Acacia Hospice Care, Inc.

“Based on interviews, record review, and agency policy review, the hospice agency failed to ensure that one out of 19 Patients (Patient (P) 1) had his/her medications reconciled from the Assisted Living Facility (ALF). This deficient practice had the potential to affect the accuracy of medications ordered for the patient.Findings include: Review of P1’s undated “Patient Profile” provided by the agency, revealed P1 was admitted to hospice on 04/30/25 with a diagnosis of Parkinson’s Disease.Review of P1’s undated “Patient Medication Report” provided by the agency revealed there were no orders for loratadine 10 milligrams (MG) tablet daily (QD) by mouth (PO).Review of P1’s undated “Medications/Treatments List” provided by the ALF, dated 01/07/26, revealed an order for loratadine 10 MG tablet QD PO for allergies.During an interview on 01/09/26 at 4:10 PM, the Director of Clinical Services (DCS) stated nurses were expected to perform a medication reconciliation during every visit. The DCS verified the agency’s orders were not compared to the ALF’s medication orders at the last visit and that the agency was not aware that P1 was ordered loratadine for allergies by the Family Nurse Practitioner (FNP).During an interview on 01/09/26 at 4:27 PM, the Administrator verified there was an order for loratadine on P1’s ALF medication list, and it was not listed on P1’s agency medication profile. The Administrator stated the DCS was supposed to visit P1 on 01/08/26, however, he/she did not make a home visit as scheduled so his/her medications were not reconciled. The Administrator also stated medications should be reconciled on each home visit or at least once a week.During an interview on 01/09/26 at 5:05 PM, Registered Nurse (RN) 1 stated no new orders were communicated to him/her from any ALF staff on his/her last home visit for P1 on 01/01/26.Review of the agency policy titled “Medication Reconciliation” revised June 2019 revealed “Policy Hospice will reconcile patient’s medications at time of admission and on an ongoing basis … Procedure … 2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication …””

“Based on observations, interviews, record review, and agency policy review, the hospice agency failed to provide patient care in a manner to prevent transfer of germs and infections for one of three patients (Patient (P) 3) observed during home visits out of a total sample of 14 patients. This had the potential to increase the risk of infection for the patient.Findings include:Review of P3’s “Patient Profile,” provided by the agency, revealed P3 was admitted to hospice on 04/11/25 with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.Observation on 01/07/26 at 2:07 PM during a home visit revealed Certified Nurse Aide (CNA) 1 completed a shower for P3. CNA1 donned his/her gloves, pulled the shower curtain around P3, removed the patient’s shirt, pulled the bath chair behind P3, and then removed P3’s pants and shoes. CNA1, wearing the same gloves, pushed P3 in the chair in the shower, turned on the water, rinsed P3’s body with the water, retrieved the shampoo bottle, poured shampoo in his/her gloved hand, and then washed P3’s hair. Next, wearing the same gloves, CNA1 picked up a clean washcloth from the counter and handed it to P3 to hold, rinsed his/her hair with water, picked up another clean washcloth, picked up the shower gel bottle, and then poured shower gel onto the washcloth. Again, wearing the same gloves, CNA1 washed P3’s back, abdomen, legs, feet, perineal area, and buttocks and then rinsed P3’s body with water. Lastly, CNA1 dried P3’s body with a clean towel, dressed him/her, and placed him/her in the wheelchair wearing the same gloves. Afterwards, CNA1 removed his/her gloves, discarded the gloves in the trash can, and then washed his/her hands.During an interview on 01/07/26 at 2:50 PM, CNA1 confirmed he/she did not change his/her gloves when he/she went from a dirty to clean area. CNA1 stated he/she should have changed the gloves prior to drying off the patient because he/she was clean at that time.During an interview on 01/09/26 at 3:00 PM, the Director of Clinical Services (DCS) confirmed that gloves should be changed, and hands washed after moving from a dirty to clean area such as washing the perineal area then washing the face. The DCS stated CNA1 was trained on infection control in April 2026 but not specifically on how to perform a shower.During an interview on 01/09/26 at 3:09 PM, the Administrator stated the DCS trained the aides on bath/shower technique which included changing gloves and washing hands afterwards when moving from dirty to clean areas.Review of agency policy titled “Hand Hygiene Policy and Compliance Program,” revised 2016 and provided by the agency, revealed “… Purpose: To prevent transfer of germs and transmission of infections to patients and caregivers and to implement a hand hygiene compliance program … 7. Hospice will follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene: … I. Indications for handwashing and hand antisepsis … after removing gloves … moving from contaminated patient body site to clean site during patient care … IV. Use of gloves … D. Change or remove gloves if moving from contaminated to clean patient site or the environment”