Wings of Hope Hospice and Palliative Care, Inc.

“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 2 of 3 (67%) clinical records revealed that the agency did not ensure the Hospice Aide (HA) received clear instructions for bathing in the HA plan of care. CLINICAL RECORD 1: The clinical record for a patient who elected the hospice benefit on 11/10/2025 with a terminal diagnosis of Alzheimer’s disease was reviewed. The physician’s certification of terminal illness for the benefit period 08/07/2026 through 10/05/2026 documented advanced cognitive impairment, orientation to self only, severe aphasia, and inability to meaningfully communicate needs. Review of the interdisciplinary plans of care for the benefit periods 06/08/2026 through 08/06/2026 and 08/07/2026 through 10/05/2026 confirmed orders for HA services two times per week. The active HA Plan of Care included two separate bathing interventions: a complete bed bath with instructions that the patient “may be transferred to her wheelchair or shower chair for bed bath to be completed,” and a separate shower chair bathing intervention. The HA Plan of Care did not include evidence of written instruction as to when to complete a bed bath or when to complete a shower. CLINICAL RECORD 2: The clinical record for a patient who elected the hospice benefit on 08/20/2025 with a terminal diagnosis of advanced Parkinson’s disease was reviewed. The physician’s certification of terminal illness for the benefit period 08/15/2026 through 10/13/2026 documented progressive neurological, functional, and cognitive decline, with the patient oriented to self only and demonstrating minimal verbal communication. Review of the interdisciplinary plans of care for the benefit periods 06/16/2026 through 08/14/2026 and 08/15/2026 through 10/13/2026 confirmed physician orders for HA services two times per week. The active HA Plan of Care included two separate bathing interventions, identifying both a shower chair and a shower as active bathing methods without clarification regarding the circumstances under which each intervention was to be performed. During an interview conducted on 09/01/2026 with the Chief Executive Officer, Medical Director, and Director of Clinical Services, the Medical Director acknowledged that the agency utilizes artificial intelligence (AI) in both clinical documentation and auditing processes. The Medical Director stated that the agency recently identified that Hospice Aide (HA) Plans of Care contained multiple bathing interventions. He further stated that the agency would be revising its clinical documentation practices to ensure HA Plans of Care are individualized and direct a single bathing intervention for each patient unless a clinical justification for multiple interventions is documented.”

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, and document review which revealed the hospice: Failed to ensure that the interdisciplinary team (IDT) accurately assessed, updated, and coordinated the patient’s plan of care to reflect the patient’s current needs {HCPC.21.I/L545/418.56(c)}; and Failed to ensure that the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care {HCPC.21. I/L548/ 418.56(c)(3)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: Interdisciplinary group, care planning, and coordination of services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes: Identifying risk for acquiring and transmitting infectious agents where the patient resides; Guidelines for addressing and preventing infection related to infusion therapy, urinary tract care, respiratory tract care, and wound care; Guidelines for caring for patients with a multi-drug resistant organism; Policies on protecting patients, staff, and families from bloodborne or airborne pathogens; Education of employees, contracted providers, patients, families, and other caregivers in infection control; How timely communication occurs with hospice staff, patients, families, and visitors about infection prevention and control issues, including their role in preventing the spread of infections and communicable diseases through daily activities. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by document review, observation, and interview which identified issues with infection control practices in the following areas: Failed to ensure that accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, were followed {HIPC.2. 1/L579/418.60 (a)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of an effective infection control program for the Condition of Participation CFR 418.70: Infection control. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency”

“It is required that the written Patient Bill of Rights includes the right to have person and property treated with respect by anyone providing services on behalf of the hospice. This standard was not met as evidenced by clinical record review, document review, observation and personnel record review. In 1 of 4 (25%) home observations, the agency did not ensure that the person was treated with respect and dignity. DOCUMENT 1: The Agency List of Patient’s Rights and Responsibilities included, in part; “The patient has the right to have his or her property and person treated with respect...” HOME VISIT 3/CLINICAL RECORD 3: This patient elected the hospice benefit on 11/11/2025 with a terminal diagnosis of Parkinsonism with progressive supranuclear ophthalmoplegia. A home visit was conducted on 07/21/2026 in a private home to observe the Hospice Aide (HA) [Personnel Record 3]. During the delivery of personal care, the HA removed the patient’s clothing and all bed coverings, leaving the patient fully exposed for several minutes of the care. The HA did not take measures to maintain the patient’s privacy and dignity, such as covering the area of the body not being actively cleansed. During an interview with the Administrator on 07/22/2026, it was stated that the Hospice Aides are instructed to provide privacy and dignity by keeping the patient covered during personal care.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 4 (50%) home visit observations conducted, the agency did not ensure that the drug profile was updated, which resulted in the medication reconciliation being incomplete. HOME VISIT 1: This patient elected the hospice benefit on 11/10/2025 with a diagnosis of Alzheimer’s Disease with late onset. During a home visit with the Chaplain (Personnel Record 1), the hospice drug profile review included the following medications: ondansetron 4 mg oral tablet, disintegrating 4 mg tablet; administer 4 milligrams SL every 6 hours PRN as needed for nausea/vomiting; administer 1 tablet PO//SL and allow to dissolve q6 hours PRN for nausea/vomiting [comments: administer 1 tablet PO/SL and allow to dissolve q4 hours PRN for nausea/vomiting, Guaiasorb DM 20mg-200mg/10ml oral liquid; (ordered on 05/17/2026), Take 20 milliliters orally 3 times a day (ordered on 06/05/2026), Loperamide 2 mg oral capsule; Take 1 cap(s) orally every 6 hours as needed for diarrhea (ordered on 07/17/2026) and Calmoseptine 0.44%-20.6% topical ointment; apply 1 application topical 2 times a day for skin protection [comments: And apply topical PRN with incontinence care.) A review of the facility medication administration record (MAR) for the date of 07/21/2026 revealed these medications were not included on the facility MAR. HOME VISIT 2: This patient elected the hospice benefit on 11/11/2025 with a terminal diagnosis of Secondary Parkinsonism. A home visit was conducted on 07/21/2026 in a group home to observe the LMSW (Personnel Record 2). The hospice drug profile included albuterol-ipratropium 2.5 mg-0.5 /3 ml inhalation solution; inhaler 3 milliliter(s) by nebulizer 4 times a day as needed for sob, cough; the group home staff member stated that the patient had never received this medication and had never used it, Lorazepam 2mg/ml concentrate; administer 0.25 milliliter(s) oral or sublingually every 2 hours as needed for anxiety or shortness of breath. (dispensed 04/17/2025-expired 10/1/2025), bisacodyl 10 mg rectal suppository; administer 1 suppository rectally once a day as needed for constipation [Comments: administer rectally if no BM X3 days] (dispensed 03/04/2025-expired 09/04/2025), Fungi-Nail 25% topical solution; apply 1 application applied topically 2 times a day as needed for nail fungus (expired 06/26), loperamide 2 mg capsule; take 1-2 cap(s) oral Special instruction as needed for diarrhea [Comments: Take 2 tablets after first episode of diarrhea and 1 tablet after subsequent episodes, not to exceed 8 pills in 24 hours] (expired 07/17/2025), morphine 20 mg/ml oral concentrate; Administer 0.25 milliliter(s) orally or sublingually every 2 hours as needed for shortness of breath/pain (expired 04/30/2026) polyethylene glycol 3350 oral powder for reconstitution; administer 17 gm(s) orally once a day as needed for constipation [Comments: administer by mouth 1 scoop mixed in 4-6 oz of any liquid as needed for constipation] This medication was not labeled for the patient and it expired on 04/2026, Preparation H Hydrocortisone 1% topical cream; Apply topically 3 times a day as needed for hemorrhoids (expired 04/2026 and was not labeled for the patient), simethicone 125 mg oral capsule; Take 1 cap(s) orally 4 times a day (after meals and at bedtime) as needed for gas/bloating (dispensed 06/30/2025-expired 12/29/2025), The Administrator was interviewed on 07/22/2026 and stated that the agency included the medication review in the patient plan of care and the expectation is that the RN’s are to review all medications at least weekly and when changes were made.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the interdisciplinary team (IDT) accurately assessed, updated, and coordinated the patient’s plan of care to reflect the patient’s current needs. CLINICAL RECORD 4/HOME VISIT 4: This patient elected the hospice benefit on 06/08/2026 with a terminal diagnosis of cerebral palsy. A home visit was conducted on 07/21/2026 in a private home to observe the RN (Personnel Record 4) with the Director of Nursing in attendance. Observation of the wound care revealed the RN cleansed the wound with wound cleanser rather than the soap and water as ordered in the POC for the dates of 06/08/2026-07/21/2026. In addition, the RN did not have ace bandages available which were ordered in the POC, and instead applied Kerlix for compression therapy, which was not ordered in the POC. Further observation revealed an additional open area on the right heel. The RN cleansed this wound and applied barrier cream. Review of the clinical record revealed no current care plan or associated physician orders for the right heel. CLINICAL RECORD 8: This patient elected the hospice benefit on 12/23/2024 with a terminal diagnosis of severe protein malnutrition. The hospice plan of care for the dates of 06/16/2026-08/14/2026 included hospice aide visits 1XW. A review of the RN visit note dated 07/13/2026, revealed documentation that the patient was totally dependent for all activities of daily living, including bathing, dressing, and toileting, and required a Hoyer lift with two-person assists with all transfers. Review of the HA care plan for 02/16/2026-04/16/2026 revealed that the Hoyer lift intervention had been removed and replaced with instructions for 2-person assists for transfers. During an interview conducted on 07/22/2026, the Administrator stated that the patient resided in two different homes and that the Hoyer lift remained in the patient’s home at the family’s request. The Director of Nursing stated that the patient was totally bedbound and that the HA’s were instructed not to use the Hoyer lift under any circumstance. This care plan did not consistently reflect the patient’s assessed transfer needs and functional status as documented by the RN. CLINICAL RECORD 11: This patient elected the hospice benefit on 10/07/2025 with a terminal diagnosis of Alzheimer’s Disease. The RN visit note dated 10/07/2025 stated the patient required a Hoyer lift for all transfers. The hospice aide care plan dated 10/7/2025-01/04/2026 directed the Hospice Aide (HA) to have patient up in the chair, wheelchair, and bath/shower chair and directed that the patient/caregiver would demonstrate necessary behaviors to maintain safety awareness and minimize falls and/or injury. It did not include instructions for the HA to use a Hoyer lift for all transfers. During an interview conducted with the Director of Nursing, it was stated that the hospice plans of care were not being followed.”

“It is required that each patient’s individualized written plan of care Includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 3: this patient elected the hospice benefit on 11/11/2025 with a diagnosis of parkinsonism/progressive supranuclear ophthalmoplegia. The hospice plan of care was reviewed for the dates of 03/06/2026-07/22/2026 and included a problem related to pain management due to the patient experiencing right wrist pain. The POC identified the presence of pain and included interventions to assess the pain and provide medications as needed, however, it did not include a measurable timeframe for expected improvement or resolution of the patient’s pain. CLINICAL RECORD 18: This patient elected the hospice benefit on 12/05/2024 with a terminal diagnosis of Parkinson’s Disease. The hospice plan of care (POC) was reviewed for the dates of 06/03/2025-08/01/2025 and included problems for medication management to promote sleep and when to notify hospice The POC identified the problem of sleep management and when to notify hospice, however, it did not include a measurable timeframe for expected improvement or resolution of sleep issues. During an interview with the QAPI RN on 07/20/2026, it was stated that the agency included a performance improvement plan to ensure that the hospice plans of care included measurable outcomes.”

“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 and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 3 of 4 (75%) home visits observed, the agency did not ensure that accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, were followed. DOCUMENT 2: Agency Policy #608 Contaminated Materials stated, in part: Materials that have been exposed to or contaminated by blood or body fluids. 2. Contaminated paper wastes (disposable gloves, gowns, dressings, etc.) are placed in clearly labeled red biohazard bags. Bags are securely closed, double bagged if necessary, and placed in a designated plastic trach container with a secure lid). HOME VISIT 1: This patient elected the hospice benefit on 11/10/2025 with a terminal diagnosis of Alzheimer’s Disease. During the home visit conducted on 07/21/2026 in an assisted living facility with the Chaplain (Personnel Record 1), the Chaplain was observed to touch the patient without performing hand hygiene. The patient was leaning with her head on the table and the Chaplain leaned over to talk with the patient and the Chaplain’s long hair touched the dining table. HOME VISIT 3: This patient elected the hospice benefit on 11/11/2025 with a terminal diagnosis of parkinsonism/progressive supranuclear ophthalmoplegia. A home visit was conducted on 07/21/2026 in a private home to observe the Hospice Aide (HA) [Personnel Record 3] provide personal care. A paid caregiver was present in the patient’s room during the bed bath. The HA performed a bed bath. The HA washed her hands at the sink, turned off the faucet using her bare hands, and dried her hands using the patient’s towel hanging on the towel rack. The HA donned two pairs of gloves and retrieved supplies from the patient’s closet. The HA removed the bed covers and handed them to the caregiver. Using disposable washcloths, the HA cleansed the patient’s perineal area. The HA removed the first pair of gloves but did not perform hand hygiene before donning a new pair of gloves. The HA used one basin of water and two washcloths to cleanse the patient’s upper front body, legs, and feet. The HA then removed gloves and transported the basin to the sink to obtain warmer water. While waiting for the water to warm up, the HA performed hand hygiene. The HA returned to the patient and cleansed the left side of the patient’s back. The HA then reached into her bag to obtain gloves without performing hand hygiene. The HA continued care by cleansing the perineal and rectal areas, changing gloves between areas without performing hand hygiene. The HA retrieved pull-ups from the closet and assisted the patient into a wheelchair with stand-by assist of the caregiver. The HA then dressed the patient and washed the patient’s face with a clean washcloth and shampooed the patient’s hair. The HA used her fingernails to clean the patient’s nails because there were no orange sticks available. HOME VISIT 4: This patient elected the hospice benefit on 05/05/2026 with a terminal diagnosis of cerebral palsy. A home visit was conducted on 07/21/2026 in a private home to observe the RN (Personnel Record 4) provide wound care. The Director of Nursing was in attendance for this visit and brought wound supplies which she gave to the RN. The RN did not perform hand hygiene prior to donning gloves and retrieved gloves from his uniform pocket before patient contact. Clean wound supplies were placed on the patient’s furniture without a protective barrier, and additional supplies were placed on the floor of the patient home. The RN removed soiled dressings from three wounds and placed them in a basin at the bedside. The RN then used wound cleanser and applied it to all three wounds, wiping with several 4X4 gauzes obtained from a Ziploc bag without performing hand hygiene or changing gloves between wound sites. Clean supplies were observed to be placed on the patient’s bed during the procedure. Following completion of wound care, the RN handled contaminated materials and transported a basin containing soiled dressings to the bathroom sink, where it was rinsed with water and then placed in the patient’s shower. The RN removed gloves and disposed of them in a trash bag, then performed hand hygiene at the patient’s sink, turning off the faucet with bare hands and drying hands with paper towels. Upon completion of the visit, the RN placed the tied-up bag of contaminated dressings in an outside trash receptacle on the apartment building property. The hand hygiene policy was reviewed with the Administrator. In an interview conducted with the Director of Hospice on 07/22/2026, it was stated that the staff members did not follow the infection control guidelines and there would be re-education provided to all staff members.”

“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, interview and observation. In 3 of 17 (18%) clinical records reviewed of patients who received hospice aide services (HA), the agency did not ensure that all written patient care instructions for the hospice aide were clear and consistent with the patient’s current needs. CLINICAL RECORD 2: This patient elected the hospice benefit on 11/11/2025 with a terminal diagnosis of Parkinson’s Disease. The hospice plan of care for the dates of 07/09/2026-07/21/2026 included orders for hospice aide visits three times a week. The RN visit note dated 07/17/2026 documented that the patient was on aspiration precautions and that caregiver education regarding aspiration precautions was provided. A review of the hospice aide care plan for the period of 11/11/2025-07/21/2026 revealed no aspiration precautions or related instructions for the hospice aide. CLINICAL RECORD 3: This patient elected the hospice benefit on 11/11/2025 with the terminal diagnosis of Parkinsonism/progressive supranuclear ophthalmoplegia. The hospice plan of care for the dates of 07/09/2026-07/21/2026 included orders for hospice aide (HA) visits three times a week and safety measures directing staff to keep the patient’s head of the bed elevated, utilize a wheelchair during transfers, and to follow aspiration precautions. Review of the hospice aide care plan for the dates of 07/09/2026-09/06/2026 revealed no instructions for the HA regarding maintaining the head of the bed in an elevated position, using a wheelchair during transfers, or implementing aspiration precautions. CLINICAL RECORD 8: This patient elected the hospice benefit on 12/23/2024 with a terminal diagnosis of severe protein malnutrition. The hospice plan of care for the dates of 06/16/2026-08/14/2026 included orders for hospice aide (HA) visits one time a week. A review of the RN visit note dated 07/13/2026, revealed the nurse documented that the patient required total assistance with bathing, dressing, and toileting and that all transfers required a Hoyer lift with 2-person assist. Review of the HA care plan for the dates of 02/16/2026-04/16/2026 revealed the Hoyer lift intervention had been removed, and the HA was instructed to use a 2-person transfer technique for all transfers. During interviews conducted on 07/21/2026, the Administrator stated that the patient was receiving care in two different family homes and that the Hoyer lift remained in the patient’s home at the family’s request. The DON stated that the patient was totally bedbound and agency Hospice Aides were instructed not to use the Hoyer lift under any circumstances. During an interview with the Administrator and the Hospice Medical Director on 07/22/2026, it was stated that the staff would be educated to improve the development of the hospice aide care plans.”

“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. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 1 (100%) home visits conducted to observe the Hospice Aide, the agency did not ensure that the Hospice Aide reported changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes related to the plan of care and any quality assessment and improvement activities. CLINICAL RECORD 3: This patient elected the hospice benefit on 11/11/2025 with a terminal diagnosis of Parkinsonism with progressive supranuclear ophthalmoplegia. A home visit was conducted on 07/21/2026 in a private home to observe the Hospice Aide (HA) [Personnel Record 3]. The patient was observed to groan as the HA provided personal care. The HA stated to the patient, “I know your arm hurts”, and stated that the patient’s arm often hurts. The HA completed the bed bath and asked the private caregiver to ask the patient’s husband if he would like for the patient to be placed in the wheelchair. The paid caregiver went to the living room and came back and stated that the husband would like for the patient to come out into the living room in her chair. The HA stated that the patient was more “mellow than normal” and was surprised that the patient was going to get up today. The HA was observed to lift the patient from the bed to the wheelchair placed next to the bed with the paid caregiver standing by the wheelchair. The patient was not able to place weight on her legs. The HA did not contact the RN during the visit. The HA visit note for 07/21/2026 was reviewed and did not include documentation that the RN was notified. The communication section of the clinical record was reviewed and did not include documentation that the RN was notified of the patient’s pain and weakness. During a joint review of the clinical record and interview conducted with the Clinical Manager on 07/22/2026, it was stated that the documentation was not present in the clinical record that the nurse was notified of the patient’s pain or weakness during the Hospice Aide visit.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. During an interview with the Volunteer Coordinator on 07/23/2026, and review of the Volunteer Services Annual reports for calendar years 2024 and 2025, it was revealed that the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Volunteer Services Annual Reports documented volunteer hours of 0.8% for 2024 and 0.9% for 2025. During an interview, The Volunteer Coordinator stated that there had been changes in leadership responsible for the Volunteer Program following the COVID-19 pandemic and that the hospice was in the process of rebuilding and restructuring the program. There was evidence of recruitment and retention for both 2024 and 2025, and the agency had implemented a performance improvement plan to increase volunteer involvement. During an interview with the Volunteer Coordinator on 07/23/2026, and review of the Volunteer Services Annual reports for calendar years 2024 and 2025, it was revealed that the agency did not ensure hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Volunteer Services Annual Reports documented volunteer hours of 0.8% for 2024 and 0.9% for 2025. During an interview, The Volunteer Coordinator stated that there had been changes in leadership responsible for the Volunteer Program following the COVID-19 pandemic and that the hospice was in the process of rebuilding and restructuring the program. There was evidence of recruitment and retention for both 2024 and 2025, and the agency had implemented a performance improvement plan to increase volunteer involvement.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 10 (10%) personnel records reviewed, the agency did not ensure that personnel were qualified and competent to perform their assigned duties, and competencies were assessed and maintained. PERSONNEL RECORD 4: This Registered Nurse (RN) was hired on 11/16/2015. A home visit was conducted on 07/22/2026 for Clinical Record 4 in a private home. The RN was observed to place clean wound supplies on the patient’s furniture without a protective barrier, and additional supplies on the floor of the patient home. The RN removed soiled dressings from three wounds and placed them in a basin at the bedside. The RN then used wound cleanser and applied it to all three wounds, wiping with several 4X4 gauzes obtained from a Ziploc bag without performing hand hygiene or changing gloves between wound sites. The review of the Competency and Skills Checklist for the RN documented on 11/17/2025 was reviewed and revealed the Skills Checklist did not include wound care education or observation. During joint review of personnel records and interview with the Administrator on 07/23/2026, The Competency and Skills Checklist for the RN were reviewed with the Administrator, and it was stated that wound care was not assessed during the Competency and Skills Checklist review for the RN.”

“It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include the patient’s full name, generic, trade, or brand name of the medication, as well as amount dispensed, directions for use, including route, rate, frequency, and method of administration prescriber’s name, expiration date, and cautionary instructions. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 4 (25%) home visits conducted, the agency did not ensure that drugs and biologicals listed on the hospice drug profile included proper labeling of drugs and biologicals which at a minimum, included the patient’s full name and administration prescriber’s name. CLINICAL RECORD 2: This patient elected the hospice benefit on 11/11/2025 with a terminal diagnosis of Parkinson’s Disease. During a home visit conducted in a group home on 07/22/2026 to observe the MSW (Personnel Record 2), the hospice drug profile dated 07/22/2026 was reconciled with the group home patient medication administration record. The group home staff member was asked to provide the medications being administered to the patient. The group staff member presented polyethylene glycol 3350 oral powder for reconstitution; administer 17 gm(s) orally once a day as needed for constipation [Comments: administer by mouth 1 scoop mixed in 4-6 oz of any liquid as needed for constipation] This medication was not labeled specific for the patient and was expired on 04/2026, and Preparation H Hydrocortisone 1% topical cream; Apply topically 3 times a day as needed for hemorrhoids (expired 04/2026) and was not labeled for the patient, The polyethylene glycol 3350 oral powder and Preparation H Hydrocortisone were listed on the hospice agency drug profile. The group home staff member stated that the hospice pharmacy had delivered this medication for this patient. The Administrator and Hospice Medical Director were interviewed on 07/22/2026 and stated that it was possible that the unmarked medications may have been delivered to the group home by an entity other than the hospice agency pharmacy which the Hospice Medical Director stated consistently ensured medications were properly labeled. The Hospice Medical Director also stated that he had spoken to the pharmacist who stated he had not sent the medication to the group home. The Administrator stated that the RN would be educated to conduct routine medication reconciliations to ensure all patients medications were properly labeled.”