Hospice of Clay County

“Based on agency policy and procedure and medical record (MR) reviews, observation, and interviews, it was determined the agency failed to ensure a current, accurate medication profile was in the MR.This affected one of three home visits (HV), including HV # 2, and had the potential to negatively affect all patients served by the agency. Findings include:Policy: Medication ProfileDate reviewed: 3/25/24Policy: ...Hospice patients shall have a current, accurate medication profile in the medical record.Procedure:A. Upon admission to hospice, a medication profile shall be completed to document the current medication regime...B. During subsequent visits, the medication profile shall be used as a care planning and teaching guide to assure the patient, family, caregiver (CG), and hospice personnel understand the medication regimen... HV # 2 was admitted to the hospice agency on 6/30/25 and recertified for care from 9/28/25 to 12/26/25, with a terminal diagnosis of Alzheimer’s Disease. A HV was conducted on 10/21/25 at 1:30 PM to observe care provided by Employee Identifier (EI) # 2, Hospice Aide. After the observation was completed, the medication list was compared to the medications in the home. The following discrepancies were identified: 1. Ambien 10 milligrams (mg) daily at bedtime was available in the home and not on the agency medication list. The fill date on the bottle was 10/8/25. The CG stated HV # 2 had been taking the medication for “three to four months.”MR review revealed a physician’s order for Ambien 10 mg at bedtime dated 7/2/25. 2. Aricept 5 mg daily was on the agency medication list but was not available in the home. The CG stated HV # 2 stopped taking the medication “four or five months ago.”An interview was conducted on 10/22/25 at 10:45 AM with EI # 1, Hospice Director, who confirmed the staff failed to follow agency policy and ensure a current, accurate medication profile was in the MR.”

“Based on observations, agency policy and procedure, employee file review, and interview, it was determined the hospice agency failed to ensure the Registered Nurse (RN) followed standard precautions to prevent the transmission of infections.This deficient practice affected one of three Home Visits (HV), including HV # 3, and had the potential to negatively affect all patients served by this hospice.Findings include:Agency Policy: Hand HygienePolicy Number: NoneLast Reviewed Date: 03-25-24Policy: It is the policy of Hospice of Clay County to provide effective hand hygiene practices to reduce transmission of pathogenic microorganisms to patients and personnel..Procedures:...B. Hand Hygiene with Hand Sanitizer:1. Use an alcohol based hand sanitizer for routine decontamination of hands:...b. Before donning gloves, especially prior to insertion of invasive devices, before performing an aseptic task......e. Before and after removing gloves. 1. HV # 3 was admitted to hospice services on 10/8/25 with a terminal diagnosis of Amyotrophic Lateral Sclerosis.Review of the MR revealed a physician’s order dated 10/8/25 for the RN to change HV # 3’s suprapubic catheter every week.A HV was conducted on 10/22/25 at 9:09 AM to observe care provided by Employee Identifier (EI) # 4, RN. The following observations were made during the visit:a. EI # 4 removed his/her gloves twice and did not perform hand hygiene.b. Sterile gloves were donned without first performing hand hygiene.c. A sterile insertion tray for use during the changing out of the suprapubic catheter was opened, and contents dumped out onto a non-sterile paper barrier.EI # 4 failed to follow agency policy and standard precautions for infection prevention.A review of EI # 4’s employee file revealed no documentation of a competency evaluation for the insertion and removal of a suprapubic catheter.An interview was conducted on 10/23/25 at 12:01 PM with EI # 1, Hospice Director, who confirmed the staff failed to follow standard precautions for infection prevention and confirmed there was no documentation EI # 4 completed a competency evaluation for insertion and removal of a suprapubic catheter.”

“Based on policy and procedure, medical record (MR) reviews, and interviews, it was determined the agency failed to ensure the hospice aide provided services included in the plan of care (POC). This deficiency was identified on the prior recertification survey dated 4/13/23.This affected two of seven MRs, including MR # 9 and MR # 10, reviewed with aide services and had the potential to negatively affect all patients served by the agency. Findings include:Agency Policy: Home Care Aide ServicesLast Review date: 3/5/25Policy: It is the policy of Clay County Healthcare Authority to specify the role of hospice home care aide. Hospice home care aide services include personal care and non-skilled services provided by trained home care aides. Procedure: A. The interdisciplinary team identifies the need for home care aide service. C. The clinical record contains the home care aide’s assignment, plan of care, and interventions. …D. Routine care includes home care aide services for personal care as needed. Home care aides provide services such as giving a bath, shampooing hair, range of motion activities, helping the patient to the bathroom, helping with use of commode or bed pan, helping with meal preparation, light housekeeping, and/or linen changes as needed… 2. MR # 10 was admitted to hospice services on 6/23/25 with a terminal diagnosis of Coronary Artery Disease. Review of the Hospice IDG Review and Update to Plan of Care dated 6/23/25 revealed orders for the hospice aide to visit three times a week, beginning 6/23/25.Review of the Aide Assignment Sheet revealed the following tasks assigned to the aide each visit:Bed bath, perineal care, skin care, comb hair, assist with dressing, and record BM.Review of the aide visit note dated 9/26/25 revealed the aide did not perform all assigned tasks.An interview was conducted on 10/23/25 at 12:43 PM with EI # 1, who confirmed the aide did not perform all assigned tasks. 1. MR # 9 was admitted to hospice services on 9/12/25 with a terminal diagnosis of Parkinson’s with Dyskinesia.Review of the Hospice Interdisciplinary Group (IDG) Review and Update to Plan of Care dated 9/16/25 revealed orders for the hospice aide to visit two times a week, beginning 9/15/25.Review of the Aide Assignment Sheet revealed the following tasks assigned to the aide each visit:Shower, perineal care, skin care, shave, shampoo, comb hair, assist with dressing, assist with toileting, record bowel movement (BM), and assist with ambulation.Review of seven aide visit notes from 9/17/25 to 10/8/25 revealed the aide did not perform all the tasks as assigned.An interview was conducted on 10/23/25 at 11:52 AM with Employee Identifier (EI) # 1, Hospice Director, who confirmed the aide did not perform all assigned tasks.”

“Based on medical record (MR) review, agency policy and procedure, and interview, it was determined the hospice agency failed to ensure the Medical Director reviewed patient clinical information prior to the recertification for continued care per the agency policy.This deficient practice affected MR # 7, one of ten active records reviewed receiving hospice services, and had the potential to affect all patients receiving hospice services.Findings include:Agency Policy: Terminal Illness Re-CertificationPolicy Number: NoneLast Reviewed Date: 03-27-2024...Procedure:...B. After 180 days of hospice service (2-90 day certification periods) the patient shall need a face-to-face re-certification, to be repeated every 60 days either until the patient passes or no longer qualifies for hospice care.C. The face-to-face portion of the recertification can be completed by the hospice Medical Director, or a hospice contracted physician up to 30 days prior to, but no later than the first day of the new certification period. These findings shall be reported to the Medical Director who shall then review the documentation and, based on qualification, shall submit a narrative and complete the certification form no more than 2 days beyond the start of the new certification period. 1. MR # 7 was admitted for hospice services on 6/29/22 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease, then recertified for care 10/11/25 to 12/9/25.Review of the MR revealed a face-to-face visit was conducted by a physician on 10/11/25. Further review revealed the hospice Medical Director signed the Recertification of Terminal Illness form on 10/9/25, which was two days prior to the face-to-face encounter.The hospice Medical Director failed to review MR # 7’s face-to-face encounter prior to the recertification of terminal illness.An interview was conducted on 10/23/25 at 12:29 PM with Employee Identifier # 1, Hospice Director, who confirmed the Medical Director failed to review MR # 7’s face-to-face encounter prior to the recertification of terminal illness.”