Creek View Hospice LLC

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, interview, and observation. In 1 of 3 (33%) home visits performed revealed that the agency did not ensure the hospice staff followed accepted standards of practice to prevent the transmission of infections. AGENCY POLICY: Policy titled “Hand Hygiene Policy 7-009 November 2021” stated in relevant parts: “3. Hand decontamination using an alcohol based hand rub should be performed: E. When moving from a contaminated body site to a clean body site during patient care. F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. G. After removing gloves.” HOME VISIT 3/CLINICAL RECORD 3: During the home visit with hospice aide (Personnel Record 6) on 06/08/2026, the aide was observed to don a pair of gloves at the beginning of the visit, after washing his hands. He then began performing several patient tasks. He was observed to wash the patients’ arms and hands. He then walked over to the patient’s couch and began picking up linens that had been set up on the couch. He then walked back to his computer/tablet and began entering information. After entering the information on his computer, he returned to the patient, got the washcloth out of the basin, and began to clean her torso. Shortly after cleaning her torso, he again returned to the couch and obtained a brief. He then returned to the patient and completed more tasks. He was not observed to change gloves or sanitize his hands throughout these tasks. An interview and joint clinical record review were conducted with the Director of Nursing on 06/09/2026, during which time he confirmed the Hospice Aide should have changed gloves and sanitized his hands more frequently during the visit.”

“It is required that a hospice aide provide services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 13 (15%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide provided services included in the plan of care. CLINICAL RECORD 3/HOME VISIT 3: The patient elected the hospice benefit on 05/18/2026 with a diagnosis of cerebrovascular disease. The hospice aide care plan dated 05/18/2026 included the following relevant tasks: “Assist patient with dressing; bed bath; shampoo; blood pressure; change linens; clean work area; comb/brush hair; deodorant; document last bowel movement; inspect feet; inspect skin; lotion; make bed; nail care; oral care; oxygen saturation check; pericare; position/reposition in bed; pulse; report respiratory difficulty to nurse; respirations; take out trash; temperature; report of vitals not in normal range.” All tasks were to be completed every visit, with an aide visit frequency of twice weekly. During the home visit with the hospice aide (Personnel Record 6) on 06/08/2026, the aide was observed to apply eye drops in the patient’s eyes “to help clean because they were crusted.” The aide was also observed to remove the patient’s bilateral heel protectors. The aide care plan did not include orders for the eye drops or the heel protectors. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/29/2025 with a diagnosis of ACVSD. The hospice aide care plan updated 10/19/2025 included the following relevant tasks: “Shower on Sundays weekly to be completed every aide visit.” The hospice aide visit dated 10/19/2025 noted the following: “Shower-No; Shower chair-No. Bed bath given. RN notified.” The hospice aide visit dated 11/02/2025 noted the following: “Shower-No; Shower chair-No. Bed bath given. RN notified.” The hospice aide visit dated 11/09/2026 noted the following: “Shower-No; Shower chair-No. Bed bath given. RN notified.” An interview and joint clinical record review were conducted with the Director of Nursing on 06/09/2026, during which time he confirmed the aide during the Home Visit 3 should not have “used the eye drops without clear direction.” When reviewing Clinical Record 12, it was determined that the Hospice Aide care plan wasn’t “adjusted when the patient began transitioning.””

“It is required that a patient’s clinical record contain correct clinical information, including physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure written physician orders were obtained. Document 2: Agency Policy titled “Clinical Services Data Collection Policy 6-022 November 2021” stated in relevant part(s): “1. A clinical/service record will be initiated and maintained for each patient receiving care or services and will include, at a minimum: E. Physician orders. 6. Entries in the clinical/service record will be made within 48 hours from the day care/service is provided to the patient. All documentation will be turned in within such time.” CLINICAL RECORD 10: A review of the clinical record on 06/10/2026 documented a nursing visit dated 07/23/2025 with the following note: “PICC (peripheral inserted central catheter) line removed from right arm.” The clinical record did not contain documentation of the physician’s order for the PICC line removal. An interview and joint clinical record review were conducted with the Director of Nursing on 06/10/2026, in which he confirmed the documentation of the physician’s order for “was not able to be located in the clinical record; however, he remembers speaking about it at IDG (interdisciplinary group) meeting.””