the right lower extremity. Clinical Record 12: The patient elected the hospice benefit on 08/15/2023 with a terminal diagnosis of senile degeneration of the brain. The nursing comprehensive assessment dated 08/15/2023 included documentation that the patient consumed two to three cans of the nutritional supplement, Ensure daily. The clinical record clinical record contained no documented evidence of a physician order for Ensure. Clinical Record 14: The updated plan of care order dated 04/22/2024 ordered an indwelling urinary catheter to be inserted, maintained, and irrigated with sterile normal saline. The order did not include the amount of irrigation solution to be used and the frequency of irrigation. Clinical Record 16: The patient elected the hospice benefit on 08/25/2023 with a terminal diagnosis of malignant neoplasm of the bronchus and lung. The nursing assessment dated 08/31/2023 included documentation that the patient was drinking three cans of Ensure per day and that the patient’s blood sugar was being checked weekly. The clinical record contained no documented evidence of a physician order for Ensure and weekly blood sugar checks. During joint clinical record reviews and interviews on 05/10/2024, the Executive Director, Compliance Officer, and Director of Clinical Services confirmed the clinical records did not include complete physician orders.

Based on record review, facility policy review, and staff interviews, it was determined the facility failed to monitor the medication for duplicate drugs for one Patient (P) (P#4) of 13 patients whose medication regimens were reviewed. This failure had the potential to cause overmedication of P#4 which could result in adverse effects and health risks. --- Findings included: Review of a facility policy titled, "Medication Monitoring," revised 05/2022, revealed, "The Case Manager will assess the effects of medications on the patient. The assessment will identify drug interactions, duplicative drug therapy and noncompliance with drug therapy." A review of a "Hospice Recertification Plan of Care Update (POCU)," dated 12/19/2022, revealed the agency admitted P#4 with diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow and shortness of breath) and anxiety. A review of a "Client Medication Record," dated 1/26/2023, revealed P#4 had a physician's order dated 09/15/2022 for oxycodone (a narcotic pain reliever) 5 milligrams (mg) to be taken by mouth every eight hours as needed for pain. Further review indicated a second physician's order was entered on 12/19/2023 for oxycodone 5 mg to be taken by mouth every eight hours as needed for pain. The duplicate oxycodone orders remained on P#4s medication profile for 35 days, until they were discontinued by Registered Nurse (RN) #1 on 01/23/2023. Further review of the "Client Medication Record," for P#4, dated 01/26/2023, revealed that on 01/03/2023, P#4s physician ordered Tramadol (a pain reliever) 50 mg to be taken by mouth every six hours as needed for pain. A second physician order was entered on 01/06/2023 for Tramadol 50 mg to be taken by mouth every six hours as needed for pain. Both Tramadol orders remained on P#4s medication profile for 16 days, until one of the orders was discontinued by RN #1 on 01/23/2023. Reviews of the clinical record of P#4 revealed RN #1 provided three nursing visits to P#4, (on 12/30/2022, 01/06/2023, and 01/20/2023) during the time frame that the duplicate oxycodone orders were on P#4s medication profile. Additionally, RN #1 provided one nursing visit to P#4 on 01/20/2023 during the time frame that the duplicate Tramadol orders were on P#4s medication profile. The results of RN #1's medication regimen reviews during these visits indicated the following: - The Visit Note Report dated 12/30/2022 indicated RN #1 reviewed P#4s medications and found no duplicate drug orders. - The Visit Note Report dated 01/06/2022 indicated RN #1 reviewed P#4s medications and found no duplicate drug orders. - The Visit Note Report dated 01/20/2023 indicated RN #1 reviewed P#4s medications and found no duplicate drug orders. During an interview on 01/26/2022 at 2:30 p.m., RN #1 stated she conducted medication reviews during visits to P#4 and noticed there were duplicate drug orders but must have forgotten to remove them from P#4s medication profile or may not have noticed the duplicate medications. During an interview on 01/26/2023 at 12:35 p.m., the Executive Director (ED) stated the agency's expectation was that nurses were to review a patients medications at every visit and compare the medications in the patients home to the patients medication profile to check for and correct duplicate drug orders. During a follow-up interview on 01/26/2023 at 3:50 p.m., the Executive Director (ED) stated the agency's expectation was that nurses were to review all medications in a patients home, compare the medications to the patients medication profile, and follow up as needed. The ED confirmed there were duplicate medications on P#4s medication profile that were not identified during nursing visits and acknowledged the agency was not following its policy.

Based on record review, facility policy review, and staff interview. it was determined the facility failed to provide services as ordered in the Hospice Plan of Care (POC - a comprehensive plan developed by nurses, social workers, chaplains, and medical directors to include the frequency of staff visits and interventions to guide staff in providing patient care) for two Patients (P) (P#4 and P#8) of 13 patients whose POCs were reviewed. The failure resulted in P#4 and P#8 not receiving necessary assessments, monitoring, and/or hospice aide services as ordered by the physician. Findings included: --- Findings included: Review of a facility policy titled, "Missed Visits," revised 05/2022, revealed, "If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained." 1. A review of a "Hospice Recertification Plan of Care Update (POCU)," dated 12/19/2022, indicated the agency admitted P#4 with diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Further review indicated the agency was to provide P#4 one nursing visit every week starting 12/27/2022. A review of the entire clinical record of P#4 revealed no evidence the agency provided a nursing visit to P#4 during the week of 01/08/2022. The agency did not provide any additional documentation of a nursing visit during that week. During an interview on 01/26/2022 at 10:15 a.m., the Clinical Director (CD) stated the agency's expectation was that visits should be provided to patients as indicated in the patients POCs. The CD confirmed P4s POCU indicated the agency was to provide a nursing visit to P#4 during the week of 01/08/2022 and that no visit was provided that week. During an interview on 01/26/2023 at 3:50 PM, the Executive Director (ED) stated the agency's expectation was that all services would be delivered as ordered in the patients POCs. The ED confirmed the agency was to provide P#4 one nursing visit during the week of 01/08/2023 as ordered and the agency did not provide a visit that week. The ED acknowledged the agency was not following its policy. 2. A review of the "Plan of Care Update" (POCU), dated 12/19/2022, for P#8 revealed the agency admitted P#8 with diagnoses that included chronic heart failure (a progressive heart disease that affects pumping action of the heart muscles and causes fatigue and shortness of breath) and senile degeneration of the brain (dementia). Further review indicated the agency was to provide P#8 three hospice aide visits per week for eight weeks, starting on 12/25/2022. A review of P#8s entire clinical record revealed no evidence the agency provided P#8 with a total of three hospice aide visits during the weeks of 12/25/2022 and 01/01/2023. The agency did not provide any additional documentation of a total of three home health aide visits during those weeks. During an interview on 01/26/2022 at 10:15 a.m., the Clinical Director (CD) stated the agency's expectation was that visits should be provided to patients as indicated in the patients POCs. The CD confirmed P#8s POCU indicated the agency was to provide three hospice aide visits to P#8 during the weeks of 12/25/2022 and 01/01/2023 and had only provided two hospice aide visits during those weeks. The CD acknowledged the agency was not following its policy. During an interview on 01/26/2023 at 3:50 p.m., the Executive Director (ED) stated the agency's expectation was that all services would be delivered as ordered in the patients POCs. The ED confirmed the agency was to provide P#8 a total of three hospice aide visits during the weeks of 12/25/2022 and 01/01/2023 and had only provided P#8 with two hospice aide visits during those weeks. The ED acknowledged the agency was not following its policy.