Every finding on record at Vitas Healthcare Corp

Based on  interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Initial & Comprehensive  Assessment of Patient was met as follows: --- A. The Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to conduct a complete medication profile review for two of 23 sampled patients (Patient 4 and Patient 20) by failing to:  -Ensure the visiting nurses (VNs) identified a discrepancy during the medication profile review when Patient 4’s caregiver (PCG 4) administered Humulin R (regular/short-acting synthetic insulin [a hormone produced by the pancreas that regulates blood sugar levels]) 20 units subcutaneously (injection method where medication is delivered into the fatty tissue layer) at bedtime to Patient 4 when the physician’s order, dated 8/8/2024, indicated to administer Humulin R insulin 17 units subcutaneously at bedtime to Patient 4.-Ensure the licensed staff monitored and evaluated Patient 4’s insulin effectiveness and side effects in accordance with the federal regulations and professional standards of practice by assessing Patient 4’s compliance with the insulin order and PCG 4’s understanding of the insulin order during the medication profile review. -Ensure the VN identified a discrepancy during a medication profile review when RN 1 (registered nurse) administered/applied  crushed Flagyl (to treat infection) medication 500 mg tab to Patient 20's sacral open wound when the physician's order dated 7/16/2025, indicated to administer crushed Flagyl 250 mg over coccyx pressure ulcer to Patient 20. As a result of the noncompliance Patient 4 was placed at an increased risk for hypoglycemic (low blood sugar) episodes related to administering insulin doses not in accordance with the physician’s order. Patient 4 and Patient 20 were at risk for ineffective drug therapy and adverse drug reactions (a harmful, unintended, or  unexpected reaction to a drug or medication when taken at normal doses)  related to noncompliance with drug therapy that could lead to seizures ( a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, or levels of consciousness), coma, hospitalization, and death. (Refer to L530). B. The HA failed to accurately assess the current medications of two of 23 sampled patients (Patient 2 and Patient 20) by failing to:Remove escitalopram oxalate (Lexapro, medication that helps increase the amount of serotonin, natural substance in the brain that helps regulate mood, perception, memory, and other behavioral processes ) 20 milligrams (mg, unit of measurement) from Patient 2’s active list of medications despite Patient 2’s primary care provider (PCP) discontinuing Lexapro as reported by Patient 2’s caregivers (PCGs).Ensure Patient 20 was taking metronidazole (Flagyl, medication to treat various infections) as ordered by the physician, with the correct dosage. These failures had the potential to cause adverse drug effects and ineffective treatment plan due to the inaccurate assessment of the patients' Lexapro and Flagyl administration. (Refer to L524). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based observation, interviews, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to accurately assess the current medications of two of 23 sampled patients (Patient 2 and Patient 20) by failing to:A.  Remove escitalopram oxalate (Lexapro, medication that helps increase the amount of serotonin, natural substance in the brain that helps regulate mood, perception, memory, and other behavioral processes ) 20 milligrams (mg, unit of measurement) from Patient 2’s active list of medications despite Patient 2’s primary care provider (PCP) discontinuing Lexapro as reported by Patient 2’s caregivers (PCGs).B. Ensure Patient 20 was taking metronidazole (Flagyl, medication to treat various infections) as ordered by the physician, with the correct dosage. These failures had the potential to cause adverse drug effects and ineffective treatment plan for Patient 2 and Patient 20. --- b. During a review of Patient 20’s “Personal Information”, indicated a start of care (SOC) date of  8/7/2024, with a primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). During a review of Patient 20's POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/16/2025, indicated the frequency of visits for skilled nurse (SN) to two visits per week plus three PRN (pro re nata, which means “as needed”) visits for assessments, comfort measures, and symptoms management) and Hospice Aide (HA) to visit three a week as needed for personal care, home making, and to promote comfort.  During a review of Patient 20’s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated there was a physician order dated 7/16/2025, for Flagyl  250 milligrams (mg) tab, to crush over coccyx pressure sore three times weekly and as needed for two weeks , then re-assess.    On 7/21/2025, at 11 a.m., a home visit was conducted at Patient 20's residence with Registered Nurse (RN 1). The patient was observed lying in bed, awake but confused with an existing Stage II coccyx pressure sore.   On 7/21/2025, at 11:10 a.m., during a interview with RN 1, when asked if she provided wound treatment, RN 1 stated she did and she applied crushed Flagyl 250 mg tab around the wound bed as ordered.  During the home visit, at 11:50 a.m., a medication review was performed with RN 1. There was one bubble pack of Flagyl 500 mg one tab medication found at medication cart.  During an interview with RN 1 on 7/21/2025, at 12 p.m., RN 1 stated she did not check Patient 20's Flagyl 500 mg tab bubble pack prior to doing wound treatment. RN 1 just asked the Medication Technician 1 to crushed the Flagyl 500 mg tab for her  and RN 1 applied the Flagyl medication at Patient 20's coccyx open wound. RN 1 also stated she was aware the Flagyl order was for 250 mg dosage but she gave the wrong dosage as ordered.  During an interview with the Director of Patient Care services (DPCS) on 7/22/2025, at 1 p.m., the DPCS stated Patient 20 should be taking correct dosage of the Flagyl medication as ordered and the visiting nurse should have check the patient's actual medication on every visits.  During a review of the undated HA’s policy and procedure, titled “The Plan of Care,” the policy and procedure indicated that a written, individualized, patient and family/caregiver plan of care would be established and maintained for everyone admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.  Findings:a. During a review of Patient 2’s Case Sheet, the Case Sheet indicated Patient 2’s start of care (SOC) date of 3/14/2024 with a terminal diagnosis of Alzheimer’s disease (progressive brain disorder that gradually impairs memory, thinking, and behavior). During a review of Patient 2’s medical record form, titled “RN – Updated Comprehensive Assessment Encounter,” dated 7/3/2025, the “RN – Updated Comprehensive Assessment Encounter” indicated the following:1.      Physician Order Start Date: 6/12/2025 – Lexapro 20 mg by mouth every day for depression (mental health disorder that causes a persistent feeling of sadness and loss of interest in activities, causing significant impairment in daily life).2.      Registered Nurse (RN) 3 conducted an in-person visit to Patient 2 at Patient 2’s home. During a review of Patient 2’s medical record form, titled “LPN – Updated Comprehensive Assessment Encounter,” dated 7/10/2025, the “LPN-Updated Comprehensive Assessment Encounter” indicated the following physician order:1.      Order Start Date: 6/12/2025 – Lexapro 20 mg by mouth every day for depression.2.      Licensed Vocational Nurse (LVN) 1 conducted an in-person visit to Patient 2 at Patient 2’s home. During an observation and concurrent interview on 7/18/2025 at 10:55 a.m. while on a joint home visit with Registered Nurse 2 (RN 2), PCG 2 and PCG 3 were present in Patient 2’s home. PCG 2 stated she was Patient 2’s regular caregiver. PCG 2 stated Patient 2’s Lexapro has been discontinued by the PCP prior to Patient 2’s start of hospice care (3/14/2024) because Lexapro “has not been effective.” PCG 2 stated only one visiting nurse checked the medications, but the other visiting nurses did not check the medications on hand. During a telephone interview on 7/18/2025 at 12:41 p.m., PCG 1 stated she was not present in Patient 2’s home during visiting nurses’ home visits, and PCG 2 and PCG 3 were Patient 2’s regular caregivers. PCG 1 stated when Patient 2 started hospice care, Patient 2’s primary physician took her off the “old medications," including Lexapro, which Patient 2 no longer needed. During an interview and a current record review on 7/21/2025 at 2:29 p.m. with the Director of Patient Care Services (DPCS) and the Administrator, Patient 2’s medical records were reviewed. The DPCS stated the visiting nurses (in general) must conduct a medication reconciliation every home visit to determine what the patient (in general) was supposed to be taking, check if any prescribed medications were discontinued, and/or ensure over-the-counter medications were not added without the physician’s knowledge due to possible drug-to-drug interaction and adverse side effects. The DPCS stated when Patient 2’s PCGs reported the Patient 2 was not taking Lexapro as ordered by the physician, during medication reconciliation, the visiting nurse must call the physician to request discontinuation of Lexapro. The DPCS stated when the physician signs the physician order to discontinue the Lexapro, the medication must be deleted immediately from Patient 2’s active medication list/records. During a review of the HA’s policy and procedures (P&P), titled “VS Initial and Comprehensive Assessment,” dated 6/6/2024, the P&P indicated the following:1.      The comprehensive assessment must take into consideration the patient’s severity of symptoms and drug profile (review of all of the patient’s prescription and over-the-counter drugs, herbal remedies, and other alternative treatments that could affect the drug therapy).2.      Unless otherwise indicated, all assessment visits must be made in person.3.      Each Initial/Updated Comprehensive Assessment must paint the picture of the current patient condition.4.      Changes in the patient condition found on assessment must be communicated to the team and attending physician.

Based on interviews and record review, the Hospice Agency (HA, an agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure a complete medication profile review was conducted for two of 23 sampled patients (Patient 4 and Patient 20) by failing to:  a. Ensure the visiting nurses (VNs) identified a discrepancy during the medication profile review when Patient 4’s caregiver (PCG 4) administered Humulin R (regular/short-acting synthetic insulin [a hormone produced by the pancreas that regulates blood sugar levels]) 20 units subcutaneously (injection method where medication is delivered into the fatty tissue layer) at bedtime to Patient 4 when the physician’s order, dated 8/8/2024, indicated to administer Humulin R insulin 17 units subcutaneously at bedtime to Patient 4.b. Ensure all the assigned licensed staff to Patient 4 monitored and evaluated Patient 4’s insulin effectiveness and side effects in accordance with the professional standards of practice by assessing Patient 4’s compliance with the insulin order and PCG 4’s understanding of the insulin order during the medication profile review.  c. Ensure the VN identified a discrepancy during a medication profile review when RN 1 (registered nurse) administered/applied crushed Flagyl (to treat infection) medication 500 mg tab to Patient 20's sacral open wound when the physician's order dated 7/16/2025, indicated to administer crushed Flagyl 250 mg over coccyx pressure ulcer to Patient 20.   As a result of the noncompliance Patient 4 was placed at an increased risk for hypoglycemic episodes (very low blood sugar levels) related to administering insulin doses not in accordance with the physician’s order. Patient 4 was also at risk for ineffective drug therapy and adverse drug reactions (a harmful, unintended, or unexpected reaction to a drug or medication when taken at normal doses) related to noncompliance with drug therapy that could lead to seizures (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, or levels of consciousness), coma (deep state of unconsciousness where a person is unresponsive), hospitalization, and death.  On 7/22/2025 at 3:52 p.m., the California Department of Public Health (CDPH) called an  Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the Chief Nursing Officer, Vice – President for Operations, Patient Care Coordinator, General Manager, Medical Director, Performance Improvement Specialist, and National Patient Care Supervisor, related to the hospice agency’s (HA, agency who provides specialized care and support for people with a serious illness who are nearing the end of life) failure to:   The Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to conduct a complete medication profile review for two of 23 sampled patients (Patient 4 and Patient 20) by failing to: 1a. Ensure the visiting nurses (VNs) identified a discrepancy during the medication profile review when Patient 4’s caregiver (PCG 4) administered Humulin R (Insulin Regular, Human, short-acting synthetic insulin that lowers the blood sugar) 20 units subcutaneously at bedtime to Patient 4 when the physician’s order, dated 8/8/2024, indicated to administer Humulin R insulin 17 units subcutaneously at bedtime to Patient 4. 1b. Ensure the VN identified a discrepancy during a medication profile review when RN 1 (registered nurse) administered/applied crushed Flagyl (to treat infection) medication 500 mg tab to Patient 20's sacral open wound when the physician's order dated 7/16/2025, indicated to administer crushed Flagyl 250 mg over coccyx pressure ulcer to Patient 20.  2. Ensure all the assigned licensed staff to Patient 4 monitored and evaluated Patient 4’s insulin effectiveness and side effects in accordance with the federal regulations and professional standards of practice by assessing Patient 4’s compliance with the insulin order and PCG 4’s understanding of the insulin order during the medication profile review.  On 7/22/2025 at 4:15 p.m., the survey team completed the survey tasks and conducted an exit conference while onsite in the presence of the Chief Nursing Officer, Vice – President for Operations, Patient Care Coordinator, General Manager, Medical Director, Performance Improvement Specialist, and National Patient Care Supervisor.   On 7/22/2025 at 4:40 p.m., the HA was unable to submit an IJ removal Plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team exited the HA with IJ not removed. --- Based on interviews and record review, the Hospice Agency (HA, an agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure that a complete medication profile review was conducted for one of 23 sampled patients (Patient 4) by failing to:  1.      Ensure the visiting nurses (VNs) identified a discrepancy during the medication profile review when Patient 4’s caregiver (PCG 4) administered Humulin R (regular/short-acting synthetic insulin [a hormone produced by the pancreas that regulates blood sugar levels]) 20 units subcutaneously (injection method where medication is delivered into the fatty tissue layer) at bedtime to Patient 4 when the physician’s order, dated 8/8/2024, indicated to administer Humulin R insulin 17 units subcutaneously at bedtime to Patient 4.  2.      Ensure all the assigned licensed staff to Patient 4 monitored and evaluated Patient 4’s insulin effectiveness and side effects in accordance with the professional standards of practice by assessing Patient 4’s compliance with the insulin order and PCG 4’s understanding of the insulin order during the medication profile review.  As a result of the noncompliance described above, Patient 4 was placed at an increased risk for hypoglycemic episodes (very low blood sugar levels) related to administering insulin doses not in accordance with the physician’s order. Patient 4 was also at risk for ineffective drug therapy and adverse drug reactions (a harmful, unintended, or unexpected reaction to a drug or medication when taken at normal doses) related to noncompliance with drug therapy that could lead to seizures (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, or levels of consciousness), coma (deep state of unconsciousness where a person is unresponsive), hospitalization, and death.  On 7/22/2025 at 3:52 p.m., the California Department of Public Health (CDPH) called an  Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the Chief Nursing Officer, Vice – President for Operations, Patient Care Coordinator, General Manager, Medical Director, Performance Improvement Specialist, and National Patient Care Supervisor, related to the hospice agency’s (HA, agency who provides specialized care and support for people with a serious illness who are nearing the end of life) failure to:   The Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to conduct a complete medication profile review for one of 23 sampled patients (Patient 4) by failing to:1.      Ensure the visiting nurses (VNs) identified a discrepancy during the medication profile review when Patient 4’s caregiver (PCG 4) administered Humulin R (Insulin Regular, Human, short-acting synthetic insulin that lowers the blood sugar) 20 units subcutaneously at bedtime to Patient 4 when the physician’s order, dated 8/8/2024, indicated to administer Humulin R insulin 17 units subcutaneously at bedtime to Patient 4. 2.      Ensure all the assigned licensed staff to Patient 4 monitored and evaluated Patient 4’s insulin effectiveness and side effects in accordance with the federal regulations and professional standards of practice by assessing Patient 4’s compliance with the insulin order and PCG 4’s understanding of the insulin order during the medication profile review.  On 7/22/2025 at 4:15 p.m., the survey team completed the survey tasks and conducted an exit conference while onsite in the presence of the Chief Nursing Officer, Vice – President for Operations, Patient Care Coordinator, General Manager, Medical Director, Performance Improvement Specialist, and National Patient Care Supervisor.   On 7/22/2025 at 4:40 p.m., the HA was unable to submit an IJ removal Plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team exited the HA with IJ not removed.    Findings: During a review of Patient 4’s Case Sheet, the Case Sheet indicated Patient 4’s start of care (SOC) date of 8/8/2024. The Case Sheet indicated Patient 4 had a terminal diagnosis of chronic congestive heart failure (CHF, gradual weakening of the heart leading to the inability to pump enough blood to meet the body’s needs) and a secondary diagnosis of hypertension (high blood pressure). During a review of Patient 4’s Interdisciplinary Care Plan, dated 8/8/2024, indicated the following interventions:1.      Visiting Nurse (Registered Nurses [RNs] and Licensed Vocational Nurses [LVNs]) to assess and monitor symptoms at each visit for diabetes mellitus (condition characterized by high blood sugar due to the body’s inability to produce enough insulin or its inability to effectively use the insulin).2.      Instruct [PCG4] to notify the HA of any change in condition. During a review of Patient 4’s Pre-Admit Evaluation, dated 8/8/2024, the Pre-Admit Evaluation, obtained from the “Physician Office,” indicated previous medication order for Humulin L (Insulin Zinc, Human, intermediate-acting synthetic insulin) 100 units per ml vial injection 17 units subcutaneously daily at bedtime.  During a review of Patient 4’s Plan of Care (POC) as of 7/17/2025, the POC indicated Patient 4’s other diagnoses that included type 2 diabetes mellitus (type of diabetes wherein the body could not produce enough insulin to maintain normal blood sugar levels), stage 4 chronic kidney disease (Stage 4 CKD, severe stage prior to kidney failure wherein the kidneys are significantly damaged and filtering blood at a severely reduced rate), and vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain). During a review of Patient 4’s Chart Medication List/Signed Physician Orders, dated 7/17/2025, it indicated physician order for Humulin R (Insulin Regular, Human) 100/ml (milliliter, unit of measurement) vial, inject 17 units (=0.17 ml) subcutaneously at bedtime for diabetes mellitus.  During an interview on 7/21/2025 at 12:48 p.m., PCG 4 stated she would administer 20 units of Humulin R to Patient 4 at bedtime. PCG 4 stated she did not check Patient 4’s blood sugar before dinner and at bedtime. However, PCG 4 stated Patient 4’s blood sugar in the morning would range from 70 milligrams per deciliter (mg/dL, unit of measurement) – 90 mg/dL (blood sugar below 70 mg/dL is considered low and may require immediate medical attention if severely low). PCG 4 stated she did not inform the visiting nurses about the insulin dosage administered to Patient 4 and Patient 4’s blood sugar because “they (visiting nurses) did not ask.” PCG 4 stated she has been administering 20 units of Humulin R since the start of care with the HA (8/8/2024). During an interview on 7/21/2025 at 1:11 p.m., Licensed Vocational Nurse (LVN) 1 stated she conducted medication reconciliation at every home visit by going through the medication list, noting medications that require refills, and providing patient education about the medications as needed. LVN 1 stated Patient 4’s physician’s order indicated to administer Humulin R 100 mg/ml 17 units subcutaneously at bedtime. LVN 1 stated she did not ask how much insulin PCG4 administered to Patient 4. LVN 1 stated she did not ask Patient 4’s blood sugar level. LVN 1 stated Patient 4 did not have a glucometer (device to measure the concentration of blood sugar) at home. LVN 1 stated she did not know Patient 4’s baseline blood sugar levels/range. LVN 1 stated Patient 4 did not have any regular laboratory tests drawn to determine blood sugar levels. LVN 1 stated it was important to know Patient 4’s blood sugar range and if Patient 4’s blood sugar was below 90 mg/dL, she would notify the physician and follow the physician’s orders. During an interview and concurrent review of Patient 4’s medical records with the Director of Patient Care Services (DPCS) and the Administrator on 7/21/2025 at 1:58 p.m., Patient 4’s assessments, physician orders, and plan of care were reviewed. The DPCS stated the visiting nurse must conduct the medication reconciliation during each home visit by verifying the medication container with the physician’s order, including the dosage, frequency, compliance with the medication order, and providing patient teaching regarding the medication. The DPCS stated if the visiting nurse identified that the PCG was administering Humulin R 20 units to Patient 4, it must be considered a medication error. The DPCS stated the HA must follow the medication error procedures and Patient 4 must be assessed for any adverse reactions. The DPCS stated there was no documented evidence of the assessment of Patient 4’s baseline blood sugar levels prior to the start of hospice services and while under hospice care. The DPCS stated baseline blood sugar levels must be documented to determine if the blood sugar levels were labile (fluctuating significantly) or not. The DPCS stated if the blood sugar levels were labile, parameters (set limits) for the insulin order must be ordered and documented.  During an interview on 7/22/2025 at 12:35 p.m., Patient 4’s primary care physician (PCP) 1 stated PCP 1 was able to prescribe insulin orders for Patient 4 based on the Patient 4’s previous insulin orders prior to the admission to the HA. PCP 1 stated for hospice patients (in general), the visiting nurse must ask the PCG or family for the patient’s blood sugar at every visit to determine insulin effectiveness and insulin side effects. PCP 1 stated for hospice patients (in general), it would be more concerning if the blood sugar was “too low—less than 70 or 80 mg/dL” because patient could get unresponsive and have seizures, and insulin administration might need to be discontinued. PCP 1 stated the physician’s order for insulin would require blood sugar parameters for regular insulin. During a review of the HA’s policy and procedure (P&P), titled “VS Obtaining Orders,” dated 10/26/2022, P&P 1 indicated the following:1.      A physician order must be obtained for all drugs and biologicals.2.      Nurses must communicate with the physician to discuss the patient’s assessment findings and rationale for requesting a new or changed order.3.      If a physician order could not be followed or the patient declines to follow the order as given, the reason and the communication with/notification of the physician must be documented. During a review of the HA’s policy and procedure (P&P), titled “VS Pharmacy Process,” dated 6/13/2025, the P&P 2 indicated the HA’s nurse was responsible for medication reconciliation (process of obtaining the most accurate list of all medications of the patient that included the name, dosage, frequency, and route, by comparing the physician orders with the medications on hand) by monitoring medication amounts, medication labels, and patient/PCG education needs. The P&P indicated the CML (Chart Medication List) must be reviewed during each patient visit and during Interdisciplinary Group (IDG, team responsible for the holistic care of the hospice patient) meetings. During a review of the Centers for Disease Control and Prevention (CDC) guidance, titled “Types of Insulin,” dated 5/15/2024, the guidance indicated the following:1.      Regular/short-acting insulin are usually taken 30 to 60 minutes before a meal.2.      Regular/short-acting insulin onset time (how quickly insulin lowers the blood sugar) is 30 minutes.3.      Regular/short-acting insulin peak time (period when insulin is at maximum strength that allows adjustment of food intake or activity level to prevent severely low blood sugar) is 2-3 hours.4.      Regular/short-acting insulin duration (how long insulin works to lower your blood sugar) is 3-6 hours.5.      Intermediate-acting insulin “covers insulin needs for half a day or overnight” with onset of 2-4 hours, peak time of 4-12 hours, and duration of 12-18 hours.[Source: https://www.cdc.gov/diabetes/about/how-to-use-insulin.html] During a review of a published journal from the American Diabetes Association (ADA), titled “Diabetes Care: 13. Older Adults: Standards of Care in Diabetes---2025,” dated 12/9/2024, the publication indicated the following:1. It is recommended that episodes of hypoglycemia at routine visits must be ascertained and addressed because older adults with diabetes have a greater risk of hypoglycemia, especially when treated with hypoglycemia agents, such as insulin.2. Older adults might be at a higher risk of hypoglycemia for many reasons, including irregular meal intake, insulin deficiency requiring insulin therapy, and worsening kidney function.3. Older adults have higher rates of unidentified cognitive impairment and dementia, leading to difficulties in performing complex self-care activities, such as blood sugar monitoring and insulin dose adjustment.4. Cognitive decline has been associated with increased risk of hypoglycemia, and severe hypoglycemia has been linked to increased risk of dementia.5. Glycemic goals (target blood sugar levels) and pharmacologic treatments might need to be adjusted to minimize the occurrence of hypoglycemic events.6. For people with diabetes receiving palliative care and end-of-life care, the focus must be to avoid hypoglycemia and symptomatic hyperglycemia while reducing the burdens of glycemic management (process of regulating blood sugar levels). Thus, as organ failure develops, the treatment plan would have to be deintensified and one or more agents would need to be discontinued. At the end of life, most agents for type 2 diabetes might be removed. [Source: https://diabetesjournals.org/care/article/48/Supplement_1/S266/157556/13-Older-Adults-Standards-of-Care-in-Diabetes-2025][Source: https://doi.org/10.2337/dc25-S013]

Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: --- -The Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the necessary education and training was provided to two of 23 sampled patients (Patient 2 and Patient 8) and/or their caregivers, in accordance with the hospice policy and procedure by failing to:a.  Implement Patient 2’s plan of care for oxygen (supplemental gas essential for human life as it is used by cells to produce energy) administration by failing to educate Patient 2’s regular caregivers (PCG 2 and PCG 3) regarding the location and use of Patient 2’s oxygen concentrator (medical device that separates nitrogen and other gases from the air to deliver a higher concentration of oxygen to the patient) provided by the HA and the physician’s order for oxygen administration as needed. b. Educate and train Patient 8 or Patient 8’s caregiver (PCG 8) on how to take a blood pressure medication with a parameter (a specific instruction or condition that must be met before or during the administration of the medication) to avoid an adverse side effect of the drug. These failures had the potential to lead to medication non-adherence, a worsening of the patients’ condition, or an increase in hospitalization. (Refer to L544). -The hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to follow the physician’s order for one of 23 sampled patients (Patient 20).The physician's order on the POC indicated to administer Flagyl (to treat various infection) medication 250 mg. crushed to Patient 20's open wound to the sacral/coccyx area. The hospice licensed staff administered Flagyl 500 mg crushed to open wound instead. This deficient practice placed the patient's wound at risk for delayed healing process leading to infection and other related wound complication. (Refer to L549).  The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with Federal regulation for IDG, Care Planning, and Coordination of Services to ensure provision of quality of care and services to certified patients receiving the Medicare hospice benefits.

Based on observation, interview, and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to ensure the necessary education and training was provided to two of 23 sampled patients (Patient 2 and Patient 8) and/or their caregivers, in accordance with the hospice policy and procedure by failing to:1.  Implement Patient 2’s plan of care for oxygen (supplemental gas essential for human life as it is used by cells to produce energy) administration by failing to educate Patient 2’s regular caregivers (PCG 2 and PCG 3) regarding the location and use of Patient 2’s oxygen concentrator (medical device that separates nitrogen and other gases from the air to deliver a higher concentration of oxygen to the patient) provided by the HA and the physician’s order for oxygen administration as needed. 2. Educate and train Patient 8 or Patient 8’s caregiver (PCG 8) on how to take a blood pressure medication with a parameter (a specific instruction or condition that must be met before or during the administration of the medication) to avoid an adverse side effect of the drug.These failures had the potential to lead to medication non-adherence, a worsening of the patients’ condition, or an increase in hospitalization. --- Findings:A.    During a review of Patient 2’s Case Sheet, the Case Sheet indicated Patient 2’s start of care (SOC) date of 3/14/2024 with a terminal diagnosis of Alzheimer’s disease (progressive brain disorder that gradually impairs memory, thinking, and behavior).During a review of Patient 2’s medical record form, titled “RN – Updated Comprehensive Assessment Encounter,” dated 7/3/2025, the “RN – Updated Comprehensive Assessment Encounter” indicated the following:1.     Order Start Date: 6/12/2025 – Inhale oxygen at 2 liters per minute (LPM, unit of measurement of volume) via nasal cannula (thin, flexible tubing used to deliver supplemental oxygen through the nose) with oxygen concentrator as needed.2.     Registered Nurse conducted an in-person visit to Patient 2 at Patient 2’s home. During a review of Patient 2’s medical record form, titled “LPN – Updated Comprehensive Assessment Encounter,” dated 7/10/2025, the “LPN-Updated Comprehensive Assessment Encounter” indicated the following physician order:1. Order Start Date: 6/12/2025 – Inhale oxygen at 2 LPM via nasal cannula with oxygen concentrator as needed.2. Licensed Vocational Nurse conducted an in-person visit to Patient 2 at Patient 2’s home. During an observation and a concurrent interview on 7/18/2025 at 10:55 a.m. while on a joint home visit with Registered Nurse 2 (RN 2), Patient 2’s caregiver (PCG 2) and PCG 3 were present in Patient 2’s home. PCG 2 stated she was Patient 2’s regular caregiver. PCG 2 stated Patient 2 was not offered an oxygen concentrator or portable oxygen tank. PCG 2 stated they did not refuse any delivery of an oxygen concentrator or portable oxygen tank. PCG 3 stated Patient 2 had episodes of shortness of breath in the past. RN 2 stated since he was not Patient 2’s regular visiting nurse, he would check Patient 2’s medical records to confirm any delivery of oxygen equipment from the HA or any documented refusal of Patient 2’s responsible party. RN 2 stated if determined that oxygen equipment was not delivered, RN 2 would order the oxygen equipment from the Home Medical Equipment (HME) company and request priority of delivery to Patient 2’s home. During a telephone interview on 7/18/2025 at 12:41 p.m., PCG 1 stated she was not always there in the home, and PCG 2 and PCG 3 were Patient 2’s regular caregivers. PCG 1 stated HA provided and delivered the oxygen concentrator to Patient 2’s home, but it was stored in the closet and PCG 2 and PCG 3 were not aware. During an interview and a current record review on 7/21/2025 at 2:29 p.m. with the DPCS and the Administrator, Patient 2’s medical records were reviewed. The DPCS stated the visiting nurses (in general) must review that patient’s (in general) physician orders and plan of care and ensure all medical equipment, such as oxygen concentrator, was delivered to the patient’s home. The DPCS stated if the oxygen concentrator’s delivery to the patient’s home was confirmed, the visiting nurse must not leave the patient’s home until the oxygen concentrator could be located. The DPCS stated if the visiting nurse and the PCG could not locate the oxygen concentrator, then a new order for the oxygen concentrator must be placed. The DPCS stated the visiting nurses must ensure Patient 2’s reguar caregivers were aware where the oxygen concentrator is, how it is used, and what the physician order is, including how many liters of oxygen to administer if needed. During a review of the HA’s policy and procedures (P&P), titled “VS Care Planning,” dated 5/16/2023, the P&P indicated the following:1.     All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group (IDG, team composed of a Registered Nurse [RN], Medical Social Worker [MSW], chaplain, and physician, who come together to discuss patient’s plan of care to provide the best individualized care and support to the patient and family) in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire.2.     The hospice must ensure that each patient and the primary caregiver/s receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the initial, comprehensive, and updated comprehensive assessments.3.     Interventions to instruct family or caregiver in the performance of the intervention must be included in the plan of care. Once the family and caregiver verbalize or demonstrate understanding of the intervention, the intervention to monitor the completion of the intervention must be added to the plan of care. B. During a record review of Patient 8’s medical record titled “Case Sheet,” the record indicated that the agency admitted Patient 8 on 12/31/2024 with a primary diagnosis of cerebral atherosclerosis (a condition where plaque builds up in the arteries supplying blood to the brain, narrowing the vessels and potentially leading to stroke).During a record review of Patient 8’s Plan of Care (POC, a comprehensive, written document that outlines the specific course of action for a patient's healthcare needs, detailing the services, support, and resources required to address those needs), the blood pressure medications of Patient 8 included Clonidine HCl, Hydralazine HCl, and Norvasc (Amlodipine Besylate).  All three blood pressure medications had a parameter that indicated to hold the drug if the systolic blood pressure (SBP, the pressure of the artery when the heart beats or the upper number of a blood pressure reading) is less than 90.During an observation and a concurrent interview while on a joint visit in an assisted living facility with Registered Nurse 1 (RN 1) on 7/18/2025 at 10:40 a.m., a medication reconciliation (a complete inventory of all the medicines the patient is taking) was conducted with RN 1. The active medication list that the HA provided for Patient 8, dated 7/17/2025, included blood pressure medications (Clonidine HCl, Hydralazine HCl, and Norvasc) with a parameter indicating to hold the drug if the SBP is less than 90. Three blood pressure medication orders (Hydralazine HCl 100 milligrams [mg, metric unit of measurement, used for medication dosage and/or amount] tablet, Norvasc 10 mg tablet, and Clonidine HCl 0.1mg tablet) were observed in their respective containers without a parameter.  RN 1 stated that the parameters of the blood pressure medications were previously indicated on the container, but it was gone since they changed their pharmacy provider.   RN 1 stated that monitoring parameters is crucial to prevent hypotension, as it could result in serious complications or death.  RN 1 stated that she did not provide education to the medication technicians of the assisted living facility regarding the blood pressure medication parameters because she was on vacation, but hospice nurses provide such education to caregivers.During an interview with the Director of Patient Care Services (DPCS) on 7/21/2025 at 2:25 p.m., the DPCS stated that the hospice nurse should provide patient education to the patient or to the caregiver when a physician orders a new medication.  The DPCS stated that patient education is crucial for improving health literacy, fostering adherence, and minimizing medication errors and adverse reactions. The DPCS was unable to provide documentation that a hospice nurse provided education to the patient or to the caregiver on how to administer the blood pressure medications of Patient 8. During a review of the facility’s P&P titled “VS Patient and Caregiver Training,” dated 8/2/2021, the P&P indicated that all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire.  The hospice must ensure that each patient and the primary caregiver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to follow the physician’s order for one of 23 sampled patients (Patient 20).The physician's order on the POC indicated to administer Flagyl (to treat various infection) medication 250 mg. crushed to Patient 20's open wound to the sacral/coccyx area. The hospice licensed staff administered Flagyl 500 mg crushed to open wound instead. This deficient practice placed the patient's wound at risk for delayed healing process leading to infection and other related wound complication. --- During a review of Patient 20’s “Personal Information”, indicated a start of care (SOC) date of 8/7/2024, with a primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). During a review of Patient 20's POC/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/16/2025, indicated the frequency of visits for skilled nurse (SN) to two visits per week plus three PRN (pro re nata, which means “as needed”) visits for assessments, comfort measures, and symptoms management) and Hospice Aide (HA) to visit three a week as needed for personal care, home making, and to promote comfort.  During a review of Patient 20’s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes), the Current Treatment/Medication/DME List indicated there was a physician's order dated 7/16/2025, for Flagyl  250 milligrams (mg) tab, to crush over coccyx pressure sore three times weekly and as needed for two weeks , then re-assess.   On 7/21/2025, at 11 a.m., a home visit was conducted at Patient 20's residence with Registered Nurse (RN 1). The patient was observed lying in bed, awake but confused with an existing Stage II coccyx pressure sore.  On 7/21/2025, at 11:10 a.m., during an interview with RN 1 if the wound treatment was provided stated she did and applied crushed Flagyl 250 mg tab around the wound bed as ordered. During the home visit, at 11:50 a.m., a medication review was performed with RN 1. There was one bubble pack of Flagyl 500 mg one tab medication found at medication cart. During an interview with RN 1 on 7/21/2025, at 12 p.m., RN 1 stated she did not check Patient 20's Flagyl 500 mg tab bubble pack prior to doing wound treatment. RN 1 would ask the Medication Technician 1 to crush Flagyl 500 mg tab for her and RN 1 would apply the crushed Flagyl medication to Patient 20's open coccyx wound. RN 1 also stated she was aware the Flagyl order was for 250 mg., but she gave 500 mg., the wrong dosage. During an interview with the Director of Patient Care services (DPCS) on 7/22/2025, at 1 p.m., the DPCS stated Patient 20 should be taking correct dosage of the Flagyl medication as ordered and the visiting nurse should have check the patient's actual medication on every visits.  During a review of the undated HA’s policy and procedure, titled “The Plan of Care,” the policy and procedure indicated that a written, individualized, patient and family/caregiver plan of care would be established and maintained for everyone admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on observation, interview, and record review, the agency's Registered Nurse 3 (RN3) failed to perform standard precautions to prevent the transmission of infections and communicable diseases for one of 14 sampled patients (Patient 29). RN 3 failed to maintain aseptic technique (free from contamination, to prevent spread of infection) by not washing hands after cleaning an open wound during wound care. This deficient practice placed Patient 29 at a potential risk for wound infection. --- During a review of Patient 29's face sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated a start of care (SOC) date of 11/22/2024 with a terminal diagnosis of Alzheimer's disease ( a progressive disease that destroys cerebral infarction affecting right dominant side (a serious condition that occurs when brain tissues die due to a lack of blood flow to the brain). During a review of Patient 29's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) dated 2/19/2025, the POC/IDG indicated the frequency of visits of the skilled nurse (SN) to one visit per week plus one prn (as needed) visit, Social worker (MSW) prn and recertification and the chaplain (SC) service was declined. The POC/IDG indicated there was a physician's order included on the POC to provide wound care on Stage II sacral ulcer (partial thickness skin loss that appears as a shallow open sore or blister) as follows: a. to cleanse wound with wound cleanser, apply Hydrogel ointment and cover with foam dressing every other day. During a joint home visit, on 2/25/2025, at 12 p.m., with Registered Nurse (RN 3), at Patient 29s residence. During a wound care observation, Patient 29 was observed lying in bed with a Stage II sacral pressure ulcer. RN 3 was observed initially washing her hands, then putting on a new pair of gloves, removed the soiled dressing at sacral area, placed it in her plastic bag. RN 3 removed her soiled gloves, donned (put on) a new pair of gloves and cleansed the wound with wound cleanser. After cleaning the wound, RN 3 then applied the Hydrogel ointment to the open wound and covered with a foam dressing. All throughout the procedure, RN 3 did not wash her hands. During an interview on 2/25/2025, at 1 p.m., with RN 3, RN3 stated she (RN3) forgot to wash her hands because she was so nervous. During an interview on 2/26/2025, at 12 p.m., with the DPCS (director of patient care services), the DPCS stated RN 3 should have washed her hands in between dressing changes. During a review of the agency's undated policy titled "Hand Hygiene ", indicated that staff should perform hand hygiene (wash hands) before and after direct patient care, when hands are soiled and after any contact with contaminated materials.

Based on interview and record review, the hospice agency (HA) failed to ensure the patient's responsible party (RP1) who was the Power of Attorney (POA), has the right to be informed of the goals and expected outcomes for continuous care (CC- around-the-clock hospice care at home to manage a crisis situation) hospice services for one of 23 sampled patients (Patient 1). This failure had resulted in the violation of the patient's bill of rights. --- During a review of Patient 1s Case Sheet (admission record), indicated Patient 1s Start of Care (SOC) date on 11/12/2024 with primary diagnosis of nontraumatic intracerebral hemorrhage (ICH, blood clot in the brain) and secondary diagnosis of hemiplegia and hemiparesis (paralysis and weakness in one side of the body), affecting the right side. During a review of Patient 1s Initial Certification, dated 11/15/2024, indicated Patient 1 had dementia (decline in mental ability that interferes with daily life) and was dependent on caregivers for all activities of daily living (ADL). During a review of Patient 1s Interdisciplinary Plan of Care Revision/Physician Orders (MD order 1), dated 11/20/2024, the MD order 1 indicated RN 1 obtained an order from MD 3 to discontinue routine level of care (LOC) and start CC on 11/20/2024 at 4 PM for pain management. During a review of Patient 1s Nursing – Updated Comprehensive Assessment (Comprehensive Assessment 1), dated 11/20/2024, RN 1 notified MD 3 of Patient 1s unmanaged pain and to provide CC starting 11/20/2024 at 4 PM. Comprehensive Assessment 1 indicated RN 1 notified Patient 1s caregiver at the bedside (Caregiver 3) regarding Patient 1s unmanaged pain and start CC services. Comprehensive Assessment 1 indicated RN 1s onsite visit started on 11/20/2024 at 3:10 PM. During an interview on 12/5/2024 at 9:24 AM with the responsible party (RP 1) stated, she notified the HA she had the Power of Attorney (POA- legal document that allows another person to act on ones behalf) to make healthcare decisions for Patient 1. RP 1 stated no HA staff discussed with her and obtained her consent regarding the start of the CC services. During an interview on 12/5/2024 at 1:52 PM, RN 1 stated she discussed the CC order with Caregiver 3, because RP 1 was not present during the majority of her visits to Patient 1. RN 1 stated RP 1 ";was not able to answer" her phone calls when RN 1 attempted to reach out to RP 1. During an interview and concurrent review of Patient 1s medical records on 12/5/2024 at 2:41 PM, the Director of Patient Care Services (DPCS) stated RN 1 spoke with Caregiver 3 onsite because RP1 was ";difficult to reach." The DPCS stated was not aware if Caregiver 1 notified the HA regarding having the POA for Patient 1. During an interview on 12/6/2024 at 8:18 AM, RP 1 stated she did not receive any phone calls from HA regarding the start of CC, including the goals and expected outcomes for Patient 1. RP 1 stated she should have been notified for any changes in the plan of care, because she was the legal decisionmaker for Patient 1 and not Caregiver 3. RP 1 stated she provided HA the POA documents on 11/4/2024. During a review of the log of RN 1s calls to RP 1, the last call attempt was on 11/20/2024 at 2:26 PM prior to the onsite visit on 11/20/2024 at 3:10 PM when RN 1 assessed Patient 1s level of pain and determined the need for CC. During a review of the HAs policy and procedures (P&P), titled ";Patient Rights," dated 10/11/2023, the P&P indicated the following: 1. The hospice must obtain the patients or representatives signature confirming that he or she has received a copy of the notice of rights and responsibilities. If there is another signer other than the patient, there must be documentation as to why. 2. Patients have the right to be involved in developing their plan of care because patients are vital in making decisions regarding their care, treatment, and services.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) Skilled Nurse (SN) failed to reassess pain level for one of twenty-three sampled patients (Patient 15) as per hospice policy and procedure. This deficient practice had the potential to result in continuous pain and bodily discomfort, affecting the patient's overall health status, wellbeing, and dignity throughout the dying process. --- During a review of Patient 15s Face sheet, the face sheet indicated an admission date of 3/28/2024, with a terminal primary diagnosis of Parkinsonism (brain conditions that cause slowed movement, stiffness, and tremors). During a review of Patient 15s medical record titled, Addendum Initial General Plan of Care Visit frequency grid, it indicated a Skilled Nurse frequency visit of one time a week, as of the date 11/27/2024. During a concurrent interview and record review on 12/6/2024 at 12:02 p.m., with the Director of Patient Care Services (DPCS), Patient 15s medical record titled, Nursing-updated comprehensive assessment, dated 11/18/2024 was reviewed. Patient 15s Nursing-updated comprehensive assessment indicated, Patient 15 had pain to right and left heel, with a throb quality, radiating to elbow, with a pain severity level of 7/10, and a Care plan Goal from 0-10, of a 0 level. Patient 15s Nursing-updated comprehensive assessment also indicated Patient 15 reporting pain increased to left heel affecting sleep. Patient 15s Nursing -updated comprehensive assessment further indicated there was no documented evidence of what pain interventions were attempted and a reassessment of Patient 15s pain level. The DPCS stated the Nursing-updated comprehensive assessment dated 11/18/2024 did not have documented evidence by the SN, of what pain interventions were performed and reassessment of Patient 15s pain level. The DPCS stated it is important for a SN to assess a patients pain level, location, duration of the pain and what interventions or medications has the patient taken and how often, to know if it is effective or not and notify the physician. During a concurrent interview and record review on 12/6/2024 at 12:15pm., with DPCS, Patient 15s Electronic Medical Record (EMR) was reviewed. Patient 15s EMR indicated there was no documented communication log of the SN reporting a follow up phone call was made to reassess Patient 15s pain. The DPCS stated during Interdisciplinary Group (IDG) meetings, the skilled nurses are educated that if a patient during a home visit reported having pain, the skilled nurse should do a follow up visit or phone call to reassess how the patient is doing and if there is relief of the pain. The DPCS stated there are also no documented communication log indicating that the SN contacted Patient 15 the following day, after the documented reported pain, on 11/19/2024, to reassess Patient 15s pain level. During a review of the HAs Policy and Procedure (P&P) titled, VS Symptom Management, dated 6/3/2022, indicated pain is documented when pain score is high at the beginning of the visit when assessing pain and completed after interventions are done during the visit to relieve pain. The P&P also indicates a level of greater than ";5" may require immediate interventions like a follow up later that day or the next day to ensure interventions are effective.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) nursing staff failed to review all the medications the patient was taking and update the medication profiles with currently used medications for two of 23 sampled patients (Patient 4 and Patient 5). This deficient practice has the potential to result in medications errors and adverse drug reactions that could affect the patients' health status and well-being. --- Findings: a. During a review of Patient 4s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 4 was admitted to the HA on 11/1/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Patient 4s Plan of Care (POC, a written document developed for each individual by the support team using a person-centered approach that describes the support, services, and resources provided or accessed to address the needs of the individual) Visit Frequency Grid, the Visit Frequency Grid indicated Patient 4 s skilled nurse frequency of visits to two times a week since 11/6/2024 to current. During a joint home visit observation and interview, on 12/4/2024 at 2:45 p.m., with the licensed vocational nurse (LVN3), at Patient 4s residence, Patient 4 was observed sitting in a sofa, awake and oriented to person, place, and time. During Patient 4s medication review with LVN3, the following medications could not be found: 1. Temazepam 15 milligrams (mg, unit of measurement) capsule, take one capsule by mouth at bedtime as needed for sleep. 2. Colace 100 mg capsule, take 1 capsule by mouth every night at bedtime for constipation (having a difficult time passing stool) 3. Ativan 1 mg tablet, take 1 tablet by mouth every 4 hours as needed for anxiety 4. Roxanol 20 mg/ml (milliliter, unit of measurement) solution, take 0.25 ml by mouth every 2 hours as needed for shortness of breath or pain. Patient 4 medication profile provided by the HA indicated patient was still taking these medications. Patient 4 stated he was not on these medications for about 3-4 weeks as per his physicians order. b. During a review of Patient 5s Face Sheet, the Face Sheet indicated Patient 5 was admitted to the HA on 11/1/2023 with a terminal diagnosis of unspecified severe protein-calorie malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). During a review of Patient 5s POC Visit Frequency Grid, the Visit Frequency Grid indicated Patient 5 s skilled nurse frequency of visits to two times a week since 11/6/2024 to current. During a joint home visit observation and interview, on 12/4/2024 at 3:10 p.m. with the LVN3, at Patient 5s residence, Patient 5 was observed sitting in a chair, alert but confused and disoriented. During Patient 5s medication review with LVN3, the following medications could not be found: 1. Prilosec 20 mg capsule, 1 capsule by mouth twice a day for dyspepsia (indigestion or upset stomach) 2. Seroquel 25 mg tablet, take 1 tablet by mouth at bedtime for agitation 3. Mobic 7.5 mg tablet, take 1 tablet by mouth every day for pain 4. Senna S 8.6-50 mg tablet, take 2 tablets by mouth every day for constipation Patient 5s medication profile provided by the HA indicated patient was still taking these medications. During an interview, on 12/6/2024 at 12:20 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that the visiting nurses should conduct medication reconciliation on every patient visit to determine current or discontinued medications to prevent possible medication errors. DPCS stated and acknowledged the findings. During a review of the agencys undated policy and procedure (P&P) titled, VS Pharmacy Process, the P&P indicated the HAs nurse was responsible for medication reconciliation (the process of identifying the most accurate list of all medications the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider). The CML (Chart Medication List) should be reviewed during each patient visit and during IDG (or Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) to ensure it is up to date including active and discontinued medications.

Based on interview and record review, the hospice agency (HA) staff failed to consistently conduct the pain assessments for one of 23 sampled patients (Patient 1), who was placed on continuous care (CC, around-the-clock hospice care at home to manage a crisis situation) for pain management in accordance with the HAs policy and procedures. This failure has the potential to result in an ineffective pain management that could lead to negative patient care outcomes. --- During a review of Patient 1s Case Sheet (admission record), the Case Sheet indicated Patient 1s Start of Care (SOC) date on 11/12/2024 with primary diagnosis of nontraumatic intracerebral hemorrhage (ICH, blood clot in the brain) and secondary diagnosis of hemiplegia and hemiparesis (paralysis and weakness in one side of the body), affecting the right side. During a review of Patient 1s Initial Certification dated 11/15/2024, indicated Patient 1 had dementia (decline in mental ability that interferes with daily life) and was dependent on caregivers for all activities of daily living (ADL). During a review of Patient 1s Nursing – Updated Comprehensive Assessment (Comprehensive Assessment 1), dated 11/20/2024, indicated RN 1 notified Medical Doctor 3 (MD 3) of Patient 1s unmanaged pain and to start CC services starting 11/20/2024 at 4 PM. Comprehensive Assessment 1 indicated Pain Assessment in Advanced Dementia (PAINAD) Scale was utilized to assess pain with a severity score of 6/10 (tool to assess pain in patients with dementia who are noncommunicative by observing breathing, negative vocalizations, facial expression, body language, and consolability {beyond comforting} with 10 as the highest severity). During a review of Patient 1s Interdisciplinary Plan of Care Revision/Physician Orders (MD order 1) dated 11/20/2024, the MD order 1 indicated, RN 1 obtained an order from MD 3 to discontinue routine level of care (LOC) and start CC on 11/20/2024 at 4 PM for pain. During an interview on 12/4/2024 at 11:29 AM, Caregiver 2 (one of Patient 1s secondary caregivers) stated HA explained when they enrolled Patient 1 in hospice that HA could help with pain control with Patient 1 being ";not completely knocked out." Caregiver 2 stated HA staff informed Caregiver 3 (one of Patient 1s secondary caregivers) they would send a nurse to monitor his pain level but felt like the hospice staff ";wanted to rush his [Patient 1s] death." During an interview on 12/4/2024 at 9:24 AM, Responsible Party 1 (RP 1, Patient 1s primary caregiver) stated when HA medical doctor (unable to recall name) explained hospice services, HA medical doctor stated it was for pain management and ";does not mean death." RP 1 stated Patient 1s family thought the HA could manage his pain under control, Patient 1 would tolerate being in a wheelchair, then Patient 1s family could take Patient 1 to the beach. RP 1 stated prior to CC, Patient 1 could open his eyes, nod, say ";yes," ";no," and ";better," (in his native language). RP 1 stated Patient 1 had ";only had pain" with movement. RP 1 HA nurse stated, ";We are trying to come up with pain management for [Patient 1]." However, RP 1 stated when she asked the nurse (unable to recall name) how much Morphine (narcotic drug for pain) was administered to Patient 1, she could not tell her the specific amount. During an interview on 12/5/2024 at 1:05 PM, Licensed Vocational Nurse 1 (LVN 1) stated Patient 1 was assessed with pain due to the grimacing (facial expression of pain/disgust) observed when being touched to obtain the radial pulse. LVN 1 stated she was not aware of the HA's policy for pain scale utilized for nonverbal patients. LVN 1 stated Patient 1 was non-verbal when Patient 1 was on CC. During an interview on 12/5/2024 at 2:13 PM, Medical Doctor 2 (MD 2) stated the patient (in general) must be started with a lower dosage of the pain medication and ";go slow" until all symptoms are managed due to the possible side effects of the pain medication. MD 2 stated the increased Morphine dosage and frequency might be acceptable if grimacing and one or more symptoms were present during assessment. During an interview on 12/5/2024 at 2:41 PM, the Medical Director (MD 1) stated per HAs policy and procedures, the HA must utilize PAINAD when assessing pain of nonverbal patients with the goal of managing pain by finding an ";acceptable level of comfort and preserving as much alertness as possible." MD 1 stated the HA would ";work with families to find out whats right for the patients." During an interview and concurrent review of Patient 1s medical records on 12/5/2024 at 3:15 PM, the Director of Patient Care Services (DPCS) stated the licensed nurses observed Patient 1s grimacing (facial expression of disgust/pain) and administered the Morphine 15 mg as ordered by the physician. The DPCS stated the licensed nurses did not consistently utilize the PAINAD scale to assess for Patient 1s pain level during CC but based on the grimacing observed and documented by the skilled nurse, the Morphine administration was appropriate. DPCS stated it was important to document the amount of Morphine left in the bottle to ensure the correct dose was administered to the patient (in general). During an interview on 12/6/2024 at 8:53 AM, LVN 2 stated she utilized Wong-Baker FACES Pain Rating Scale (self-assessment tool that helps a patient communicate how much pain he/she is experiencing) when assessing for pain level in nonverbal patients. During a review of the HAs policy and procedures (P&P), titled ";Symptom Management," dated 6/3/2022, the P&P indicated the following: 1. If a patient is cognitively unable to self-report pain, behavioral observations must be used. The HA uses the Pain Assessment in Advanced Dementia (PAINAD) method to assess pain in cognitively impaired individuals. 2. Patients must be asked about or observed for pain every visit. 3. A pain assessment must be completed and documented at every visit when a patient is on any pain medication, when the patient has a diagnosis that puts him/her at risk for pain (that is, pain can be anticipated based on the diagnosis), or when the patient expresses pain verbally or exhibits non-verbal pain behavior/s.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to meet the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services as follows: a. The Hospice failed to develop an individualized Plans of Care (POC, a written document developed for each individual by the support team using a person-centered approach that describes the support, services, and resources provided or accessed to address the needs of the individual) for five of 23 sampled patients (Patient 4, Patient 12, Patient 15, Patient 21, and Patient 22). Patient 4's diagnosis included Type 2 diabetes mellitus (chronic condition of persistently high blood sugar levels in the blood). The POC failed to identify and develop an individualized POC for diabetic management. Patient 12's physician's order included Humulin R and Lantus Solostar for diabetes mellitus. The POC failed to develop diabetic management for the use of these medications. Patient 15's physician's order included Humulin N insulin. There was no POC developed and implemented for diabetes management for the use of this medication. Patient 21's physician's order included Eliquis (anticoagulant medication used to treat and prevent blood clots). There was no POC developed for management of the use of this anticoagulant medication. Patient 22's physician's order included Humulin R (insulin, a hormone that removes excess sugar from the blood). There was no POC developed for diabetic management for using this medication. These failures had the potential to result in the delayed provision of the necessary care and services that could lead to affect the patients' health status and wellbeing. (Refer to L545) b. The Hospice failed to ensure the responsible party (RP 1) of one of 23 sampled patients (Patient 1) understood and agreed with Patient 1's plan of care for continuous care initiated on 11/20/2024, that included individualized goals, interventions, and expected outcomes to manage pain. This failure resulted in the further decline in Patient 1s condition with ineffective pain management due to the disagreement with Morphine (opioid, a controlled medication to treat moderate to severe pain that can cause respiratory distress and death when taken in high doses) administration and medication discrepancies between the hospice staff and the familys expected outcomes for Patient 1. Refer to L551. c. The Hospice failed to ensure the physician one of 23 sampled patients (MD 1) was notified of Patient 1s significant change of condition when Morphine (opioid, a controlled medication to treat moderate to severe pain that can cause respiratory distress and death when taken in high doses) medication order was increased in dosage and frequency, and the refusal of the responsible party (RP 1) for the medication to be administered. The deficient practice resulted in Patient 1 had a decline in vital signs with blood pressure (BP) of 83/56 and respiratory rate (RR) of 10 breaths per minute, and Patient 1s status changed to ";imminent" (ready to take place) with decreased response to verbal and visual stimuli. (Refer to L554) The cumulative effect of these systemic practices resulted in the failure of the Hospice to deliver statutorily (written law) mandated compliance with Federal regulations for IDG, Care Planning, and Coordination of Services to ensure the highest quality of hospice care and services were provided to patients certified to receive the benefits. --- .

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to develop an individualized Plans of Care (POC, a written document developed for each individual by the support team using a person-centered approach that describes the support, services, and resources provided or accessed to address the needs of the individual) for five of 23 sampled patients (Patient 4, Patient 12, Patient 15, Patient 21, and Patient 22). Patient 4's diagnosis included Type 2 diabetes mellitus (chronic condition of persistently high blood sugar levels in the blood). The POC failed to identify and develop an individualized POC for diabetic management. Patient 12's physician's order included Humulin R and Lantus Solostar for diabetes mellitus. The POC failed to develop diabetic management for the use of these medications. Patient 15's physician's order included Humulin N insulin. There was no POC developed and implemented for diabetes management for the use of this medication. Patient 21's physician's order included Eliquis (anticoagulant medication used to treat and prevent blood clots). There was no POC developed for management of the use of this anticoagulant medication. Patient 22's physician's order included Humulin R (insulin, a hormone that removes excess sugar from the blood). There was no POC developed for diabetic management for using this medication. These failures had the potential to result in the delayed provision of the necessary care and services that could lead to affect the patients' health status and wellbeing. --- Findings: a. During a review of Patient 4s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 4 was admitted to the HA on 11/1/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The Face Sheet indicated other diagnosis including essential hypertension (high blood pressure) and type 2 diabetes mellitus. During a joint home visit observation and interview, on 12/4/2024 at 2:45 p.m., with the licensed vocational nurse (LVN3), at Patient 4s residence, Patient 4 was observed sitting in a sofa, awake and oriented to person, place, and time. Patient 4 stated he has been checking and monitoring his blood sugar level daily and takes medication to manage his diabetes. During an interview and concurrent record review, on 12/5/2024 at 12:30 p.m., with the Director of Patient Care Services (DPCS), Patient 4s POC records was reviewed by the DPCS. The DPCS stated and confirmed Patient 4s POC records did not have specific plan which includes goals and interventions for diabetic management. The DPCS stated Patient 4s POC should have included diabetic management. b. During a review of patient 12s Face sheet, the face sheet indicated an admission date of 6/4/2024, with a terminal primary diagnosis of Heart Failure (a condition in which the heart muscle cannot pump enough blood to meet the bodys need for blood and oxygen) During a review of Patient 12s medical record titled, Addendum Initial General Plan of Care Visit frequency grid, it indicated a Skilled Nurse (SN) frequency visit of two times a week as of the date 11/28/2024. During a review of Patient 12s Medication List/Signed Physician Orders, undated, the medication list indicated an order for Humulin R (insulin, a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication, regular, human) 100/milliliter (mL, unit of measurement) vial, indication diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), inject 10 units subcutaneously (beneath the skin), before breakfast and lunch, an order for Humulin R 100/ml via, indication DM, inject 20 units subcutaneously before supper, Lantus Solostar (insulin, a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication in a disposable prefilled pen) 100/ml insulin pen, indication DM, inject 65 units subcutaneously every morning at 6:30 a.m., and Lantus (insulin, a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication, regular, human) 100/ml vial, indication DM, inject 55 units subcutaneously at bedtime. During a joint visit on 12/4/2024 at 10:16 a.m., with Registered Nurse (RN 1), at Patient 12s nursing facility, Patient 12 was observed sitting up in a wheelchair, awake, and oriented to self, and on oxygen via nasal cannula (medical device that provides supplemental oxygen through two prongs that fit into the nostrils) connected to portable oxygen tank. RN 1 was observed communicating with the nursing facility Licensed Vocational Nurse (LVN), assessed Patient 12, did not assess Patient 12s blood sugar nor asked the nursing facility LVN for Patient 12s blood sugar levels. During a concurrent interview and record review on 12/5/2024 at 3:37 pm., with the Director of Patient Care Services (DPCS), Patient 12s Plan of Care was reviewed. The Plan of Care indicated it was for unrelated symptom of DM and did not have documented interventions. The DPCS stated and confirmed, that Patient 12 did have a care plan for DM, however the care plan did not have interventions that included monitoring blood sugar or checking symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). The DPCS further stated that it was important to look at the whole patient and address their symptoms appropriately, to be able to educate the patient/caregiver and facility staff. During a concurrent interview and record review on 12/5/2024 at 3:45 pm., with the DPCS, Patient 12s Nursing-updated comprehensive assessments with dates of 10/22/24, 10/27/2024, 11/1/2024, and 11/19/2024 were reviewed. Patient 12s Nursing-updated comprehensive assessments did not indicate the SN documented Patient 12s blood sugar levels during those visits. The DPCS stated and confirmed, that there was no documented evidence that the SN checked Patient 12s blood sugar levels during the visits of 10/22/2024, 10/27/2024, 11/1/2024, and 11/19/2024. The DPCS stated since Patient 12 lives in a nursing home, the facility nurses will check Patient 12s blood sugar and the agencys SN would ask the nursing staff what Patient 12s blood sugar level was, at every visit, and document it in the nursing updated comprehensive assessment. The DPCS further stated that it was important to look at the whole patient and address their symptoms appropriately, to be able to educate the patient/caregiver. c. During a review of Patient 15s Face sheet, the face sheet indicated an admission date of 3/28/2024, with a terminal primary diagnosis of Parkinsonism (brain conditions that cause slowed movement, stiffness, and tremors). During a review of Patient 15s medical record titled, Addendum Initial General Plan of Care Visit frequency grid, it indicated a Skilled Nurse frequency visit of one time a week, as of the date 11/27/2024. During a review of Patient 15s Medication List/Signed Physician Orders, undated, the medication list indicated an order for Humulin N (insulin, a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication, regular, human) 100/milliliter (mL, unit of measurement) vial, indication diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), inject 11 units subcutaneously (beneath the skin), in the morning and 12 units in the night. During a concurrent interview and record review on 12/5/2024 at 3:37 pm., with the Director of Patient Care Services (DPCS), Patient 15s Plan of Care records were reviewed. The DPCS stated and confirmed Patient 15s Plan of Care records did not have a specific and individualized plan of care, with goals and interventions, for Patient 15s DM management. The DPCS further stated there should have been a care plan developed for Patient 15s DM, because the patient should be cared for as a whole and it is important to monitor the patient for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) and provide appropriate education to the patient or caregiver. During a concurrent interview and record review on 12/5/2024 at 3:45pm with the DPCS, Patient 15s Nursing-updated comprehensive assessments with dates of 11/11/2024, 11/18/2024, 11/25/2024, and 12/2/2024 were reviewed. Patient 15s Nursing-updated comprehensive assessments did not indicate the SN documented Patient 15s blood sugar levels during those visits. The DPCS stated and confirmed, that there was no documented evidence that the SN checked Patient 15s blood sugar levels during the visits of 11/11/2024, 11/18/2024, 11/25/2024, and 12/2/2024. The DPCS stated since Patient 15 lives at home, the patient and caregiver are educated on how to check Patient 15s blood sugar levels, and at every visit the SN should ask the patient and/or caregiver what the blood sugar level was and document it in the nursing updated comprehensive assessment. The DPCS further stated that it was important to look at the whole patient and address their symptoms appropriately, to be able to educate the patient/caregiver. d. During a record review of Patient 21s Face Sheet, the Face Sheet indicated Patient 21 was admitted to the HA on 1/12/2024 with a terminal diagnosis of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) and a secondary diagnosis of vascular dementia (a progressive state of decline in mental abilities caused by an impaired supply of blood to the brain). During a record review of Patient 21s Medication List/Signed Physician Orders, the medication list indicated for Eliquis (Apixaban, anticoagulant medication used to treat and prevent blood clots) 5 milligram (mg, unit of measurement), indication atrial fibrillation (A-fib, an irregular and often very rapid heart rhythm [arrhythmia] that can lead to blood clots in the heart), take one tablet (=5mg) by mouth twice a day for the heart. During a concurrent interview and record review on 12/5/2024 at 3:58 p.m., Patient 21s POC records were reviewed. The DPCS stated that Patient 21 did not have a care plan for risk for bleeding and a patient on anticoagulants should be monitored for signs and symptoms of bleeding. The DPCS stated that a bleeding risk can impact the patient and the overall care and that it was important to assess any kind of complication that could occur with this type of patient. e. During a record review of Patient 22s Face Sheet, the Face Sheet indicated Patient 22 was admitted to the HA on 1/12/2024 with a terminal diagnosis of congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and a secondary diagnosis of essential hypertension (high blood pressure). During a record review of Patient 22s Medication List/Signed Physician Orders, the medication list indicated for Humulin R (insulin, a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication, regular, human) 100/milliliter (mL, unit of measurement) vial, indication diabetes mellitus, inject 17 units subcutaneously (beneath the skin), at bedtime for controlling blood sugars. During a concurrent interview and record review on 12/6/2024 at 3:37 p.m., with the DPCS, Patient 22s POC records were reviewed. The DPCS stated that Patient 22 had a care plan, however, did not have interventions that included monitoring blood sugar, or checking symptoms of hypoglycemia and hyperglycemia. The DPCS stated that if the family member or caregiver checks the blood sugar, the nurse would ask the family member what the blood sugar level was, and it would be documented in the nurses notes. During a concurrent interview and record review on 12/6/2024 at 3:43 p.m., with the DPCS, Patient 22s updated comprehensive assessments from 11/11/2024 though 12/3/2024 was reviewed. The DCPS stated that there was no documentation that Patient 22s blood sugar was checked. The DCPS stated that the nurse should be documenting the patients blood sugar on the updated comprehensive assessment and that it was important to look at the whole patient and address symptoms appropriately. During a review of the agencys undated policy and procedure (P&P) titled, VS Pharmacy Care Planning, the P&P indicated the hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of terminal illness and related conditions.

Based on interviews and record review, the hospice agency (HA) failed to ensure the responsible party (RP 1) of one of 23 sampled patients (Patient 1) understood and agreed with Patient 1's plan of care for continuous care initiated on 11/20/2024, that included individualized goals, interventions, and expected outcomes to manage pain. This failure resulted in the further decline in Patient 1s condition with ineffective pain management due to the disagreement with Morphine (opioid, a controlled medication to treat moderate to severe pain that can cause respiratory distress and death when taken in high doses) administration and medication discrepancies between the HA staff and the familys expected outcomes for Patient 1. --- During a review of Patient 1s Case Sheet (admission record), indicated Patient 1s Start of Care (SOC) date on 11/12/2024 with primary diagnosis of nontraumatic intracerebral hemorrhage (ICH, blood clot in the brain) and secondary diagnosis of hemiplegia and hemiparesis (paralysis and weakness in one side of the body), affecting the right side. During a review of Patient 1s Initial Certification, dated 11/15/2024, indicated Patient 1 had dementia (decline in mental ability that interferes with daily life) and was dependent on caregivers for all activities of daily living (ADL). During a review of Patient 1s Interdisciplinary Plan of Care Revision/Physician Orders (MD order 1), dated 11/20/2024, MD order 1 indicated RN 1 obtained an order from MD 3 to discontinue routine level of care (LOC) and start continuous care (CC, around-the-clock hospice care at home to manage a crisis situation) on 11/20/2024 at 4 PM for pain. During a review of Patient 1s Nursing – Updated Comprehensive Assessment (Comprehensive Assessment 1), dated 11/20/2024, Comprehensive Assessment 1 indicated the following: 1. RN 1 was unable to take blood pressure due to increased pain with blood pressure cuff inflation, respirations were 18 breaths per minute with no signs and symptoms of respiratory distress, and pain severity score of 6 out of 10. 2. Patient 1 had small intake of pureed food with sips of a nutritional drink. 3. RN 1 notified Medical Doctor 3 (MD 3) regarding Patient 1s unmanaged pain. 4. HA to start CC on 11/20/2024 at 4 PM. 5. The primary symptom communication source was Caregiver 3, and the visit start time was 3:10 PM. There was no documented evidence of communication attempts to RP 1 after the 11/20/2024 Skilled Nursing visit. During a review of Patient 1s Interdisciplinary Care Plan: Continuous Care Shift Care (CP 1), dated 11/20/2024, CP 1 indicated the following: 1. The reason for CC was pain. 2. The interventions included observing for signs and symptoms of pain, documenting how the interventions helped, and calling HA for any changes in condition, concerns, or if interventions are ineffective and symptoms persist. 3. The additional interventions for the skilled nurse included documenting symptom severity rating, administering medications per physician orders, and calling the physician if medications are ineffective. During a review of Patient 1s Focus Visit: Updated Comprehensive Assessment (Comprehensive Assessment 2), dated 11/21/2024, Comprehensive Assessment 2 indicated the following: 1. There was no documented evidence of physician notification regarding the change in condition and the expected outcome/s. Patient 1 had a decline in vital signs with blood pressure of 83/56 and respirations of 10 breaths per minute and Patient 1s status changed to ";imminent (signs or symptoms are consistent with a prognosis of less than 5 days)" with decreased response to verbal and visual stimuli. 2. RN 1 documented, ";Family was upset with patient appearing sedated, asked nurses to hold Roxanol (liquid form of immediate-release Morphine)." There was no documented evidence that RP 1 was informed of the change in expected outcomes/ for Patient 1. 3. RN 1 documented to ";Continue Current Plan of Care." There was no documented evidence of any revisions to Patient 1s plan of care interventions for pain management and expected outcomes. During an interview on 12/5/2024 at 9:24 AM, RP 1 stated she was surprised to see a HA nurse when she got home from work. RP 1 stated LVN 4 stated she was there for pain management but ";did not give much information." RP 1 stated prior to CC initiation, Patient 1 was able to open eyes, nod, say ";Yes," ";No," ";Better" in Patients native language. RP 1 stated, ";They said they were there for pain management. We were hoping one day, pain would be managed, and we could take [Patient 1] to the beach again." RP 1 stated on 11/21/2024 at 6:30 AM, Patient 1 had bluish gray lips and looked like a ";corpse." RP 1 stated he was not responsive but was still breathing. RP 1 stated she was not notified immediately when Patient 1 was placed on oxygen therapy at 2 liters per minute via nasal cannula. RP 1 stated she believed Patient 1 was ";overdosed with Morphine," so she requested the staff to hold the Morphine doses. RP 1 stated on 11/22/2024, Patient 1 ";looked better" after Morphine doses were held but Patient 1 was ";still not responding." RP 1 stated she then administered to Patient 1 glucose liquid (to treat low blood sugar) and 2 doses of Narcan (medicine that reverses an opioid overdose) she bought over the counter, then Patient 1 started to respond, woke up, and yelled, ";No, Mama! No!" RP 1 stated she called 911 and was admitted in the hospital for about 11 days, given antibiotics, and discharged to home with home health services. RP 1 stated Patient 1 gained back his appetite at the hospital and still had pain with movement. During an interview on 12/5/2024 at 1:52 PM, Registered Nurse 1 (RN 1) stated during a routine visit on 11/20/2024, Patient 1 presented with grimacing and moaning when touched. RN 1 stated caregivers and staff were not able to ";touch" him, ";barely able to change him (adult incontinence pad)." RN 1 stated she obtained an order from the physician (MD 3) to initiate the CC to ";get his pain under control." RN 1 stated she reached out to the CC team to start CC for Patient 1 because the CC team was in-charge of staffing and scheduling. RN 1 stated she discussed the CC plan of care with Caregiver 3, because the legal decisionmaker, RP 1, ";was not able to answer" her calls and was ";always at work." RN 1 did not recall if she documented her call attempts to RP 1. RN 1 stated during her follow-up visit on 11/21/2024, RN 1 stated Patient1 declined, and she documented the vital signs obtained. RN 1 stated she was informed that the family requested to hold the Morphine order due to Patient 1 ";appearing sedated." RN 1 stated she did not notify the physician because the CC staff would notify the CC team regarding the changes in Patient 1s condition and refusal of Morphine. RN 1 stated she spoke with Caregiver 3, who was mostly present at the bedside with Patient 1. During an interview and a concurrent review of Patient 1s clinical records on 12/5/2024 at 2:41 PM, Director of Patient Care Services (DPCS) stated she was not aware RP 1 had POA to make healthcare decisions for Patient 1. DPCS stated RN 1 spoke to Caregiver 3 regarding the CC order but failed to document the call attempts to RP 1. DPCS stated Patient 1s baseline vital signs prior to CC initiation were 118/90, 104/65, 114/71, and 118/60 with respirations ranging from 13-18 breaths per minute. DPCS stated if Patient 1s expected outcome was to decline, the physician did not need to be notified by the skilled nurse. During a review of the HAs policy and procedures (P&P 1), titled ";Symptom Management," dated 6/3/2022, P&P 1 indicated the following: 1. Patient and family education is an important part of symptom management and should be included on patient care plans. 2. Symptoms should be care planned with goals, interventions, and outcomes based on assessment findings and patient/family input. During a review of the HAs policy and procedures (P&P 2), titled ";Care Planning," dated 5/16/2023, indicated the following: 1. The VITAS RN must initiate the Continuous Care Shift Care Plan of Care for the patient and include problems and interventions provided to patients and families by the Continuous Care Shift Care staff. 2. The ideal score or goal is rated on a scale of 0-10 and documented on the care plan as a numeric goal. 3. The outcome describes the result desired by the patient/family and team. 4. Interventions must be individualized and include steps/tasks for the IDG to meet the goals and outcomes of the patient/caregiver. During a review of the HAs policy and procedures (P&P 3), titled ";Continuous Care," dated 9/4/2024, P&P 3 indicated the following: 1. The care plan must be updated when a patient is placed on continuous care. The RN, or LPN/LVN in collaboration with a RN, must ensure changes to patient goals, outcomes, and interventions (initiation of the Shift Care POC, includes specific interventions for Shift Care staff) is in place on the POC. 2. The RN must update the visit staff POC and Shift Care POC, as needed, based on findings and analysis. The RN must utilize the information from shift notes to complete assessment, care plan, provide interventions and supervise the care provided.

Based on interview and record review, the HA failed to ensure the physician of one of 23 sampled patients (MD 1) was notified of Patient 1s significant change of condition when Morphine (opioid, a controlled medication to treat moderate to severe pain that can cause respiratory distress and death when taken in high doses) medication order was increased in dosage and frequency, and the refusal of the responsible party (RP 1) for the medication to be administered. The deficient practice resulted in Patient 1 had a decline in vital signs with blood pressure (BP) of 83/56 and respiratory rate (RR) of 10 breaths per minute, and Patient 1s status changed to ";imminent" (ready to take place) with decreased response to verbal and visual stimuli. --- During a review of Patient 1s Case Sheet (admission record) indicated Patient 1s Start of Care (SOC) date on 11/12/2024 with primary diagnosis of nontraumatic intracerebral hemorrhage (ICH, blood clot in the brain) and secondary diagnosis of hemiplegia and hemiparesis (paralysis and weakness in one side of the body) affecting the right side. During a review of Patient 1s Initial Certification, dated 11/15/2024, indicated Patient 1 had dementia (decline in mental ability that interferes with daily life) and was dependent on caregivers for all activities of daily living (ADL). During a review of Patient 1s Interdisciplinary Plan of Care Revision/Physician Orders (MD order 1), dated 11/20/2024, MD order 1 indicated RN 1 obtained an order from MD 3 to discontinue routine level of care (LOC) and start continuous care (CC, around-the-clock hospice care at home to manage a crisis situation) on 11/20/2024 at 4 PM for pain. During a review of Patient 1s Nursing – Updated Comprehensive Assessment (Comprehensive Assessment 1) dated 11/20/2024, indicated the following: 1. RN 1 notified Medical Doctor 3 (MD 3) of Patient 1s unmanaged pain the start of continuous care starting on 11/20/2024 at 4 PM. 2. RN 1 was unable to take blood pressure due to increased pain with blood pressure cuff inflation, respiratory rate of 18 breaths per minute with no signs and symptoms of respiratory distress, and pain severity score of 6 out of 10. 3. Patient was confused but able to make some needs known, Spanish-speaking, and communicated with Caregiver 3. 4. Patient 1 had small intake of pureed food with sips of Ensure. 5. The primary symptom communication source was Caregiver 3, and the visit start time was 3:10 PM. There was no documented evidence of communication attempts to RP 1 regarding the 11/20/2024 Skilled Nursing visit. 6. Patient 1 was not determined a ";high risk for imminent death (signs or symptoms are consistent with a prognosis of less than 5 days). During a review of Patient 1s Interdisciplinary Care Plan: Continuous Care Shift Care (CP 1), dated 11/20/2024, CP 1 indicated the following: 1. The reason for CC was pain. 2. The interventions included observing for signs and symptoms of pain, documenting how the interventions helped, and calling HA for any changes in condition, concerns, or if interventions are ineffective and symptoms persist. 3. The additional interventions for the skilled nurse included documenting symptom severity rating, administering medications per physician orders, and calling the physician if medications are ineffective. During a review of Patient 1s Focus Visit: Updated Comprehensive Assessment (Comprehensive Assessment 2), dated 11/21/2024, Comprehensive Assessment 2 indicated the following: 1. There was no documented evidence of physician notification regarding the change in condition and the expected outcome/s. Patient 1 had a decline in vital signs with blood pressure of 83/56 and respirations of 10 breaths per minute and Patient 1s status changed to ";imminent (signs or symptoms are consistent with a prognosis of less than 5 days)" with decreased response to verbal and visual stimuli. 2. RN 1 documented, ";Family was upset with patient appearing sedated, asked nurses to hold Roxanol (liquid form of immediate-release Morphine)." There was no documented evidence that RP 1 was informed of the change in expected outcomes for Patient 1. 3. RN 1 documented to ";Continue Current Plan of Care." There was no documented evidence of any revisions to Patient 1s plan of care interventions for pain management and expected outcomes. During an interview on 12/5/2024 at 9:24 AM, RP 1 stated she was surprised to see a HA nurse when she got home from work. RP 1 stated LVN 4 stated she was there for pain management but ";did not give much information." RP 1 stated prior to CC initiation, Patient 1 was able to open eyes, nod, say ";Yes," ";No," ";Better" in Patients native language. RP 1 stated, ";They said they were there for pain management. We were hoping one day, pain would be managed, and we could take [Patient 1] to the beach again." RP 1 stated on 11/21/2024 at 6:30 AM, Patient 1 had bluish gray lips and looked like a ";corpse." RP 1 stated he was not responsive but was still breathing. RP 1 stated she was not notified immediately when Patient 1 was placed on oxygen therapy at 2 liters per minute via nasal cannula. RP 1 stated she believed Patient 1 was ";overdosed with Morphine," so she requested the staff to hold the Morphine doses. RP 1 stated on 11/22/2024, Patient 1 ";looked better" after Morphine doses were held but Patient 1 was ";still not responding." RP 1 stated she then administered to Patient 1 Glucose liquid (to treat low blood sugar) and 2 doses of Narcan (medicine that reverses an opioid overdose) she bought over the counter, then Patient 1 started to respond, woke up, and yelled, ";No, Mama! No!" RP 1 stated she called 911 and was admitted in the hospital for about 11 days, given antibiotics, and discharged to home with home health services. RP 1 stated Patient 1 gained back his appetite at the hospital and still had pain with movement. During an interview on 12/5/024 at 1:05 PM, Licensed Vocational Nurse 1 (LVN 1) stated when she started her shift, Patient 1 had respirations from 9-10 breaths per minute. LVN 1 stated at the end of her shift, respirations went down to 7 breaths per minute. LVN 1 stated she was not able to take the blood pressure during the shift due to Patient 1s grimacing, but LVN 1 was able to take radial pulse 90 at the start of shift to 120 at the end of shift. LVN 1 stated she was ";not able to measure" the amount of Morphine left in the bottle but notified the family how many Morphine doses were administered. LVN 1 stated at around 5:45 AM, she placed Patient 1 on Oxygen therapy at 2 liters per minute due to deep breaths with a rate of 8 per minute. LVN 1 stated she did not directly notify the physician or RN about the change in condition but gave the report to the incoming Home Health Aide. During an interview on 12/5/2024 at 1:52 PM, Registered Nurse 1 (RN 1) stated during a routine visit on 11/20/2024, Patient 1 presented with grimacing and moaning when touched. RN 1 stated caregivers and staff were not able to ";touch" him, ";barely able to change him (adult incontinence pad)." RN 1 stated she obtained an order from the physician (MD 3) to initiate the CC to ";get his pain under control." RN 1 stated she reached out to the CC team to start CC for Patient 1 because the CC team was in-charge of staffing and scheduling. RN 1 stated she discussed the CC plan of care with Caregiver 3, because the legal decisionmaker, RP 1, ";was not able to answer" her calls and was ";always at work." RN 1 did not recall if she documented her call attempts to RP 1. RN 1 stated during her follow-up visit on 11/21/2024, RN 1 stated Patient 1 declined, and she documented the vital signs obtained. RN 1 stated she was informed that the family requested to hold the Morphine order due to Patient 1 ";appearing sedated." RN 1 stated she did not notify the physician because the CC staff would notify the CC team regarding the changes in Patient 1s condition and refusal of Morphine. RN 1 stated she spoke with Caregiver 3, who was mostly present at the bedside with Patient 1. During an interview and a concurrent review of Patient 1s clinical records on 12/5/2024 at 2:41 PM, Director of Patient Care Services (DPCS) stated she was not aware RP 1 had POA to make healthcare decisions for Patient 1. DPCS stated RN 1 spoke to Caregiver 3 regarding the CC order but failed to document call attempts to RP 1. DPCS stated Patient 1s baseline documented vital signs prior to CC initiation were 118/90, 104/65, 114/71, and 118/60 with respirations ranging from 13-18 breaths per minute. DPCS stated if Patient 1s expected outcome was to have a decline, the physician did not need to be notified. In addition, DPCS stated CC team supervisors were not physicians or licensed nurses. During a review of the HAs policy and procedures (P&P 1), titled ";Continuous Care," dated 9/4/2024, P&P 1 indicated the following: 1. The RN must collaborate with IDG on Plan of Care (POC) changes and call the physician for changes in condition and new orders. 2. The RN must update the POC as the frequent changes in the POC, such as changes in medication, equipment, medical supplies, treatment, and patient/family education, support intensive symptom management and the need for continuous care. 3. The RN must review the POC, and the CC shift notes from the last 24 hours prior to beginning patient assessment and include report/input from patient, family/caregivers, CC shift notes and CC shift staff. The RN must document any analysis, clarification, or follow up from the RN assessment as well as report or input received.

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 clinical record review and interview. In 5 of 23 (22%) clinical records reviewed of patients receiving Hospice Aide (HA) services, the agency did not ensure that the HA received specific written patient care instructions from the Registered Nurse (RN). Clinical Record 1: The patient elected the hospice benefit on 02/05/2024 with a terminal diagnosis of Parkinson's disease. The HA care plan dated 02/08/2024 assigned the HA the relevant tasks of a sponge bath and shower with bath chair. The HA care plan did not specify the type of bath the patient was to receive. Clinical Record 3: The patient elected the hospice benefit on 02/08/2024 with a terminal diagnosis of malignant melanoma of the skin. The HA care plan dated 02/13/2024 assigned the HA the relevant tasks of sponge bath and shower with bath chair. The HA care plan did not specify the type of bath the patient was to receive. Clinical Record 12: The patient elected the hospice benefit on 02/03/2024 with a terminal diagnosis of cerebral infarction. The HA care plan dated 02/06/2024 assigned the HA the relevant tasks of sponge bath and shower with bath chair. The HA care plan did not specify the type of bath the patient was to receive. The HA care plan also assigned the HA the relevant tasks for transfers and ambulation, including Pivot 1 person and Pivot 2 person. The HA care plan allowed the HA to determine the type of transfer to provide and did not include specific instructions or parameters for the HA to follow when determining the kind of transfer to provide. Clinical Record 15: The patient elected the hospice benefit on 12/15/2021 with a terminal diagnosis of Alzheimer's disease. The HA care plan dated 08/15/2023 assigned the HA the relevant tasks of sponge bath and shower with bath chair. The HA care plan did not specify the type of bath the patient was to receive. Clinical Record 17: The patient elected the hospice benefit on 08/16/2023 with a terminal diagnosis of moderate protein-calorie malnutrition. The HA care plan dated 08/18/2023 assigned the HA the relevant tasks of sponge bath and shower with bath chair. The HA care plan did not specify the type of bath the patient was to receive. During interview and joint record reviews on 05/06/2024, 05/07/2024, and 05/09/2024, the Patient Care Administrator/RN confirmed the findings and stated they would re-educate the RNs to provide specific parameters for the HA to follow. In 5 of 23 (22%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse (RN) provided specific written patient care instructions for the hospice aide.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed of patients receiving Hospice Aide services, the agency did not ensure the Hospice Aide (HA) provided services included in the plan of care Clinical Record 12: The patient elected the hospice benefit on 02/03/2024 with a terminal diagnosis of cerebral infarction. On 04/11/2024, the Registered nurse (RN) documented "HA is performing ROM exercises per daughter's request." There was no evidence that ROM exercises were added as a task to the HA plan of care. During interview and joint record reviews on 05/06/2024, 05/07/2024, and 05/09/2024, the Patient Care Administrator/RN confirmed the findings and stated that the RN should have updated the HA plan of care. In 1 of 23 (4%) clinical records reviewed with aide services provided, the agency did not ensure the hospice aide (HA) provided services as ordered by the IDG and included in the plan of care

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed of patients receiving Hospice Aide services, the agency did not ensure that the Hospice Aide documented communication and coordination with the Registered Nurse (RN) when there were deviations from the written aide care plan. Clinical Record 20: The patient elected the hospice benefit on 12/25/2023 with a terminal diagnosis of esophageal cancer. The HA care plan dated 08/18/2023 assigned the HA the relevant tasks for transfers and ambulation. The tasks included the following: non-weight bearing, 2-person assist. On 12/26/2023, 12/27/2023, 12/28/2023, 01/02/2024, 01/03/2024, and 01/05/2024, the HA documented that the non-weight bearing, 2-person assist was "not performed/declined." There was no documented evidence that the HA notified the RN of the patient’s refusal of the non-weight bearing, 2-person assist. During interview and joint record reviews on 05/06/2024, 05/07/2024, and 05/09/2024, the Patient Care Administrator/RN confirmed the findings. In 1 of 23 (4%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide documented communication and coordination with the Registered Nurse (RN) when there were deviations from the written aide care plan

Based on interview and recod review, the hospice agency failed to ensure oxygen was administered in accordance with the plan of care (POC) for 1 of 16 sampled patients (Patient 14). This failure had the potential to affect the health and safety of the patient. Findings: A review of Patient 14's Patient's "Profile" indicated, a start of care (SOC) dated of 4/27/20 with a diagnosis of chronic obstructive pulmonary disease ( a group of lung diseases that block airfow and make it difficult to breathe). The physician's order dated 11/2/21 indicated to administer oxygen 2 liters per minute (LPM) continously with oxygen concentrator. The supplemental interdisciplinary note dated 5/2/20 indcated oxygen was increased to 4 LPM. During review of nurse visit notes, the oxygen was at 3 LPM. There was no new order from the physician to increase the oxygen admnistration. During an interview with the Director of Patient Care Services (DPCS) on 6/17/22 at 12 p, m., she stated the oxygen should be administered as ordered by the physician. The hospice agency's undated policy and procedure titled "Obtaining orders" indicated the POC should include patient/family safety education and other related safety measures when oxygen is ordered for the patient. The policy indicated to not turn up the oxygen higher than the prescribed amount.

Based on observation, interview and record review, the hospice agency (HA) failed to observe proper infection control measures while performing wound care on 1 of 16 sampled patients (Patient 10). This deficient practice had the potential in contamination and placed Patient 10 at risk for infection. Findings: A review of Patient 10's face sheet indicated an admission date of 6/27/2021 with the diagnosis of atherosclerotic heart disease (the build-up of fats, cholesterol, and other substances in and on the artery walls) and vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain such as stroke). A review of the HA's document titled "Physician face to face encounter" dated 4/11/2022 indicated Patient 10 was dependent on activities of daily living (ADLs) and very confused. The form indicated, Patient 10 has an unstageable, nonhealing right heel wound and a DTI (deep tissue injury) on the right 1st toe. A review of HA's document titled "Interdisciplinary Plan of Care Revision/Physicians Orders" dated 5/16/22 indicated nursing to educate wound care to facility staff , nursing to monitor signs and symptoms of infection and utilize positioning to facility staff. Clean with wound spray, pack tunneled area with Iodoform packing, cover with Medi honey. Exposed wound care with moisture dressing, wrap with soft cling gauze daily and prn when soiled. On 6/16/2022 at 1:00 p.m., during a home visit at Patient 10's assisted living facility, observed patient awake, sitting on her recliner. Registered Nurse (RN) was observed washed her hands in patients sink using her own soap and towels, and don (put on) gloves. RN removed her gloves and used her cellphone to call staff for assistance and don gloves again but did not wash her hands after using her cellphone. During wound care RN was observed to place a box of gloves on the carpeted floor while doing wound care. After doing wound care she placed the box of gloves inside the wound care supply box on top of Patient 10's cabinet. On 6/21/2022 during an interview with the Director of Patient care Services (DPCS ) stated that the box of the gloves was placed inside the bag with clean belongings was considered a break in infection control. A review of the HA's document titled "Hand Hygiene: Responsibility of VITAS patient care employees" indicated to wash hands: Before and after contact with each patient. After contact with environmental surfaces in immediate vicinity of patients. Before and after donning sterile gloves. Before and after use of non-sterile gloves. A review of the HA's document titled "Bag technique: Responsibility VITAS Patient Care Employees" indicated the purpose to establish a clean work area, prevent contamination of bag equipment and supplies and avoid cross infection. Utilize universal precautions at all times. Open bag, remove PPE and items necessary for visit. Items not in use should be returned to the bag or placed on a clean surface or barrier. Do not return potentially contaminated equipment to the bag.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the accurate labeling, disposal, and administering of all drugs and biologicals in accordance to professional standards and manufacturer's recommendations to meet the needs of 2 out of 16 sampled patients (Patients 9 and Patient 10). This deficient practice had the potential to result in inconsistent medication administration, risks of physical and chemical incompatibilities between the medications and patient altered drug responses. Findings: a. A review of Patient 9's face sheet indicated an admission date of 12/3/2018 with the medical diagnosis of Alzheimer's disease (A progressive disease that destroys memory and other important mental functions) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Patient 9's "Physician Face to Face Encounter" dated 5/15/2022 indicated that Patient 9 is dependent on her activities of daily living (ADLs) such as grooming, bathing and toileting). On 6/16/2022 at 2:42 p.m., a home visit was conducted at Patient 9's board and care. Patient 9's was observed to be in bed, nonverbal, with her upper extremities were severely contracted. A review of the patient medication profile, with Registered Nurse 1 (RN 1), Patient 9 had several missing medications and medications with incomplete labeling as follows. 1. An order for Bisacodyl 10 mg (milligram- a unit of measurement) suppository, insert 1 suppository as needed for constipation. During the inspection of the label dated 12/27/2021 expiration date cut off at 12/27/202. 2. Lactulose 10 gm (grams- a unit of measurement) per 15 ml (milliliter- unit of measuring liquids) give 15ml or 1 tablespoon by mouth twice a day for constipation dated 11/26/2021 and expiration date cut off at 11/26/202. 3. Levsin 0.125 mg 1 tablet under the tongue every four hours as needed for excess secretions dated 12/15/2021 with the expiry date cut off at 12/15/202. 4. Duoneb(Ipratropium/Albuterol Sulfate) 0.5-3 mg/3 ampul-neb inhale 1 vial via nebulizer every 4 hours as needed for shortness of breath /wheezing missing from patients medication box. 5. Roxanol(Morphine sulfate) 20mg/ml solution take 0.25 ml. orally every four hours for pain or shortness of breath as needed missing from medication box. On 6/16/2022 at 4:00 p.m., during an interview with patient 9's caregiver (CG) stated she threw out the roxanol and the duoneb because it was expired. Patient 9's caregiver also stated she forgot to notify the hospice that she threw out the medications. CG astated that she knows the medications will expire in a year. CG further stated that Patient 9 had not used Roxanol and duoneb ever since it was ordered. On 6/16/2022 at at 4:00 p.m., during an interview with the RN 1 stated based on their policy medications usually expires in a year after it was ordered. RN 1 stated, Roxanol and duoneb were not discontinued from the medication profile because Patient 9 may need it for pain or shortness of breath. b. A review of Patient 10's face sheet indicated an admission date of 6/27/2021 with the diagnosis of atherosclerotic heart disease (the build-up of fats, cholesterol, and other substances in and on the artery walls) and vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain such as stroke). A review of Patient 10's document titled "Physician face to face encounter" dated 4/11/2022 indicated Patient 10 is dependent on ADLs and very confused. PPS is 30 percent, getting weaker and is mostly in bed. On 6/16/2022 at 1:00 p.m., during a home visit conducted at Patient 10's assisted living facility during a medication review with the RN 2 (Registered Nurse 2) noted one medication Daily Vite 400 mg 1 tablet by mouth daily was not listed on Patient 10's medication profile with date ordered 5/23/2022 by hospice physician. On 6/16/2022 at 2:00 p.m., RN 2 stated to call the doctor if there are new orders or orders that need clarification at least every visit. On 6/21/2022 at 9:45 a.m., during an interview with the Director of Patient care services (DPCS) stated that per their policy medications if expired the RN should call the hospice physician and ask to discontinue medications and if not discontinued to reorder them from the pharmacy. A review of the undated HA's policy titled "VS Pharmacy process and Obtaining Orders" indicated to utilize the hospice medical director, the corporate medical director, respiratory therapist, pharmacist, or physician specialist as needed to review questionable orders for symptom management collaboration. Be aware of orders that require renewal. All visits begin with a review of the patient's plan of care which includes current medications. Ensure availability of medications. Monitor medication amounts every visit and order refills to ensure adequate supply in place until next visit. Care plan and provide patient/family/caregiver education regarding medication including Administration and return demonstration/verbalization of understanding. Patients/caregivers have access to current pharmacy orders via medication bottle labels, patient medication list. The nurse shall ensure that the above documents contain the most updated information each visit.