Every finding on record at Wiregrass Hospice, LLC

Upon patient record review 3 of 14 (Patient #2,7,14) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 2: No evidence that spiritual assessment was completed within 5 days after election. Assessment completed during survey. Patient 7: Admitted on 11/06/2023, no psychosocial or spiritual assessment completed within the first 5 days. Psychosocial assessment completed on 11/15/23. Spiritual assessment completed on 11/16/2023. Patient 14: No evidence that spiritual assessment was completed no later than 5 days after election. Assessment completed during survey.

Upon patient record review, 3 of 19 (Patient #1,4,13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: Duplicate drug therapy on medication profile: Vistaril 25mg 1 twice daily listed on the MAR twice. Patient 4: Duplicate drug therapy on medication profile. Hydrocodone 7.5mg-acetaminophen 1 tab 3x daily PRN for pain Instructions: take 1 tablet BID PRN for pain. Hydrocodone 7.5mg-acetaminophen 1 tablet 2x daily for pain. Instructions: take 1 tablet 3xdaily PRN for pain. Patient 13: Duplicate drug therapy: Bumetanide 2mg tablet daily PRN for edema. Furosemide 40mg tablet daily PRN for edema. No evidence that instructions were given on which medication should be given first for edema.

Upon patient record review, 4 of 19 (Patient #4,6,9,12) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 4: No evidence that initial bereavement risk assessment was completed within 5 days of admit. Admitted on 07/06/2023, assessment completed on 07/24/2023. Patient 6: No evidence that initial bereavement risk assessment was completed within 5 days of admit. Admitted on 08/07/2023, assessment completed on 08/14/2023. Patient 9: No evidence that initial bereavement risk assessment was completed within 5 days of admit. Admitted on 08/16/2023, assessment completed on 08/22/2023. Patient 12: No evidence that initial bereavement risk assessment was completed within 5 days of admit. Admitted on 08/16/2023, assessment completed on 08/22/2023.

Upon patient record review, 2 of 19 (Patient #3,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/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 the terminal illness and related conditions. Patient 3: Patient identified as a risk for falls upon admit and ongoing via RN assessments. No evidence that risk for falls was added active on current plan of care. Patient 10: Patient identified as a risk for falls upon admit and ongoing via RN assessments. No evidence that risk for falls was added active on current plan of care.

Upon patient record review, 1 of 19 (Patient #2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2: Wound care supplies on current plan of care. Wound care discontinued on 09/25/2023.

Upon patient record review, 1 of 19 (Patient #8) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 8: Patient developed a wound on her coccyx during a hospital stay for an unrelated diagnosis. Patient discharged home on 12/21. No evidence that altered skin integrity was added to the current plan of care. No evidence that wound documentation occurred at the time of survey, no descriptions or measurements noted. Wound care orders were entered on 01/02/2024.

Upon client record review, 7 of 19 (Patient #2,6,7,10,11,13,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: Original plan of care has one Chaplain visit for evaluation. No evidence that evaluation visit occurred. No evidence that a mini spiritual assessment occurred. Patient 6: Plan of care has MSW frequency as 3 times monthly. No evidence that 3 visits occurred for the month of October, November, nor December. Only one visit occurred for each month. No missed visit notes or physician order to decrease visits for those months. Plan of care has Chaplain frequency as 4 times a month for the month of October, 2 times for the month of November and December. No evidence that 4 visits occurred for the month of October. No evidence that 2 visits occurred for November or December. Chaplain performed one visit for each of those months. No missed visit notes or physician order to decrease visits for those months. Patient 7: Patient admitted with one wound to the left heel. No evidence that the hospice nurse measured the wound weekly between 11/10/2023 & 12/04/2023 and 12/08/2023 & the time of survey as ordered and per Gentiva policy. No evidence that patient refused measurements. Hospice nurse wrote in the comment section of the wound chapter during both visits that the wound Patient 10: Plan of care has SN frequency as 2 times a week. No evidence that 2 visits occurred for the week of 11/19/2023. No missed visit notes or physician order to decrease visits for that week. Patient 11: Plan of care has MSW frequency at 2 times monthly. No evidence that 2 visits occurred for the month of November and December. No missed visit notes or physician order to decrease visits for those months noted in the chart. Patient 13: Plan of care has SN frequency as 2 times a week. No evidence that 2 visits occurred for the weeks of 10/08/2023 and 10/29/2023. No missed visit notes or physician order to decrease visits for that week. Patient 14: Volunteer evaluation/referral note entered. No evidence of a follow up from Volunteer coordinator. Plan of care has SN frequency as 2 times a week. No evidence that 2 visits occurred for the weeks of 12/10/2023. Only one missed visit note entered for the visit occurring on 12/15/2023. No missed visit notes or physician order to decrease visits for that week. Corrected on site.

Upon patient record review, 1of 19 (Patient #8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient 8: Aide plan of care has oral care listed a task for the aide to complete. No evidence that a frequency was listed for that task.

Upon patient record review 2 of 19 (Patient #1,4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training. Patient 1: Missed visit for 11/24/2023, aide documented that she missed the visit a due to the holiday. No evidence that the visit was missed at the request of the patient/family or if they were offered to move the visit. Patient 4: Missed aide visit for 11/28/2023. No evidence that the visit was missed at the request of the patient/family or if an order was received to decrease visits for that week.

Upon patient record review, 1 of 19 (Patient #2) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 2: No evidence of a complete CTI for the 2nd benefit period. No evidence of a physician narrative on the recertification CTI. No evidence that the CTI was signed by the medical director at the time of survey. Agency has policy that all doctors orders are to be signed within 30 days.

Upon patient client record review, 1 of 10 (Patient #10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 10: Missed visit note dated for 11/16/2023 mostly blank. MD name and RN CM name listed on note. No evidence that any of the remaining questions were answered or documentation as to the reason for missing the visit, discipline scheduled to provide visit reason visit was not made, efforts made to avoid missed visits, nor was the visit date included.

Upon client record review, 1 of 19 (Patient #1) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 1: Plan of care has MSW frequency as 4 times monthly. No evidence that 4 visits occurred for the month of December. No missed visit note or other documentation present and No evidence of an order to change visits for that month or miss visit communications from the caregiver to refuse the visit. Plan of care has Chaplain frequency ordered at once every 2 months. Chaplain visited the patient 3 times during the month of December. No evidence of an order to increase visit frequency for that month.

Based on record reviews, family and staff interviews, and review of facility policy, it was determined the hospice failed to protect and promote patient rights by failing to respond to the patient representatives requests for treatment and pain management for one patient (P) (P#1) of six sampled patients. --- Findings include: On 12/18/2023 at 4:40 p.m., a telephone interview with family member of P#1 revealed that P#1 had a sudden decline the weekend of 9/30/2023. The patient stopped eating and became unable to swallow her pills. The family member of P#1 stated she asked RN BB about starting morphine (pain medication), discontinuing the pacemaker, and stopping some of the medications, but RN BB became argumentative, not seeming to believe what she was telling her. Additionally, family member of P#1 requested a transfer and went to the hospice agency as instructed to sign paperwork on 10/6/2023. Later that day, three Sherriffs officers came to her home to discuss the hospices report of safety concerns that was made. She reported showing the sheriffs the morphine administration log and bottle of morphine. She revealed the new hospice was very helpful, providing much education on disease progression and the dying process. (Refer to L0500)

Based on record reviews, family and staff interviews, and review of facility policy, it was determined the hospice failed to protect and promote patient rights by failing to respond to the patient representatives requests for treatment and pain management for one patient (P) (P#1) of six sampled patients. --- Findings include: On 12/18/2023 at 4:40 p.m., a telephone interview with family member of P#1 revealed Family member of P#1 had requested a nurse visit on 10/5/2023 when the prescribed dose of morphine was not keeping the patient comfortable with P#1 complaining of pain from her heart. She states she did not receive a return call and no visit was ever made. Family member reports RN BB stated, ";do you just want this over with?", to which the daughter replied, ";Yes". The family member clarified that she did not want her mother to suffer any more, not that she would do anything to harm her. The family member of P#1 reports prior experience with hospice for her father was a positive one. Family member of P#1 requested a different nurse for P#1 on 10/4/2023 due to RN BBs confrontational manner but never saw another nurse. (Refer to L0500)

Based on record reviews, staff and family member interviews, and review of facility policy, it was determined the hospice failed to provide care consistent with patient and family needs and failure to make on-call visits as when requested for two patients (P) (P#1, P#6) of six sampled patients --- Findings include: Review of a triage note documented by RN II dated 9/30/2023 reveals a call from the family member of P#1 at 11:19 a.m. stating the patient was up all night with leg pain. Tramadol (opioid analgesic) seemed to make it worse. Requesting morphine (pain medication) and a plan to discontinue most of her medications. After further record review, no new orders or interventions noted. Review of Coordination Note dated 10/2/2023 by Licensed Practical Nurse (LPN) CC revealed patient in bed, lethargic. Family member of P#1 requesting morphine but is ";aware she is not at that point". LPN CC discussed with RN BB and Executive Director (ED), who ";agreed with my decision to hold off on this for now. Patient is currently comfortable on Tramadol". After further record review, no documentation that the physician was contacted, or new orders were received. Review of Coordination Note dated documented by Chaplain JJ 10/3/2023 revealed patient appears very weak. The family of P#1 reported patient made a drastic decline over the weekend, being unresponsive at times, becoming aggressive with paid caregiver and sleeping at least 20 hours a day. Review of Coordination Note for visit by RN BB on 10/4/2023 revealed family member ";has indicated that patient has been restless and agitated" and again requested morphine, stating that ";during her bath time the patient just screamed in pain, and she was unable to give her anything since she is not swallowing properly and not taking in any food." Physician order received for morphine, 5 mg every three hours as needed. Further review of the clinical records failed to reveal any follow-up to the new morphine order. Review of note by Chaplain JJ for a visit dated 10/5/2023 revealed the patient appeared to be weak and in pain. Further additional review of records revealed no new interventions. Review of Coordination Note by RN BB dated 10/5/2023 revealed that the family of P#1 called reporting patient was in excruciating pain and that the morphine was not lasting the three hours as prescribed. Per family member, P#1 ";stated that it was in her heart." The family member ";also insisted that her pacemaker be discontinued as this was just prolonging her life." RN BB documented telling the family member that the patient was not in pain when she had visited the day before but advised that she would contact the physician. RN BB then contacted the Executive Director (ED) to report concerns that family member of P#1 ";does not have the best interest in the patient and fear that the patients daughter is trying to end her life too soon." After further additional record review revealed no visit, new interventions or physicians orders were available in the clinical record. Review of On Call Log dated 10/5/2023 signed by RN KK reveals a phone call from family member of P#1 at 5:57 p.m. requesting ";visit ETA". Notation made ";Ebony follow-up". After further additional record review revealed no other documentation noted regarding the visit. (Refer to L0648).

Based on record reviews, staff and family member interviews, and review of facility policy, it was determined the hospice failed to provide care consistent with patient and family needs and failure to make on-call visits as when requested for two patients (P) (P#1, P#6) of six sampled patients. --- Findings include: On 12/20/2023 at 10:55 a.m., an interview with the Executive Director (ED) confirmed no on-call visits were made to P#1 or P#6. She was unable to provide any reasons why no visits were made to either patient. (Refer to L0648).

Based on record reviews, staff and family member interviews, and review of facility policy, it was determined the hospice failed to provide care consistent with patient and family needs and failure to make on-call visits as when requested for two patients (P) (P#1, P#6) of six sampled patients. --- Findings include: Interview with P#1s family member further revealed that she had requested a nurse visit on 10/5/2023 when the prescribed dose of morphine was not keeping the patient comfortable, with P#1 complaining of pain from her heart. She states she did not receive a return call or a visit. No visit was ever made. The daughter states that RN BB was ";combative" and argumentative when discussing morphine and pacemaker. The daughter states that she requested a different nurse for her mother on 10/4/2023 due to RN BBs confrontational manner. No nurse came to see the patient after 10/4/2023. Review of the policy titled, ";On-Call/Weekend Services", Policy No. 4-036, revised 11.15.2023, reveals the following: b. Visit the patient, if necessary 7. If a visit is required, the on-call staff will attempt to arrive at the patient home/facility as quickly as possible, but no later than (1) hour. (Refer to L0648)