Assisted Home Hospice

“Based on interview and record review, the hospice agency failed to ensure a home medication list, and instructions were provided for two of 19 sampled patients (Patients 14 and 13).This failure had the potential to result in the patients not receiving the correct medication, dose or frequency affecting quality of life. During a home visit for Patient 14 with a licensed nurse on 4/2/25 at 11:49 am, Patient 14’s home hospice binder was reviewed. The home medication list or medication instructions was not in the home binder. The patient’s caregiver with the power of attorney (POA) stated they don’t have a copy of Patient 14’s medication list.During an interview with the licensed nurse (LN2) on 4/2/25 at 12:19, LN2 stated she was not aware the POA did not have the home medication list.During a home visit for Patient 13 with the licensed nurse (LN1) on 4/2/25 at 3:15 pm, the home hospice binder was reviewed. The home medication list/instruction was not in the home hospice binder. The daughter of Patient 13 stated she does not have the home medication list/instructions.During an interview with the LN1 on 4/2/25 at 3:47, LN1 acknowledged home medication list/instruction was unavailable at the patient’s home.During an interview with the executive director (ED) on 4/3/25 at 11:47 am, the ED acknowledged the caregiver/POA should have a copy of the home medication list or instruction.The facility policy and procedure titled “Medication Management” dated 3/2019 indicated “ The patient or family shall be provided instructions regarding specific medication knowledge and skills as part of the patient’s plan of care and skilled nursing visit and described in Medication Education policy.””

“Based on interview and record review, the hospice agency failed to ensure social work home visits were followed as written in the plan of care for two of 19 sampled patients (Patients 6 and 11)This failure had the potential to result in the patient and family’s social and emotional needs not being met. During a review of Patient 6’s health record on 4/3/25 at 11:02 am, plan of care (POC) indicated social work visit order of 1 visit weekly and 1 as needed every 7 days for the certification period 1/8/25 to 3/8/25. Review of the visit calendar indicated on week of 1/19/25to 1/25/25, 2/2/25 to 2/8/25, and 3/2/25 to 3/8/25 the social worker did not visit the patient. No missed visit documentation in the health record were located.During a review of Patient 11’s health record on 4/3/25 at 4:05 pm, plan of care (POC) indicated social work visit order of 2 visits monthly with 1 as need for every 30 days for the certification period of 2/6/25 to 4/6/25. Review of the visit calendar indicated the social worker had only visited the patient once a month instead of 2. No documentations of the missed visits were in the health record.During an interview with the director of patient care services (DPCS) on 4/4/25 at 11:21 am, the DPCS acknowledged the social work missed home visits for Patient 6 and 11.The facility policy and procedure titled “Hospice Interdisciplinary POC” dated 4/2022 indicates “A written plan of care must be established and maintained for each individual admitted to the Hospice, and the care provided to the individual must be in accordance with the plan”.”

“Based on interview and record review, the hospice agency failed to complete registered nurse (RN) supervisory visits every 14 days for five of 15 sampled patients (Patients 1, 2, 8, 10, 15) receiving hospice aide (HA) services.This failure had the potential to result in inadequate or inappropriate healthcare practices by hospice aides due to lack of supervision resulting in less than desirable care delivery. During a review of Patient 15’s “Face Sheet (FS),” dated 1/12/25, the FS indicated in part, Patient 15 is a 100-year-old female admitted for routine hospice care on 1/12/25 with a primary admitting diagnosis of Alzheimer’s Disease, unspecified (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks).During a review of Patient 15’s “Plan of Care (POC),” for recertification period 1/12/25 – 4/11/25, the POC indicated the order, “Hospice Aide (HA) two (2) visit(s) weekly.”During a concurrent interview and record review on 4/4/25 at 11:43 a.m., with DPCS, Patient 15’s “Electronic Medical Record (EMR)” was reviewed. The “Clinical Chart Search (CCS – a file-searching tool to find provider-specific charting and/or visit documentation)” section of the EMR for “HA Visit,” dated 8/1/24 – 4/3/25, indicated HA visits for Patient 15 started on 1/4/25. When reviewing Patient 15’s “CCS for Supervisory Visit (SV),” dated 8/1/24 – 4/3/25, the record failed to indicate SVs were done in January 2025. DPCS verbalized that SVs will be conducted by an RN at least 14 days after the start of HA services and every 14 days thereafter until HA visits are discontinued. DCPS verbalized further and acknowledged that SVs should have been done for Patient 15 in January 2025.During review of the facility’s policy and procedures (P&P) titled, “Hospice Aide Supervision,” dated 3/24, the P&P indicated, “When Hospice Aide services are being provided, The RN (Registered Nurse) Case Manager or designated RN shall make an on-site visit to the patient at least every 14 days to assess whether the aide is following the patient’s plan of care and is competently completing tasks assigned by the RN…” During a review of Patient 1’s “Face Sheet (FS),” dated 10/09/24, the “FS” indicated, “Patient 1 is a 75-year-old female admitted to hospice on 10/09/24 for breast cancer.”During a review of Patient 1’s “IDG assignments (IDG),” dated 02/07/25, the “IDG” indicated, “Hospice Aide: 1 visit weeklyDuring a concurrent interview and record review on 4/4/25 at 10:00 a.m. with the Director of Patient Care Services (DPCS), “The Wellsky Hospice Electronic Clinical Charts Review (ECC),” dated 01/01/25 to 04/03/25 was reviewed for Patient 1. The “ECC” indicated, only one visit done in January on 01/27/25. The DPCS agreed, there were missing supervisory visits for January for Patient 1. During a review of Patient 2’s “FS,” dated 12/26/2024, the “FS” indicated, “Patient 2 is a 68-year-old female admitted to hospice on 12/26/24 for Parkinson’s disease (disorder of the central nervous system that affects movement).”During a review of Patient 2’s “Plan of Care (POC),” dated 2/18/25, the “POC” indicated, “Hospice Aide: 3 visits weekly.”During a concurrent interview and record review on 4/4/25 at 10:00 a.m. with the DPCS, “ECC,” dated 02/01/25 to 04/03/25 was reviewed for Patient 2. The “ECC” indicated, only one visit done March on 03/11/25. The DPCS agreed, there were missing supervisory visits for March for Patient 2. During a review of Patient 8’s “FS,” dated 08/09/24, the “FS” indicated, “Patient 8 is an 80-year-old male admitted to hospice on 08/09/24 for Parkinson’s disease.”During a review of Patient 8’s “POC,” dated 3/21/25, the “POC” indicated, “Hospice Aide: 2 visits weekly.”During a concurrent interview and record review on 4/4/25 at 10:00 a.m. with the DPCS, “ECC,” dated 02/01/25 to 04/03/25 was reviewed for Patient 8. The “ECC” indicated, only one visit done March on 03/14/25. The DPCS agreed, there were missing supervisory visits for March for Patient 8. During a review of Patient 10’s “FS,” dated 06/21/2024, the “FS” indicated, “Patient 10 is a 91-year-old female admitted to hospice on 06/21/24 for Chronic Obstructive Pulmonary disease (ongoing lung condition caused by damage to the lungs).”During a review of Patient 10’s “POC,” dated 2/5/25,the “POC” indicated, “Hospice Aide: 2 visits weekly.”During a concurrent interview and record review on 4/4/25 at 10:00 a.m. with the DPCS, “ECC,” dated 02/01/25 to 04/03/25 was reviewed for Patient 10. The “ECC” indicated, only one visit done in February on 2/4/25 and one in March on 03/14/25. The DPCS agreed, there were missing supervisory visits for February and March for Patient 10. During review of the facility’s policy and procedure titled, “Hospice Aide Supervision,” dated 3/24, indicated, “When Hospice Aide services are being provided, The RN (Registered Nurse) Case Manager or designated RN shall make an on site visit to the patient at least every 14 days to assess whether the aide is following the patient’s plan of care and is competently completing tasks assigned by the RN…””