Hospice of Palm Beach County Inc.

“Based on interview and record review the provider failed to follow their grievance policy for 2 of 2 sampled patients as evidenced by the failure to timely respond to voiced concerns by representatives of Patient #1 and #2.The findings included: Review of the policy Customer Complaint Process, effective 12/2025, documented in part, “Policy: Complaints are defined as an expression of dissatisfaction with the care and treatment that is (or fails to be) provided by the agency … All complaints are to be reported and documented in the Riskconnect portal. This includes complaints in various forms including verbal, letters, and/or social media notifications. … Procedure: … 3. When complaints are received, colleagues must make every attempt to follow these steps: … b. Listen carefully, gathering as much information as possible. … f. Report the concern to an immediate supervisor. G. Document the complaint and information into the quality & safety portal (Riskconnect) within 24 hours.”1) Review of the record revealed Patient #1 was admitted to the Hospice inpatient unit (IPU), after having been transferred from the hospital’s Intensive Care Unit, on 03/27/26, and passed away on 03/29/26. Patient #1 had diagnoses to include Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Sepsis from MRSA (methicillin-resistant Staphylococcus aureus, a multi drug-resistant bacterium). The patient was admitted to the IPU on 15 liters of oxygen via a non-rebreather mask.The record documented the adult daughter as next of kin.Review of the Complaint log revealed a grievance only for the missing cell phone.During a phone interview on 07/28/26 at 9:47 AM, the daughter of Patient #1 voiced concerns with the lack of coordination between the hospital and arrival of the patient to the IPU and not being able to locate her mother for nearly an hour upon arrival, failure of Hospice staff to have a conversation with the patient and family related to the goals of care and specifically the use of oxygen, failure to respond to a request to discontinue oxygen as per patient desire to have no supportive therapy, failure to communicate and educate family on the infectious status of the patient, failure of staff to utilize personal protective equipment (PPE) during patient care, failure to ensure patient dignity, and failure to protect patient property (a lost cell phone). When asked if anyone was aware of her concerns, the daughter stated Patient #1’s physician was aware of the concerns as they had a lengthy discussion.During a phone interview on 07/29/26 at 11:22 AM, when asked the process for admitting a patient from the hospital to the IPU, Staff A, Registered Nurse (RN) and the admission nurse for Patient #1, gave a lengthy explanation of how she obtains the referral and subsequent order, reviews the medical record, speaks with the patient and family to go over the Hospice options available related to location of care, coordinates the transition with both the hospital and Hospice staff, and does whatever it takes to give the family support. The RN further stated that during this whole process she is documenting all, ensures the family is supported during transportation, to make sure the patient is the priority. When asked specifically about Patient #1, the RN stated she recalled the patient and that the daughter was driving 12 hours on the day of admission to meet Patient #1 upon arrival to the IPU. The RN recalled the daughter would be arriving at the IPU past 7:30 PM and the RN stated she told the daughter to call the 24-hour Hospice number and then texted her that number. Review of the medical record lacked those instructions to the daughter. Staff A explained she had left that evening, was off work for a couple of days, and upon return to work she noted a missed call. Staff A called that number, and it was the daughter of Patient #1, who was “very upset.” The RN stated the daughter told her she was going to report her to the physician of Patient #1. The RN stated she tried to apologize and stated she “mentioned it (the voiced concerns from the daughter) to her supervisor.”During a phone interview on 07/29/26 at 1:03 PM, when asked the process should a family member voice concerns or complaints about patient care, Staff B, the physician of Patient #1 stated she would typically listen and try to have an open discussion with the family to see how they could help going forward. The physician stated she would touch bases with the nurses on how to improve care and reach out to the nurse managers if needed. When asked when she would escalate the concerns to a formal grievance, the physician stated if they could not help enough or if their expectations were more than they could help, she would reach out to the administrator on call. When asked specifically if she recalled Patient #1 and the family, the physician stated she did and that she had had a lengthy conversation with the daughter and other family members. When asked if she recalled any voiced concerns, the physician stated she recalled the daughter had a lot of concerns about what had happened in the hospital, why she ended up in Hospice, not being notified of the patient’s change in status of being less alert, and a cell phone issue. When asked specifically about any concerns with the oxygen, the physician stated the first day the Patient was on a non-rebreather mask and had continuous oxygen. The physician stated she had spoken to the family that first day about oxygen and the family just wanted the patient to be comfortable. The physician stated the second day they spoke more about the oxygen, and the family wanted it discontinued, which she did. When asked if she recalled voiced concerns about a lack of coordination and communication upon arrival to the IPU, the physician stated she did. When asked if she recalled voiced concerns related to the MRSA and lack of information on PPE use, the physician stated she did not. When asked if she recalled voiced concerns about patient dignity, as the family arrived the second day and the patient was lying there naked, the physician stated she did not, but she did recall ordering more comfort medications and that those are often ordered for restlessness and the patient could have pulled off her clothing. Finally, when asked if she escalated and or documented these concerns as per their written grievance policy the physician stated she did not as she thought after the lengthy discussion with the daughter and family, they had resolved the concerns.2) Review of the record revealed Patient #2 was referred to Hospice services on 06/11/26 and after a few conversations with the patient and the family, the referral was closed as a non-admission as of 06/26/26. Further review of the coordination notes documented the following messages from their call log:a) On 06/27/26 at 7:36 PM the son of Patient #2 stated the patient was not admitted to Hospice services, but he was unable to order the patient’s medication through the patient’s mail in order system as the patient’s pharmacy now had Hospice as the primary pharmacy. This note documented that the caller was requested to speak to the pharmacy directly and the triage staff transferred the call.b). On 06/29/26 at 1:13 PM the son of Patient #2 called and stated he tried to order medication refills, and the pharmacy is stating they still have the Hospice as the billing ID number. The son requested an urgent call back, so he can get the issue straightened out, so he could order the refills for Patient #1.c) On 07/09/26 at 3:16 PM the son of Patient #2 stated he had been trying to get prescriptions for Patient #2 and the pharmacy continues to inform him the Hospice billing ID is still attached to the patient so he can not refill the medications. The son stated this was his third call in two weeks. The son could not recall the name of the nurse who called him back on 06/29/26, but he wanted to make sure the patient’s future medication needs would not have the Hospice billing ID attached to any pharmacy. The writer ensured follow-up and sent a priority email to the admissions coordinator.Review of the coordination notes lacked any further documentation.Review of the complaint log lacked any entry for Patient #2.During an interview on 07/29/26 at 12:05 PM, when asked how the Hospice billing ID number ended up on this non-admit patient, the VP of Organizational Integrity stated she was not sure. When asked if the pharmacy issue had been resolved and or if the concern had been initiated as per their grievance process, The VP of Organizational Integrity confirmed the grievance process was not followed for Patient #2, and that she was unsure if the issue had been resolved as the record lacked any further documentation past the 07/09/26 entry.”

“Based on record review and interview the provider failed to ensure an infection control program that protects patients, staff and others for 1 of 1 sampled patient on contact precautions as evidenced by the failure to ensure timely initiation of contact precautions as ordered, ensure use of PPE (Personal Protective Equipment) by staff, provided education to family, and ensure completion of a care plan related to the infection of Patient #1.The findings included: Review of the policy Implementing contact Precautions with a copyright of 2026, documented in part, “Procedure Steps: … 4. Place stocked isolation cart with PPE outside entrance to patient room. … 7. Put on routine PPE for contact precautions, including gown and gloves. … Patient/Family Education: Explain purpose of contact precautions and steps involved to implement. Emphasize importance of performing hand hygiene, using PPE, and disinfecting environment/equipment. … Educate patient/family about spread of antibiotic-resistant organisms, including multidrug-resistant organisms. … Documentation: Update patient’s plan of care and medical record, as appropriate. Include: Date/time contact precautions were implemented. … Patient’s tolerance of isolation precautions, including emotional response. … Patient/family education, such as topics presented, response to education, plan for follow-up education, any communication barriers, and techniques that promoted successful communication.”Review of the record revealed Patient #1 was admitted to the Hospice inpatient unit (IPU), after having been transferred from the hospital’s Intensive Care Unit, on 03/27/26, and passed away on 03/29/26. Patient #1 had diagnoses to Sepsis from MRSA (methicillin-resistant Staphylococcus aureus, a multi drug-resistant bacterium). Initial physician orders dated 03/27/26 included contact precautions per protocol. Further review of the record lacked any evidence of the date and time the precautions were initiated, any mention of the provision of contact precautions until 03/29/26, or any education to the family related to the MRSA infection of Patient #1 or the use of PPE.During a phone interview on 07/28/26 at 9:47 AM, when asked about the care and services provided by the Hospice team, the daughter of Patient #1 voiced concern that no one had told her the patient had MRSA. The daughter stated there was an infection control bag hanging on the door but no PPE in the bag. The daughter stated again that no staff told any of the family about the infection or the need for PPE. The daughter further stated she herself was immunocompromised (a weakened system related to disease) and concerned about her own health and possibly catching something. The daughter finally stated the staff were not wearing gowns upon entering the patient’s room.During a side-by-side review of the record on 07/28/26 beginning at 11:00 AM the Regulatory Accreditation Specialist agreed with the findings.”

“Observed in Record Review. In 4 of 4 patient records reviewed, During the record review for HV 1,2,3 and 4; the hospice surveyor noted that the care plan goals were not individualized. For example, the goal for pain was pain is managed at a level acceptable to the patient but no specific number was indicated that could be measured. This was validated in a discussion with and observation by the Director of Patient Care. Observed in Record Review. In 1 of 14 patient records reviewed, the goals were not individualized. RR#14 NHV had issues with pain and the care plan goal reflected the following- patient will have acceptable level of pain. There was no further qualification of this goal. This observation was discussed with the RN”

“Observed in Record Review. In 1 of 14 patient records reviewed, the comprehensive care plan did not include all the interventions required based on the patient assessment. RR#13 NHV had a Foley, and the comprehensive care plan/485 did not include the size of the foley or the balloon size, the frequency of change or who was responsible for changing the Foley. Additionally, for the same patient, the nursing care plan reflected port flushes monthly however this order was not reflected on the 485/comprehensive care plan. This observation was discussed with the RN.”

“Observed in Record Review. In 3 of 14 patient records reviewed, did not have an accurate medication profile. The medication profile for RR#13 NHV reflected that patient was receiving the same doe, frequency, and schedule of methadone twice daily. Per discussions with the RN there was a disconnect between the profile electronically displayed on the computer terminal versus what was displayed on the RN’s device and subsequently provided to the patient. Similarly, the medication administration records (MAR) in the nursing home of RR#6 HV and RR#11 did not match the hospice medication profile. Specifically, the hospice medication profile reflected that the patient should be on lorazepam and Pyridium and these medications were not on the nursing home MAR. Finally, the MAR for RR#5 did not include Lasix, Hyoscyamine, Jardiance, and Lorazepam which appeared on the hospice medication profile. This observation was discussed with the RN.”